Increased Fellow Scholarly Publication Rate After Implementation of a Comprehensive Research Curriculum and Milestone-Based Research Timeline for Pediatric Emergency Medicine Fellows.

OBJECTIVE: Pediatric subspecialty fellows are required to complete a scholarly product during training; however, many do not bring the work to publication. To amplify our fellows' publication success, our pediatric emergency medicine fellowship program implemented a comprehensive research curriculum and established a milestone-based research timeline for each component of a project. Our objective was to assess whether these interventions increased the publication rate and enhanced the graduated fellows' perceived ability to perform independent research. METHODS: Our study was conducted at a tertiary children's hospital affiliated with an academic university, enrolling 3 fellows each year in its pediatric emergency medicine program. A comprehensive research curriculum and a milestone-based research timeline were implemented in 2011. We analyzed the publication rate of our graduating fellows before (2004-2011) and after (2012-2016) our intervention. In addition, in 2017 we surveyed our previous fellows who graduated from 2004 to 2016 and analyzed factors favoring manuscript publication and confidence with various research skills. RESULTS: During the study period, 38 trainees completed the fellowship program. Publication rate increased from 26% ± 17% to 87% ± 30 % ( P < 0.05). When scoring the importance of various factors, fellows most valued mentorship (5 ± 0 vs 4.3 ± 1.0, P < 0.05, postintervention vs preintervention) for the completion of the fellowship study and manuscript. Fellows after the intervention reported greater confidence in performing an analysis of variance (89% vs 36%, odds ratio, 6.3; 95% confidence interval, 1.4-150.1). CONCLUSIONS: Implementation of a comprehensive research curriculum and a milestone-based research timeline was associated with an increase in the publication rate within 3 years of graduation of our pediatric emergency medicine fellows. After implementation, fellows reported an increased importance of mentorship and greater confidence in performing an analysis of variance. We provide a comprehensive curriculum and a research timeline that may serve as a model for other fellowship programs.

Guiding Fellows to Independent Practice: Current Trends in Pediatric Emergency Medicine Fellow Supervision.

BACKGROUND: Recent studies highlight the importance of physician readiness to practice beyond graduate training. The Accreditation Council for Graduate Medical Education mandates that pediatric emergency medicine (PEM) fellows be prepared for independent practice by allowing "progressive responsibility for patient care." Prior unpublished surveys of program directors (PDs) indicate variability in approaches to provide opportunities for more independent practice during fellowship training. OBJECTIVES: The aims of the study were to describe practices within PEM fellowship programs allowing fellows to work without direct supervision and to identify any barriers to independent practice in training. DESIGN/METHODS: An anonymous electronic survey of PEM fellowship PDs was performed. Survey items were developed using an iterative modified Delphi process and pilot tested. Close-ended survey responses and demographic variables were summarized with descriptive statistics. Responses to open-ended survey items were reviewed and categorized by theme. RESULTS: Seventy two of 84 PDs (88%) responded to the survey; however, not all surveys were completed. Of the 68 responses to whether fellows could work without direct supervision (as defined by the Accreditation Council for Graduate Medical Education) during some part of their training, 31 (45.6%) reported that fellows did have this opportunity. In most programs, clinical independence was conditional on specific measures including the number of clinical hours completed, milestone achievement, and approval by the clinical competency committee. Reported barriers to fellow practice without direct oversight included both regulatory and economic constraints. CONCLUSIONS: Current training practices that provide PEM fellows with conditional clinical independence are variable. Future work should aim to determine best practices of entrustment, identify ideal transition points, and mitigate barriers to graduated responsibility.

Management and Outcome of Pediatric Patients With Transient Small Bowel-Small Bowel Intussusception.

