Challenges Meeting Training Requirements in the Care of Children in Family Medicine Residency Programs: A CERA Study.

BACKGROUND AND OBJECTIVE: In 2014, the Accreditation Council for Graduate Medical Education (ACGME) implemented numeric requirements for family medicine (FM) pediatric patient encounters. Impact on residency programs is unclear. We aimed to identify any difficulties faced by FM program directors (PDs) meeting these numeric requirements. METHODS: Questions about pediatric training in family medicine residencies were included in a survey of PDs conducted by the Council of Academic Family Medicine Educational Research Alliance (CERA). We performed univariate analysis of the demographic and program characteristics. We then used χ2 tests of independence to test for bivariate associations between these characteristics and our primary outcome: the most difficult ACGME pediatric care requirement to meet. RESULTS: Most programs reported the hospital as the primary location of training (n=131, 46%) and their family medicine practice (FMP) patient population consisted of over 20% pediatric patients (n=153, 56%). Over 80% of program directors reported challenges meeting FM requirements for the care of children. Challenges meeting pediatric requirements were associated with fewer than 20% FMP patients under 19 years of age (P<.0001), fewer than 50% of core FM faculty caring for sick children (P=.0128), and primary location of pediatric training in a family health center (P=.0006). CONCLUSION: Difficulty meeting ACGME requirements for the care of children in FM residency programs is common, especially for programs with fewer than 20% FMP patients under 19 years of age. Further research is needed to determine how best to assure FM resident competencies in the care of children and adolescents.

The Future of Inpatient Community Hospital Care: Is There One?

Community hospital inpatient pediatric programs face a variety of challenges including financial instability, variable censuses, difficulty maintaining qualified staff, and a lack of focus for the hospital. With the addition of new payment models, such as bundled payments and global budgets, along with a global pandemic, the future of community hospital pediatric inpatient care is uncertain at best. In this article we summarize the challenges, opportunities, and potential solutions to maintaining high-quality care for hospitalized children in community hospitals.

Spanish-speaking patients perceive high quality care in resident continuity practices: a CORNET study.

Prior research has demonstrated that limited English proficiency in Hispanic patients is associated with adverse health outcomes. The authors sought to compare the perception of primary care in resident practices between Spanish-speaking and English-speaking parents using a previously validated tool, the Parents' Perception of Primary Care. Using survey results from 19 CORNET sites nationwide, they compared mean scores for each primary care domain and the full scale between the groups using Student's t test. Multiple linear regression models compared outcomes controlling for demographic variables. Of the 2122 analyzable surveys, 490 (23%) were completed in Spanish and 1632 (77%) in English. The mean scores for each domain and the total scale were not statistically different between the 2 groups. After adjustment, Spanish-speaking parents rated communication significantly higher. Resident clinics may use systems to provide high quality care to Spanish-speaking patients, which may help other sites improve care.

A Hospital-Based Initiative to Reduce Postdischarge Sudden Unexpected Infant Deaths.

BACKGROUND AND OBJECTIVES: Sudden unexpected infant deaths (SUID) most often occur because infants are placed in unsafe sleep environments. Although authors of previous literature have demonstrated that parents who receive comprehensive safe sleep education increase knowledge and intention to place children in safe sleep environments, no studies have demonstrated improved outcomes. We describe the development of a hospital-based newborn SUID risk reduction quality improvement project and its effectiveness in reducing subsequent SUIDs in a community using linked outcome data from local Child Fatality Review Teams. METHODS: Qualitative and quantitative evaluation of a long-term iterative performance improvement intervention for a nursery-based comprehensive safe sleep program in a community teaching hospital. Key themes and exemplary comments were noted. The rate of infant deaths per 1000 births was the primary quantitative outcome. The rate is calculated quarterly and monitored with control charts by using Child Fatality Review data about infant sleep deaths. RESULTS: The average death rate fell from 1.08 infants per 1000 births preintervention to 0.48 infants per 1000 births after complete intervention, and the average number of deaths between deliveries increased from 1 in every 584 deliveries (upper control limit: 3371) to 1 in every 1420 deliveries (upper control limit: 8198). Qualitative observation of nursery providers revealed 3 themes, including routine inclusion of sleep safety information, dissemination of safety information by all staff, and personal commitment to success. CONCLUSIONS: A comprehensive sleep safety culture change can be effectively integrated into a nursery setting over time by using feedback from Child Fatality Review and performance improvement methodology. Repeated messaging and education by the entire nursery staff has the potential to play a role in reducing sleep-related deaths in infants born at their hospital.

Forced suffocation of infants with baby wipes: a previously undescribed form of child abuse.

