When Differing Perspectives Between Health Care Providers and Parents Lead to "Communication Crises": A Conceptual Framework to Support Prevention and Navigation in the Pediatric Hospital Setting.

OBJECTIVES: The communication experience and therapeutic relationships between parents and health care providers (HCPs) impacts the quality of patient care. A guiding "communication crisis" description was created to encourage study participants to describe difficult communication encounters between parents and HCPs where their perspectives regarding the recommended patient care conflicted (ie, parent refusal of a lumbar puncture), which created barriers to the provision of optimal care and the development of therapeutic relationships in the pediatric hospital setting. The purpose of this research was to highlight factors that may contribute to communication crises through the characterization of these circumstances. METHODS: Participants were multidisciplinary HCPs and parents (n = 37) with firsthand experience regarding communication crises. Data were collected through focus groups (7), semistructured interviews (2), and a verification focus group where open-ended questions regarding participants' experiences were used. Data were analyzed by using a constructivist grounded theory approach. RESULTS: Three themes and 11 subthemes (communication crisis risk factors) were identified: (1) health care team factors (communication skills, care processes, and interprofessional communication), (2) family and/or parent factors (language or cultural barriers, mental health conditions, socioeconomic factors, and beliefs), (3) patient factors (acute condition, unclear diagnosis, unstable condition, and medical complexity). A core theory emerged: parent trust in their HCP significantly impacts the therapeutic relationship and can mitigate communication crises despite the presence of risk factors. CONCLUSIONS: We highlight factors that may be predisposing to communication crises in pediatric hospital settings. Awareness of these factors can support timely identification and implementation of relationship care and foster the establishment of trusting relationships.

Pseudomonas aeruginosa necrotizing chondritis complicating high helical ear piercing case report: clinical and public health perspectives.

BACKGROUND: Auricular or high helical ear piercing is an increasingly widespread fashion trend that is associated with an increased risk of potentially serious post-piercing complications such as auricular perichondritis. CASE REPORT: An 11-year-old girl developed severe auricular perichondritis following piercing of the upper helical cartilage of her ear at a hairdressing salon. Four days post piercing, she returned to the same salon for a haircut during which the pierced site was manipulated. She presented to her family physician and was treated unsuccessfully with oral cephalexin. She was then referred to an infectious diseases consultant and received antipseudomonal intravenous antibiotics with subsequent resolution. She also required debridement and removal of necrotic cartilage. Public health investigation evaluated potential sources of infection including the piercing gun, disinfectant solutions, and hair cutting spray water bottles. Final culture results of the ear helical aspirate grew Pseudomonas aeruginosa. Pseudomonas aeruginosa was also cultured from one of the water bottles used to wet her hair during the haircut. DISCUSSION: Although the pseudomonal strains from the water bottle were different than the infecting one, this contamination presents a potential source of wound infection. Damage to the helical cartilage caused by the piercing gun may also have contributed to this infection. Initial empiric antibiotic therapy for these kinds of infection must include anti-pseudomonal coverage. Auricular or high helical ear piercing using a piercing gun is not recommended.

Documenting junctional ectopic tachycardia following pediatric open heart surgery.

OBJECTIVE: To determine appropriated documentations for diagnosis junctional ectopic tachycardia (JET) before treatment in post-operative open heart surgery and identify risk factors for post-operative cardiac arrhythmias in children. MATERIAL AND METHOD: The authors performed a retrospective chart review in 277 patients who underwent surgical corrections at British Columbia's Children Hospital from January 1st, 2000 to December 31st, 2001. History, clinical symptoms, complication of surgery and post-operative cardiac arrhythmias were reviewed from medical records. The authors investigated whether JET was being diagnosed accurately and whether it was being adequately documented prior to the initiation of therapy. The authors also identified risk factors that were associated with JET. All documentations before treatment were reviewed by Pediatric cardiologists to confirm diagnosis. RESULTS: Although the diagnostic accuracy (84%), sensitivity (87%), and specificity (84%) are high, a significant number of patients with post-operative arrhythmias were treated without adequate documentation of the arrhythmia. The documentation of arrhythmias in the Intensive Care Unit was largely limited to rhythm strips, with very few 12-lead ECGs and wire studies performed to assist with the diagnosis. CONCLUSION: The presented data indicates that, in this critically-ill population, there was an unacceptable number of patients with post-operative arrhythmias who may have been treated inappropriately. It is very important to emphasize the interpretation of wire studies, an investigation normally done in a critical care setting and whose interpretation is very important to the accurate diagnosis of pediatric arrhythmias.