OBJECTIVE: The aim of this study was to assess the management and outcomes of healthy pediatric patients diagnosed radiologically with transient and benign small bowel-small bowel intussusception (SB-SBI). METHODS: Retrospective cohort study of healthy patients 0 to 18 years of age who presented to a children's hospital emergency department from January 1, 2005, to June 30, 2015, and had transient and benign SB-SBI characterized by spontaneous resolution (ie, transient), diameter of less than 2.5 cm, no lead point, normal bowel wall thickness, nondilated proximal small bowel, and no colonic involvement (ie, benign radiographic features). Charts were reviewed for demographics, clinical presentation, radiologic studies obtained, outcomes, and further management. Medical and radiologic records were also reviewed for 1 year after presentation for any subsequent pathologic diagnoses. RESULTS: Sixty-eight patients were included in our study, with a total of 87 episodes of transient and benign SB-SBI on initial or follow-up examination. Overall, 39 patients (57%) were admitted to the hospital, and 38 patients (56%) had a surgical consultation. Twenty-four patients (35%) had further radiologic studies obtained, including computed tomography scans, esophagogastroduodenoscopy, Meckel's scan, barium swallow studies, and magnetic resonance imaging. All studies were negative for concerning pathology including apparent lead points. None of the patients required surgical intervention or had any complications. CONCLUSIONS: Transient and benign SB-SBIs with reassuring radiologic and clinical features diagnosed in healthy pediatric patients are likely incidentally found and are unlikely to be associated with a pathologic lead point.

Management and Outcomes of Spontaneous Pneumomediastinum in Children.

OBJECTIVES: Management of spontaneous pneumomediastinum in the pediatric population is highly variable. There are limited data on the use of diagnostic tests and the need for admission. Our objectives were to characterize the management of pediatric spontaneous pneumomediastinum, determine the diagnostic yield of advanced imaging, and describe the patients' outcomes. METHODS: This is a retrospective cohort study of all patients presenting to a single tertiary pediatric emergency department between January 2008 and February 2015 diagnosed with pneumomediastinum. Patients were identified using 2 complementary strategies: International Classification of Diseases, Ninth Revision billing codes and a keyword search of the hospital radiology database. RESULTS: We identified 183 patients with spontaneous pneumomediastinum. The mean age was 12.8 ± 4.8 years. Diagnosis was established by chest radiograph (CXR) in 165 (90%) patients, chest computed tomography in 15 (8%), neck imaging in 2 (1%), and abdominal imaging in 1. After diagnosis, many patients underwent additional studies: repeat CXR (99, 54%), chest computed tomography (53, 29%), esophagram (45, 25%), and laryngoscopy (15, 8%). Seventy-eight percent of patients (n = 142) were admitted with a median length of stay of 27 hours (18.4-45.6 hours). Six patients returned to the emergency department within 96 hours for persistent chest pain; 2 were admitted, and 1 was found to have worsening pneumomediastinum on CXR. We performed a secondary analysis on 3 key subgroups: primary spontaneous pneumomediastinum (64, 35%), secondary gastrointestinal-associated pneumomediastinum (31, 17%), and secondary respiratory-associated pneumomediastinum (88, 48%). No patients in the study received an invasive intervention for pneumomediastinum. In all patients, further studies did not yield additional diagnostic information. CONCLUSIONS: Our data suggest that patients with spontaneous pneumomediastinum who are clinically well appearing can be managed conservatively with clinical observation, avoiding exposure to radiation and invasive procedures.

Risk of Serious Bacterial Infection in Infants Aged ≤60 Days Presenting to Emergency Departments with a History of Fever Only.