BACKGROUND: Foreign body aspiration in children is commonly seen in emergency departments and carries a significant mortality. Abusive foreign body suffocation is not well described. METHODS: We present a case-series of four infants who presented with aspiration of a baby wipe. RESULTS: Each child was found to be a victim of child physical abuse with substantial morbidity and mortality associated with the aspiration of the wipe and associated injuries. CONCLUSIONS: We recommend that infants who present with a baby wipe aspiration should be considered as likely victims of child abuse and physicians should evaluate each infant for associated injuries of the oropharynx, skin, skeleton, and head.

Redefining the community pediatric hospitalist: the combined pediatric ED/inpatient unit.

BACKGROUND: The use of pediatric hospitalists in community hospitals has increased over the past decade in response to the desire to provide high-quality pediatric care. Many hospitals are challenged to create financially independent and productive programs. OBJECTIVE: To evaluate an alternative approach to traditional community hospital pediatric care of having pediatricians work in a combined pediatric Emergency Department (PED)/inpatient unit. DESIGN/METHODS: Franklin Square Hospital Center converted its pediatric hospitalist program from a traditional inpatient with partial Emergency Department (ED) coverage program to one that covers a combined PED/inpatient unit. Outcome categories were compared between the year before opening, 2003, to the year after, 2004. Measures included total part B billing, overall patient satisfaction scores for the PED and inpatient unit from the Press Ganey patient satisfaction survey, perception of wait times and time to admission, and risk-adjusted inpatient length of stay (ALOS). RESULTS: Part B billings from the 5.5 Full Time Equivalent (FTE) pediatric hospitalists increased 82% from increased 61% from 2003 to 2004, from 1,631,583 dollars in 2003 to 2,967,715 dollars in 2004 as a result of increased volume of ED patients seen by pediatricians. The mean inpatient satisfaction score did not significantly change, 75.7 in 2003 and 79.0 in 2004 (P = 0.432), but the mean PED score significantly increased from 75.8 to 83.4 (P = 0.0001). Mean scores of the efficiency measures on the survey increased for PED patients, with the mean score for wait time to treatment increasing from 62.0 to 75.3 (P < 0.0001). Total throughput time through the ED improved significantly as well from 143 minutes to 122 minutes (P = 0.0003). Risk-adjusted length of stay performance did not change; for calendar year 2003, the mean monthly ALOS was 1.883 (95% range 1.503, 2.263), compared with a 2004 mean monthly ALOS of 1.869 (95% range 1.523, 2.216). CONCLUSIONS: Implementation of a combined PED/inpatient unit was associated with increased billing by hospitalists, increased satisfaction scores of ED patients, and decreased ED throughput times. Pediatric hospitalist programs that want to improve financial and patient outcomes in a community setting could consider adopting the combined unit approach.

Changes in Asthma Maintenance Therapy Prescribing Patterns Following the 2006 Long-acting ß-Agonist FDA Drug Warning.

PURPOSE: The US Food and Drug Administration issued a boxed warning on all products containing a long-acting ß-agonist (LABA) in March 2006, after the findings from a trial suggested an increased risk for death in patients treated with salmeterol monotherapy. Almost nothing is known about the impact of this warning on LABA prescribing patterns or on clinicians' approaches to asthma maintenance therapy. METHODS: A cohort of asthmatic adults on LABA therapy was retrospectively identified from a Baltimore-area Medicaid data warehouse. Pharmacy claims were used for determining the utilization rates of all asthma maintenance medications. Rates from the 6-month period before the warning (September 1, 2005, to February 28, 2006) were compared with rates from a similar 6-month period 1 year afterward (September 1, 2006, to February 28, 2007). The demographic characteristics of patients who continued LABA use were compared with those of discontinuers. In LABA discontinuers, utilization of alternative maintenance drugs was assessed. FINDINGS: In this cohort of 455 asthmatic patients, LABAs were prescribed only in combination with inhaled corticosteroids. Following the warning, 53% of patients discontinued LABA use, and the mean number of LABA prescription fills per patient decreased from 2.6 to 1.8 (P < 0.0001). Concurrently, the use of inhaled corticosteroids increased from 0.3 to 0.8 fills per patient (P < 0.0001). LABA continuers were younger (P = 0.0005), more likely to be black (P = 0.0079), and more consistent with LABA fills prewarning (P < 0.0001). Of the 243 LABA discontinuers, 155 were placed on no alternative maintenance therapy. IMPLICATIONS: The management of asthma changed significantly after the LABA warning. The use of LABAs combined with inhaled corticosteroids plummeted, while the use of inhaled corticosteroid monotherapy increased. More than half of patients who discontinued LABAs were not placed on alternative maintenance therapy.

Support for emergency department screening for intimate partner violence depends on perceived risk.

Emergency department (ED) screening for intimate partner violence (IPV) faces logistic difficulties and has uncertain efficacy. We surveyed 146 ED visitors and 108 ED care providers to compare their support for ED IPV screening in three hypothetical scenarios of varying IPV risk. Visitor support for screening was 5 times higher for the high-risk (86%) than for the low-risk (17%) scenario. Providers showed significantly more support for the need for ED IPV screening than visitors. Controlling for confounding by gender, race, experience with IPV, hospital, and marital status did not affect comparisons between groups. These responses indicate greater support for IPV screening in the ED for high-risk than for low-risk cases, particularly among visitors.

