Improving the Pediatric Emergency Department Learning Experience: A Simulation-Based Orientation for Pediatric PGY 1 Residents.

Introduction: Rotations in the pediatric emergency department (PED) may expose residents to very few critically ill patients. In our previous work, interns at our institution showed low self-confidence in decision-making and preparedness to stabilize acutely ill patients. In order to improve this, we designed a new, peer-led, simulation-based orientation to the PED rotation for interns focusing on workflow and decision-making. The cases presented learners with practical and generalizable challenges, such as ordering initial labs and medications and defining the ultimate disposition for the patient. Methods: This orientation curriculum was designed for first-year residents using high-fidelity simulation mannequins. In the first of two cases, learners managed a 10-year-old boy presenting with status asthmaticus who required continuous albuterol and parenteral magnesium to achieve stability for admission. In the second case, a 4-year-old girl with short gut syndrome and an indwelling central line presented with fever, was found to be septic, but responded well to fluid resuscitation and antibiotic therapy. Results: Over 2 years of implementation, 39 residents participated. Pre- and postintervention Likert-based survey evaluations showed significant increases in confidence in decision-making and preparedness to stabilize acutely ill children that were not seen in a control group during the pilot year. A subsequent class-wide implementation showed similar significant improvements, as well as increased comfort initiating treatment prior to staffing. Discussion: Using simulation mannequins in a case-based orientation can improve PGY 1 residents' self-confidence and sense of preparedness during their first rotation in the PED.

Functional Impairment Predicts Outcome of Youth With Headache in the Emergency Department.

Headache is a common presenting complaint in emergency departments (EDs), with the goal of improving acute pain. However, youth with chronic headaches may demonstrate broad functional impairment in their lives due to headaches. Our objective was to determine if degree of functional impairment predicts ED course for patients with headache as part of a clinical protocol. One hundred and thirty-seven pediatric patients presenting to an ED with headache were included. Patients and parents were administered the Functional Disability Index (FDI) and ED charts were reviewed to evaluate outcomes. Higher child-reported FDI scores were associated with more medications, longer ED stay, and admission. High parent-proxy FDI score was associated with longer ED stay. Both pain score and parent-proxy FDI score were associated with imaging. The FDI was a more useful predictor of visit resources than pain score. FDI scores could be used to help anticipate patients who may require greater time and resources.

Child Abuse and Conditions That Mimic It.

One percent to 2% of children in the United States are confirmed victims of child abuse, with many more likely affected. It can be difficult to diagnose, with often misleading medical histories, but acute care providers should be aware of its presenting warning signs and how to evaluate and document suspicious physical findings. Young children who cannot disclose are most vulnerable to forms of abuse with high morbidity and mortality, so it is important to keep it in the differential diagnosis and to be aware of and know how to rule out medical conditions that mimic abuse.

Pediatric Emergency Department Resource Utilization among Children with Primary Care Clinic Contact in the Preceding 2 Days: A Cross-Sectional Study.

OBJECTIVES: To characterize pediatric patient contacts with their primary care clinic in the 2 days preceding a visit to the emergency department (ED) and explore how the type of clinic contact relates to ED resource use. STUDY DESIGN: We conducted a retrospective chart review of 368 pediatric ED visits in the first 7 days of each month, from September 2012 to August 2013. Visits were included if the family contacted their child's general pediatric clinic in the study health system in the 2 days preceding the ED visit. Descriptive statistics were calculated. Primary outcomes were ED resource use (tests, treatments) and disposition (admission or discharge). Outcomes by type of clinic contact were compared with χ2 statistics. RESULTS: Of 1116 records with ED visits in the 12 study weeks extracted from the electronic medical record, 368 ED visits met inclusion criteria. Most ED visits followed a single clinic contact (78.8%). Of the 474 clinic contacts, 149 were in-person visits, 216 phone calls when clinic was open, and 109 phone calls when clinic was closed. ED visits that followed an in-person clinic contact with advice to go to the ED had significantly greater rates of testing and admission than those advised to go to the ED after phone contact and those never advised to go to the ED. CONCLUSIONS: In-person clinic visits with advice to go to the ED were associated with the greatest ED resource use. Limitations include a study of a single health system without a uniform process for triaging patients to the ED across clinics.

Family structure and child abuse.

Knowledge of the characteristics of family structure may be helpful to the pediatrician for predicting child abuse. During the past several decades progressive shifts from the classic family unit of two biological parents and their children to a variety of parental living arrangements have occurred. Most notable are the increases in teenage pregnancies, unmarried motherhood, divorce rates approximating 50% of marriage rates, and frequency of unrelated surrogate parents, most often male, cohabitating in the home. In these settings, identifiable characteristics of the mother, the father or surrogate, the child, the family history, and the immediate neighborhood of the family have been associated with a greater likelihood of child and/or spousal abuse. The accumulated information may be used for preventative intervention.