OBJECTIVE: To compare the risk of serious bacterial infection between infants aged ≤60 days who are febrile in the emergency department (ED) and those who have only a history of fever and are afebrile on arrival to the ED. STUDY DESIGN: In this secondary analysis of a multicenter prospective study using data collected between December 2008 and May 2013, we compared the rate of serious bacterial infection (urinary tract infection [UTI], bacteremia, and/or bacterial meningitis) between infants who have a history of fever but are afebrile on arrival to the ED and those with fever documented in the ED (rectal temperature ≥38.0 °C) using relative risk (RR) with 95% CI. Stratified analyses were performed for age (≤28 and 29-60 days) and serious bacterial infection type. Infants born prematurely and those with a clinical focal infection or serious illness were excluded. RESULTS: A total of 3825 infants (mean age, 35.2 days; 56.9% male) were included. Of the 1233 (32.2%) who were afebrile in the ED, 108 (8.8%) had a serious bacterial infection (UTI, n = 94 [7.6%]; bacteremia, n = 19 [1.5%]; bacterial meningitis, n = 8 [0.6%]). Of the 2592 infants (67.8%) who were febrile in the ED, 331 (12.8%) had a serious bacterial infection (UTI, n = 285 [11.0%]; bacteremia, n = 61 [2.4%]; bacterial meningitis, n = 17 [0.7%]). The RR for serious bacterial infection for afebrile vs febrile infants was 0.68 (95% CI, 0.56-0.84). A lower risk of serious bacterial infection was also seen among afebrile vs febrile infants aged ≤28 days (RR, 0.69; 95% CI, 0.52-0.93) and age 29-60 days (RR, 0.67; 95% CI, 0.50-0.89). CONCLUSIONS: The prevalence of serious bacterial infection is lower in infants aged ≤60 days with a history of fever compared with those who are febrile on arrival to the ED. The small risk reduction in this group is unlikely to alter decision making.

Seasonal, Weather, and Temporal Factors in the Prediction of Admission to a Pediatric Trauma Center.

BACKGROUND: Our objective is to identify seasonal and weather trends associated with pediatric trauma admissions. METHODS: We reviewed all trauma activations leading to admission in patients ≤18 years admitted to a regional pediatric trauma center from January 1, 2000, to December 31, 2015. We reviewed climatologic measures of the mean temperature, mean visibility, and precipitation for each admission in the 6 h prior to each presentation in addition to time of arrival, weekday/weekend presentation, and season. We used a negative binomial regression model with multivariable analysis to estimate associations between weather and rate of trauma admissions. Results were presented as incidence rate ratios (IRR) with 95% confidence intervals (CI). RESULTS: In total, 3856 encounters [2539 males (65.8%), mean age 10.2 years ± SD 5.1 years] were included. Results from multivariable analysis (IRR, 95% CI) suggested an association of admissions with rain (0.82, 0.75-0.90) and overnight hours (23:51-05:50; 0.69, 0.58-0.82) as compared to morning (05:51-11:50). The IRR of trauma increased during the afternoon (11:51-17:50; 4.05, 3.57-4.61), night periods (17:51-23:50; 5.59, 4.94-6.33), and weekends (1.24, 1.15-1.32), and with every 1 °C increase in temperature (1.04, 1.03-1.04). After accounting for other variables, season was not found to be independently predictive of trauma admission. CONCLUSION: Trauma admissions had a higher rate during afternoon, evening hours, and weekends. The presence of rain lowered the rate of pediatric trauma admission. Each degree increase in temperature increased the rate of trauma admissions by 4%. The findings provide information from the perspective of emergency preparedness, resource utilization, and staffing to pediatric trauma centers.

The Burden of Ionizing Radiation Studies in Children with Ventricular Shunts.