Improving infant sleep safety through a comprehensive hospital-based program.

We evaluated a comprehensive hospital-based infant safe sleep education program on parental education and safe sleep behaviors in the home using a cross-sectional survey of new parents at hospital discharge (HD) and 4-month follow-up (F/U). Knowledge and practices of infant safe sleep were compared to the National Infant Sleep Position Study benchmark. There were 1092 HD and 490 F/U surveys. Supine sleep knowledge was 99.8% at HD; 94.8% of families planned to always use this position. At F/U, 97.3% retained supine knowledge, and 84.9% maintained this position exclusively (P < .01). Knowledge of crib as safest surface was 99.8% at HD and 99.5% F/U. Use in the parents' room fell to 91.9% (HD) and 68.2% (F/U). Compared to the National Infant Sleep Position Study, the F/U group was more likely to use supine positioning and a bassinette or crib. Reinforcing the infant sleep safety message through intensive hospital-based education improves parental compliance with sudden infant death syndrome risk reduction guidelines.

Variability in institutional review board assessment of minimal-risk research.

OBJECTIVES: To examine variability in responses from institutional review boards (IRBs) to submission of a proposed minimal-risk survey. METHODS: Identical research proposals to obtain information concerning beliefs about the needs of victims of intimate partner violence via surveys were submitted for IRB approval to three institutions in the Baltimore metropolitan area. One institution is an academic center, one is an inner-city hospital affiliated with the academic center, and the third is a suburban community hospital. The study population consisted of emergency department health care providers and individuals in emergency department waiting areas. RESULTS: Inconsistencies emerged among the three IRBs in the review process itself, the need for participant consent, and the need for revision of the consent form and study protocol. One institution approved the proposal in 15 business days after expedited review. The second institution approved the proposal in 12 business days and waived the requirement for informed consent. The third institution approved the research in 77 business days after three revisions. Questions raised included: methodology for selecting participants; appropriateness of surveying individuals in emergency department waiting areas; a request for background literature to assure that the research questions had not already been answered; and concerns about study methodology and sample size justification. CONCLUSIONS: In this sample, there is considerable variability in IRB processes even for minimal-risk studies.

Parental beliefs and practices regarding early introduction of solid foods to their children.

This study was a cross-sectional survey of primary female caregivers during their child's 4-month well-child visit. Our objectives were to document current caregiver awareness of infant feeding guidelines, and calculate the frequency of and reasons for early introduction of solid foods. Questionnaires were completed for 102 children. Forty-five respondents (44%) introduced solids at less than 4 months of age. Hispanic caregivers, OR 0.2 (0.07-0.9), and those who breastfed (partial or exclusive), OR 0.4 (0.2-0.9), were less likely to introduce cereal at less than 4 months of age. Among caregivers who introduced solids at less than 4 months, 36 (80%) stated that the child was not satisfied with formula or breast milk alone and 24 (53%) stated that solids helped the child sleep better at night. Thirty-four caregivers (76%) who started solids at less than 4 months were aware of guidelines regarding proper infant feeding practices. Despite knowledge of infant feeding guidelines, female caregivers frequently introduce solids at less than 4 months of age. Early targeted anticipatory guidance is needed to address the most common reasons caregivers begin solid foods before the recommended age.

Perceptions of help resources for victims of intimate partner violence.

Intimate partner violence (IPV) constitutes a major public health problem in the United States. This cross-sectional survey of 108 emergency department (ED) care providers and 146 ED visitors at three metropolitan EDs compared the beliefs of ED health care providers with those of community members about the relative benefits of the helpfulness of resources for IPV victims using hypothetical case scenarios. Although providers generally indicated that help resources were helpful in all scenarios, visitors were more discriminating, showing less support for resources in the lower-risk scenario. Regarding differences between groups, visitors selected police and attorneys more frequently than providers as a helpful resource, whereas providers selected shelters and counselors more frequently than visitors. Adjustment for previous experience with IPV did not change these results. Understanding the differences between health care providers' and community members' perceptions of resources for victims of IPV may improve the effectiveness of referral to IPV resources.

Advocacy and child neglect.

Pediatricians have a unique opportunity to intervene in the lives of children to identify and to prevent neglect. While it remains important to care for individual patients affected by neglect, the ecological model of child neglect requires intervention at the parent, family, community, and societal levels. Pediatricians can improve the outcomes for children by advocating for policies and interventions at each level. Effective advocacy principally requires the willingness to tackle broader issues beyond individual clinical care. Working with local, state, and national organizations, pediatricians can contribute a unified voice to promote evidence-based policies and programs that improve the well-being of children.