Defining leadership competencies for pediatric critical care fellows: Results of a national needs assessment.

INTRODUCTION: Physicians in training, including those in Pediatric Critical Care Medicine, must develop clinical leadership skills in preparation to lead multidisciplinary teams during their careers. This study seeks to identify multidisciplinary perceptions of leadership skills important for Pediatric Critical Care Medicine fellows to attain prior to fellowship completion. METHODS: We performed a multi-institutional survey of Pediatric Critical Care Medicine attendings, fellows, and nurses. Subjects were asked to rate importance of 59 leadership skills, behaviors, and attitudes for Pediatric Critical Care practitioners and to identify whether these skills should be achieved before completing fellowship. Skills with the highest ratings by respondents were deemed essential. RESULTS: Five hundred and eighteen subjects completed the survey. Of 59 items, only one item ("displays honesty and integrity") was considered essential by all respondents. When analyzed by discipline, nurses identified 21 behaviors essential, fellows 3, and attendings 1 (p < 0.05). Nurses differed (p < 0.05) from attendings in their opinion of importance in 64% (38/59) of skills. CONCLUSIONS: Despite significant variability among Pediatric Critical Care attendings, fellows, and nurses in identifying which clinical leadership competencies are important for graduating Pediatric Critical Care fellows, they place the highest importance on skills in self-management and self-awareness. Leadership skills identified as most important may guide the development of interventions to improve trainee education and interprofessional care.

Diagnosis of a craniopharyngioma after acute brainstem herniation in an emergency department.

A 9-year-old previously healthy girl presented with 3 weeks of intermittent emesis and headache to a community emergency department, where she had rapid decompensation due to increased intracranial pressure. Head computed tomography revealed a calcified suprasellar mass consistent with a craniopharyngioma. Despite medical and surgical intervention, the patient had progression of herniation with global cerebral infarction, and care was withdrawn. Although craniopharyngiomas are typically thought to be benign, slow-growing intracranial tumors, this case emphasizes the need for an expeditious diagnostic evaluation when symptoms that may be referable to intracranial hypertension are evident. Craniopharyngiomas and emergency management of intracranial hypertension are reviewed.

Patient Handoffs: Is Cross Cover or Night Shift Better?

OBJECTIVES: Studies show singular handoffs between health care providers to be risky. Few describe sequential handoffs or compare handoffs from different provider types. We investigated the transfer of information across 2 handoffs using a piloted survey instrument. We compared cross-cover (every fourth night call) with dedicated night-shift residents. METHODS: Surveys assessing provider knowledge of hospitalized patients were administered to pediatric residents. Primary teams were surveyed about their handoff upon completion of daytime coverage of a patient. Night-shift or cross-covering residents were surveyed about their handoff of the same patient upon completion of overnight coverage. Pediatric hospitalists rated the consistency of information between the surveys. Absolute difference was calculated between the 2 providers' rating of a patient's (a) complexity and (b) illness severity. Scores were compared across provider type. RESULTS: Fifty-nine complete handoff pairs were obtained. Fourteen and 45 handoff surveys were completed by a cross-covering and a night-shift provider, respectively. There was no significant difference in information consistency between primary and night-shift (median, 4.0; interquartile range [IQR], 3-4) versus primary and cross-covering providers (median, 4.0; IQR, 3-4). There was no significant difference in median patient complexity ratings (night shift, 3.0; IQR, 1-5, versus cross cover, 3.5; IQR, 1-5) or illness severity ratings (night shift, 2.0; IQR, 1-4, versus cross-cover, 3.0; IQR, 1-6) when comparing provider types giving a handoff. CONCLUSIONS: We did not find a difference in physicians' transfer of information during 2 handoffs among providers taking traditional call or on night shift. Development of tools to measure handoff consistency is needed.

Successful use of plasmapheresis for granulomatosis with polyangiitis presenting as diffuse alveolar hemorrhage.

Diffuse alveolar hemorrhage (DAH) is uncommon in pediatric patients and is a rare presenting sign of granulomatosis with polyangiitis (GPA). We present the case a 14-year-old girl who presented with respiratory failure secondary to DAH as the initial presenting sign of GPA. Her clinical course improved after initiation of plasmapheresis therapy and she is now in clinical remission.

Admission handoff communications: clinician's shared understanding of patient severity of illness and problems.

OBJECTIVE: Communication errors are a leading cause of medical mistakes. Handoff communications during the admission of a patient are a critical point of communication during which patient care is transferred from one clinician to another. The transmission of the patient's current severity of illness and active problems is integral to this communication. Our objective was to determine if this information is conveyed by the current handoff process between resident physicians. METHODS: We recorded admission handoff communications between residents and then asked each resident to independently rate the patient's severity of illness and to list the patient's problems. The scores and lists were compared for agreement. Attending physicians listened to the recordings and also assessed severity of illness and patient's problem lists. RESULTS: Three quarters of the handoffs had agreement about the severity of the patient's illness. However, there was low agreement about the most severe problem and the total problem lists between residents involved in the handoff communication. Attending physicians were able to identify more patient problems. CONCLUSIONS: We conclude that information needed to assess the patient's severity of illness and problems may have been present in the handoff communications but may not have been fully received and integrated by the residents. In addition, attending physicians may have an additional capacity to "infer"" information, perhaps because of prior clinical experience or expertise. This study implies that residents may need more formal education, training, and evaluation of their handoffs to improve patient safety.