OBJECTIVES: To quantify the number of shunt-related imaging studies that patients with ventricular shunts undergo and to calculate the proportion of computed tomography (CT) scans associated with a surgical intervention. STUDY DESIGN: Retrospective longitudinal cohort analysis of patients up to age 22 years with a shunt placed January 2002 through December 2003 at a pediatric hospital. Primary outcome was the number of head CT scans, shunt series radiograph, skull radiographs, nuclear medicine, and brain magnetic resonance imaging studies for 10 years following shunt placement. Secondary outcome was surgical interventions performed within 7 days of a head CT. Descriptive statistics were used for analysis. RESULTS: Patients (n = 130) followed over 10 years comprised the study cohort. The most common reasons for shunt placement were congenital hydrocephalus (30%), obstructive hydrocephalus (19%), and atraumatic hemorrhage (18%), and 97% of shunts were ventriculoperitoneal. Patients underwent a median of 8.5 head CTs, 3.0 shunt series radiographs, 1.0 skull radiographs, 0 nuclear medicine studies, and 1.0 brain magnetic resonance imaging scans over the 10 years following shunt placement. The frequency of head CT scans was greatest in the first year after shunt placement (median 2.0 CTs). Of 1411 head CTs in the cohort, 237 resulted in surgical intervention within 7 days (17%, 95% CI 15%-19%). CONCLUSIONS: Children with ventricular shunts have been exposed to large numbers of imaging studies that deliver radiation and most do not result in a surgical procedure. This suggests a need to improve the process of evaluating for ventricular shunt malfunction and minimize radiation exposure.

Bloodstream Infections in Patients With Intestinal Failure Presenting to a Pediatric Emergency Department With Fever and a Central Line.

OBJECTIVE: Previous small studies have found a high occurrence of bloodstream infections (BSIs) in patients with intestinal failure, and these rates are higher than reported rates in other pediatric populations with central lines. The primary study objective was to describe the occurrence of BSIs in patients with intestinal failure who present to the pediatric emergency department (ED) with fever. METHODS: This 5-year retrospective chart review included febrile patients with intestinal failure and central lines who presented to the Children's Hospital of Pittsburgh ED between 2006 and 2011. Each febrile episode was analyzed at the visit level. RESULTS: During the study, 72 patients with 519 febrile episodes were identified. Central blood cultures were obtained in 93% (480/519) of episodes and 69% (330/480) were positive. Of all BSIs, 38% (124/330) were polymicrobial, 32% (105/330) were a single gram-positive organism, 25% (84/330) were a single gram-negative organism, and 5% (17/330) were a single fungal organism. Of the bacterial pathogens, 48% (223/460) were gram-negative. Overall, 60% were enteric organisms. CONCLUSIONS: Pediatric patients with intestinal failure and central lines have a high occurrence of BSIs with 69% of cultures positive in this study of ED febrile episodes. In contrast to reports in other populations with central lines, BSI occurrence in patients with intestinal failure and fever is higher and larger proportions are gram-negative and enteric organisms. For these patients, we recommend central and peripheral blood cultures, empiric broad spectrum antibiotics targeting gram-negative and enteric organisms, and hospital admission.

History of Somatization Is Associated with Prolonged Recovery from Concussion.

OBJECTIVE: To determine the association between a history of somatization and prolonged concussion symptoms, including sex differences in recovery. STUDY DESIGN: A prospective cohort study of 10- to 18-year-olds with an acute concussion was conducted from July 2014 to April 2015 at a tertiary care pediatric emergency department. One hundred twenty subjects completed the validated Children's Somatization Inventory (CSI) for pre-injury somatization assessment and Postconcussion Symptoms Scale (PCSS) at diagnosis. PCSS was re-assessed by phone at 2 and 4 weeks. CSI was assessed in quartiles with a generalized estimating equation model to determine relationship of CSI to PCSS over time. RESULTS: The median age of our study participants was 13.8 years (IQR 11.5, 15.8), 60% male, with separate analyses for each sex. Our model showed a positive interaction between total CSI score, PCSS and time from concussion for females P < .01, and a statistical trend for males, P = .058. Females in the highest quartile of somatization had higher PCSS than the other 3 CSI quartiles at each time point (B -26.7 to -41.1, P values <.015). CONCLUSIONS: Patients with higher pre-injury somatization had higher concussion symptom scores over time. Females in the highest somatization quartile had prolonged concussion recovery with persistently high symptom scores at 4 weeks. Somatization may contribute to sex differences in recovery, and assessment at the time of concussion may help guide management and target therapy.