Leading educationally effective family-centered bedside rounds.

BACKGROUND: Family-centered bedside rounds (family-centered rounds) enable learning and clinical care to occur simultaneously and offer benefits to patients, health care providers, and multiple levels of learners. OBJECTIVE: We used a qualitative approach to understand the dimensions of successful (ie, educationally positive) family-centered rounds from the perspective of attending physicians and residents. METHODS: We studied rounds in a tertiary academic hospital affiliated with the University of Calgary. Data were collected from 7 focus groups of pediatrics residents and attendings and were analyzed using grounded theory. RESULTS: Attending pediatricians and residents described rounds along a spectrum from successful and highly educational to unsuccessful and of low educational value. Perceptions of residents and attendings were influenced by how well the environment, educational priorities, and competing priorities were managed. Effectiveness of the manager was the core variable for successful rounds led by persons who could develop predictable rounds and minimize learner vulnerability. CONCLUSIONS: Success of family-centered rounds in teaching settings depended on making the education and patient care aims of rounds explicit to residents and attending faculty. The role of the manager in leading rounds also needs to be made explicit.

Development and evaluation of global child health educational modules.

OBJECTIVES: To determine if a standardized global child health (GCH) modular course for pediatric residents leads to satisfaction, learning, and behavior change. METHODS: Four 1-hour interactive GCH modules were developed addressing priority GCH topics. "Site champions" from 4 Canadian institutions delivered modules to pediatric residents from their respective programs during academic half-days. A pre-post, mixed methods evaluation incorporated satisfaction surveys, multiple-choice knowledge tests, and focus group discussions involving residents and satisfaction surveys from program directors. RESULTS: A total of 125 trainees participated in ≥1 module. Satisfaction levels were high. Focus group participants reported high satisfaction with the concepts taught and the dynamic, participatory approach used, which incorporated multimedia resources. Mean scores on knowledge tests increased significantly postintervention for 3 of the 4 modules (P < .001), and residents cited increases in their practical knowledge, global health awareness, and motivation to learn about global health. Program directors unanimously agreed that the modules were relevant, interesting, and could be integrated within existing formal training time. CONCLUSIONS: A relatively short, participatory, foundational GCH modular curriculum facilitated knowledge acquisition and attitude change. It could be scaled up and serve as a model for other standardized North American curricula.

Moving into medical practice in a new community: the transition experience.

INTRODUCTION: Physicians undertake many transitions during the course of a medical career. The purpose of this study was to explore the experiences of physicians who moved to a new community. METHODS: A semistructured interview format was used to explore transitional experiences, including reasons for moving; the role of colleagues, learning, and organizational structures; how various mediating factors affected perceptions; and how the experience affected the physicians personally. We used qualitative methods in which data were collected, coded, and analyzed concurrently. RESULTS: 20 physicians from family medicine, internal medicine, and pediatrics described their experiences. Both the professional context and the geographic location affected physicians' perceptions of the move. Both internal and external mediating factors appeared to influence how physicians experienced and adjusted to the move. Physicians who joined functioning units appeared to have fewer problems. The physicians who had more difficulty were physicians who did not come to a specific job, often coming as the result of a spousal move; did not have a professional network in the city; had not sorted out licensure requirements; and were entering community (not institutional) practice. DISCUSSION: This study demonstrates the critical nature of institutional support structures to integrate the newcomer, collegial relationships within the workplace, and the importance of family and friends in mediating the adjustment period. Consideration should be given to structured mentorship or peer-buddy programs and longitudinal educational programs (eg, rounds) that may enable physicians to establish networks and gain practical local knowledge quickly.