Neck Pain in a 12-Year-Old Female: An Unusual Diagnosis.

BACKGROUND: Neck pain in the pediatric population has a broad differential diagnosis, ranging from benign to imminently life-threatening causes. Trauma and infection represent the most common etiologies of pediatric neck pain in the pediatric emergency department (PED) setting. Malignancy, though a rare cause of pediatric neck pain, is important to consider in patients with acquired torticollis or focal neurologic signs. CASE REPORT: We describe the case of a previously healthy 12-year-old female who presented to the PED with neck pain radiating down her upper extremities. The physical examination revealed diminished strength in her upper extremities compared to her lower extremities. Further evaluation revealed lymphadenopathy in the cervical and mediastinal areas and an epidural tumor in the cervical spinal column. The ultimate diagnosis was Hodgkin lymphoma presenting in an unusual manner with cervical spinal cord compression. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Neck pain is a common chief complaint among pediatric patients in the emergency setting. This case of spinal cord compression caused by malignancy illustrates the necessity of detailed spinal imaging in patients with neck pain and "red flag" signs, including but not limited to an abnormal neurologic examination.

Essentials of Pediatric Emergency Medicine Fellowship: Part 3: Clinical Education and Experience.

This article is the third in a 7-part series that aims to comprehensively describe the current state and future directions of pediatric emergency medicine fellowship training from the essential requirements to considerations for successfully administering and managing a program to the careers that may be anticipated upon program completion. This article focuses on the clinical aspects of fellowship training including the impact of the clinical environment, modalities for teaching and evaluation, and threats and opportunities in clinical education.

Missed opportunities to diagnose child physical abuse.

OBJECTIVES: This study aimed to determine the incidence of missed opportunities to diagnose abuse in a cohort of children with healing abusive fractures and to identify patterns present during previous medical visits, which could lead to an earlier diagnosis of abuse. METHODS: This is a retrospective descriptive study of a 7-year consecutive sample of children diagnosed with child abuse at a single children's hospital. Children who had a healing fracture diagnosed on skeletal survey and a diagnosis of child abuse were included. We further collected data for the medical visit that lead to the diagnosis of child abuse and any previous medical visits that the subjects had during the 6 months preceding the diagnosis of abuse. All previous visits were classified as either a potential missed opportunity to diagnose abuse or as an unrelated previous visit, and the differences were analyzed. RESULTS: Median age at time of abuse diagnosis was 3.9 months. Forty-eight percent (37/77) of the subjects had at least 1 previous visit, and 33% (25/77) of those had at least 1 missed previous visit. Multiple missed previous visits for the same symptoms were recorded in 7 (25%) of these patients. The most common reason for presentation at missed previous visit was a physical examination sign suggestive of trauma (ie, bruising, swelling). Missed previous visits occurred across all care settings. CONCLUSIONS: One-third of young children with healing abusive fractures had previous medical visits where the diagnosis of abuse was not recognized. These children most commonly had signs of trauma on physical examination at the previous visits.

Use of emergency ultrasound in United States pediatric emergency medicine fellowship programs in 2011.

OBJECTIVES: The purpose of this study was to evaluate the use of and training in emergency ultrasound (US) in pediatric emergency departments (EDs) with pediatric emergency medicine (EM) fellowship programs. We hypothesized that emergency US use and pediatric EM fellow training have become widespread and that more structured training is being offered. METHODS: A survey instrument was sent via e-mail to all 69 United States pediatric EM fellowship directors or associate directors in the spring of 2011. We used descriptive summary statistics and χ(2) tests to determine characteristics associated with having a formal emergency US training program for pediatric EM fellows. RESULTS: The survey response rate was 87% (60 of 69). Among responding programs, 40 (67%) resided within a children's hospital (versus general ED). Fifty-one (85%) were designated level 1 pediatric trauma centers. Fifty-seven programs (95%) endorsed the use of emergency US in their EDs. Fifty-three (88%) provided at least some emergency US training to fellows, and 42 (70%) offered a structured emergency US rotation. Training has existed for a median of 3 years (interquartile range, 2-4 years). Twenty-eight programs (67%) with emergency US rotations provided fellow training in the both a general ED as well as a pediatric ED. There were no hospital or program level factors statistically associated with having a formal training program for pediatric EM fellows. CONCLUSIONS: As of 2011, nearly all pediatric EDs with pediatric EM fellowship programs use emergency US. Pediatric EM fellowship programs provide emergency US training to their fellows, with a structured rotation being offered by most of these programs.

Pediatric facial fractures: occurrence of concussion and relation to fracture patterns.

BACKGROUND: Children and adolescents with injuries resulting in facial fractures are a population that is potentially at risk for suffering concomitant concussion. Concussion results in a variety of physical symptoms and often affects cognition, emotion, and sleep. These effects can have a significant impact on academics and social functioning. Early recognition of concussion and active management have been shown to improve outcomes. The goal of this study was to describe the occurrence of concussion in patients sustaining facial fractures and to determine whether certain fracture types are associated with concussion. METHODS: We performed a retrospective review of patients aged 0 to 18 years who were evaluated in the emergency department of the Children's Hospital of Pittsburgh from 2000 to 2005 with an International Classification of Diseases, Ninth Revision code indicative of facial fractures. Data included demographics, documentation of concussion, and facial fracture type. Patients with intracranial injury were excluded from the study. Univariate χ2 analysis and logistic regression were performed to determine characteristics associated with concussion. RESULTS: Facial fracture was diagnosed in 782 patients. Ninety-one patients had an intracranial injury and were excluded, leaving 691 patients for evaluation. The mean age was 11.1 (SD, 4.6) years. Males made up 69.6% of patients, and 80.6% of patients were white. Concussion was diagnosed in 31.7% of patients. Age, sex, and race were not associated with concussion. Univariate analysis demonstrated that skull and orbital fractures were associated with higher rates of concussion, whereas maxillary fractures showed a trend toward higher rates of concussion, and nasal and mandible fractures showed a trend toward lower rates of concussion. Logistic regression analysis demonstrated the odds of having a concussion were higher in those with skull fractures (odds ratio, 2.3; confidence interval, 1.5-3.7). CONCLUSIONS: Nearly one third of pediatric patients with facial fractures in this retrospective series were diagnosed with a concomitant concussion. Our data suggest that a higher index of suspicion for concussion should be maintained for patients with concomitant skull fractures and potentially orbital and maxillary fractures. Given the possibility of a worse outcome with delayed concussion diagnosis, patients with facial fractures may benefit from more active early concussion screening.

Increasing Frequency of Affirmed Name and Pronoun Documentation in a Pediatric Emergency Department.

BACKGROUND AND OBJECTIVES: In a previous study of 204 transgender and gender diverse youth in our region, 44% reported being made to feel uncomfortable in the emergency department (ED) because of their gender identity. The objective of our study was to conduct a 2 year quality improvement project to increase affirmed name and pronoun documentation in the pediatric ED. METHODS: Using process mapping, we identified 5 key drivers and change ideas. The key driver diagram was updated as interventions were implemented over 3 Plan-Do-Study-Act cycles. Our primary outcome, the percentage of ED visits per month with pronouns documented, was plotted on a run chart with the goal of seeing a 50% increase in form completion from a baseline median of ∼14% over the 2 year study period. RESULTS: The frequency of pronoun documentation increased from a baseline median of 13.8% to a median of 47.8%. The most significant increase in pronoun documentation occurred in Plan-Do-Study-Act cycle 3, immediately after ED-wide dissemination of a near-miss case and subsequent call for improvement by ED leadership. Roughly 1.7% of all encounters during the study period involved patients whose pronouns were discordant from the sex listed in their electronic health record. CONCLUSIONS: This quality-improvement project increased the frequency of pronoun documentation in the ED. This has the potential to improve the quality of care provided to transgender and gender diverse youth in the ED setting and identify patients who may benefit from receiving a referral to a pediatric gender clinic for additional support.

Pediatric craniofacial fractures due to violence: comparing violent and nonviolent mechanisms of injury.

BACKGROUND: This study examines the epidemiologic data of pediatric craniofacial fractures secondary to violence, comparing these data to craniofacial fractures sustained from all other causes. METHODS: A retrospective review was completed on all patients who presented to the emergency department of a major urban children's hospital from 2000 to 2005 with a craniofacial fracture. Data were compared between patients with fractures due to violent and nonviolent mechanisms. Socioeconomic analysis was performed using Geographic Information System mapping and 2000 US Census data by postal code. RESULTS: One thousand five hundred twenty-eight patients were diagnosed with skull and/or facial fractures. Isolated skull fractures were excluded, leaving 793 patients in the study. Ninety-eight children were injured due to violence, and 695 were injured from a nonviolent cause. Patients with violence-related fractures were more likely to be older, male, and nonwhite and live in a socioeconomically depressed area. A greater number of patients with violence-related injuries sustained nasal and mandible angle fractures, whereas more patients with non-violence-related injuries sustained skull and orbital fractures. Those with violence-related craniofacial fractures had a lower percentage of associated multiorgan system injuries and a lower rate of hospital admissions and intensive care unit admissions. The rate of open reduction and internal fixation for craniofacial fractures was similar in both groups. CONCLUSIONS: Patients with violence-related fractures had fewer associated serious injuries and lower morbidity and lived in a more socioeconomically depressed area. The information gained from this descriptive study improves our ability to characterize this population of pediatric patients and to identify the associated constellation of injuries in such fractures.

Morbidity associated with golf-related injuries among children: findings from a pediatric trauma center.

OBJECTIVE: To describe injuries due to golf-related activities among pediatric patients requiring hospital admission. METHODS: We conducted a retrospective analysis of all sports-related injuries from 2000 to 2006 using a level 1 trauma center database. RESULTS: Of 1005 children admitted with sports-related injuries, 60 (6%) had golf-related injuries. The mean injury severity score was significantly higher for golf-related injuries (11.0) than that for all other sports-related injuries (6.8). Most golf-related injuries occurred in children younger than 12 years (80%), at home (48%), and by a strike from a club (57%) and resulted in trauma to the head or neck (68%). CONCLUSIONS: Golf-related injuries, although an infrequent cause of sports-related injuries, have the potential to result in severe injuries, especially in younger children. Preventive efforts should target use of golf clubs by younger children in the home setting.

Pediatric emergency medicine fellows' milestone evaluations: Do they all meet the targets for graduation?

BACKGROUND: The ACGME Milestone Project created a competency-based trainee assessment tool. Subcompetencies (SCs) are scored on a 5-point scale; level 4 is recommended for graduation. The 2018 Milestones Report found that across subspecialties, not all graduates attain level 4 for every SC. OBJECTIVE: The objective was to describe the number of pediatric emergency medicine (PEM) fellows who achieve ≥ level 4 in all 23 SCs at graduation and identify SCs where level 4 is not achieved and factors predictive of not achieving a level 4. METHODS: This is a multicenter, retrospective cohort study of PEM fellows from 2014 to 2018. Program directors provided milestone reports. Descriptive analysis of SC scores was performed. Subanalyses assessed differences in residency graduation scores, first-year fellowship scores, and the rate of milestone attainment between fellows who did and did not attain ≥ level 4 at graduation. RESULTS: Data from 392 fellows were obtained. There were no SCs in which all fellows attained ≥ level 4 at graduation; the range of fellows scoring < level 4 per SC was 7% to 39%. A total of 67% of fellows did not attain ≥ level 4 on one or more SC. While some fellows failed to attain ≥ level 4 on up to all 23 SCs, 26% failed to meet level 4 on only one or two. In 19 SCs, residency graduation and/or first year fellow scores were lower for fellows who did not attain ≥ level 4 at graduation compared to those who did (mean difference = 0.74 points). Among 10 SCs, fellows who did not attain ≥ level 4 at graduation had a faster rate of improvement compared to those who did attain ≥ level 4. CONCLUSION: In our sample, 67% of PEM fellows did not attain level 4 for one or more of the SCs at graduation. Low scores during residency or early in fellowship may predict difficulty in meeting level 4 by fellowship completion.

Gender Differences Among Milestone Assessments in a National Sample of Pediatric Emergency Medicine Fellowship Programs.

BACKGROUND: Understanding gender gaps in trainee evaluations is critical because these may ultimately determine the duration of training. Currently, no studies describe the influence of gender on the evaluation of pediatric emergency medicine (PEM) fellows. OBJECTIVE: The objective of our study was to compare milestone scores of female versus male PEM fellows. METHODS: This is a multicenter retrospective cohort study of a national sample of PEM fellows from July 2014 to June 2018. Accreditation Council for Medical Education (ACGME) subcompetencies are scored on a 5-point scale and span six domains: patient care (PC), medical knowledge, systems-based practice, practice-based learning and improvement, professionalism, and interpersonal and communication skills (ICS). Summative assessments of the 23 PEM subcompetencies are assigned by each program's clinical competency committee and submitted semiannually for each fellow. Program directors voluntarily provided deidentified ACGME milestone reports. Demographics including sex, program region, and type of residency were collected. Descriptive analysis of milestones was performed for each year of fellowship. Multivariate analyses evaluated the difference in scores by sex for each of the subcompetencies. RESULTS: Forty-eight geographically diverse programs participated, yielding data for 639 fellows (66% of all PEM fellows nationally); sex was recorded for 604 fellows, of whom 67% were female. When comparing the mean milestone scores in each of the six domains, there were no differences by sex in any year of training. When comparing scores within each of the 23 subcompetencies and correcting the significance level for comparison of multiple milestones, the scores for PC3 and ICS2 were significantly, albeit not meaningfully, higher for females. CONCLUSION: In a national sample of PEM fellows, we found no major differences in milestone scores between females and males.

Milestone achievements in a national sample of pediatric emergency medicine fellows: impact of primary residency training.

BACKGROUND: Pediatric emergency medicine (PEM) fellowships recruit trainees from both pediatric and emergency medicine (EM) residencies. The Accreditation Council for Graduate Medical Education (ACGME) defines separate training pathways for each. The 2015 PEM milestones reflect a combination of subcompetencies from the two residencies. This project aims to compare the milestone achievement of PEM fellows based on their primary residency training. We hypothesize that fellows trained in pediatrics achieve PEM milestones at different rates than EM-trained fellows in the ACGME domains of patient care, medical knowledge, systems-based practice, practice-based learning, professionalism, and interpersonal and communication skills. METHODS: This is a multicenter, retrospective cohort study of fellows from a national sample of U.S. PEM fellowship programs. Basic demographic information and deidentified, biannual milestone scores for 23 competencies were collected for fellows training between 2015 and 2018. Subcompetencies are scored on a 5-point milestone scale. Descriptive and multivariable analyses for longitudinal data were performed to compare milestone assessments by primary residency training. RESULTS: Complete data were obtained for 600 fellows; 95% (570) and 5% (30) completed pediatric and EM residency, respectively. In both year 1 and year 2 of fellowship, the mean milestone scores of EM-trained fellows were statistically higher than pediatrics-trained fellows across the majority of subcompetencies. By the final year of training, there were no statistically significant differences in milestone scores for any of the subcompetencies. CONCLUSIONS: Fellow milestone achievement between groups was not significantly different by graduation. However, fellows entering PEM training from an EM background attained higher scores on the milestones than fellows from a pediatric background in the first year of fellowship.