Med-Peds Residents' Career Plans and the Impact of Pediatric Hospital Medicine Fellowship: A Nationwide Survey.

BACKGROUND: The establishment of pediatric hospital medicine (PHM) as a fellowship-trained subspecialty represents a major change in the practice landscape, particularly for combined internal medicine-pediatrics (med-peds) residents. The most recent literature on med-peds residents' career choices predates PHM fellowship and its impact has not been well studied. We aimed characterize med-peds residents' career plans and the factors influencing their choices. METHODS: We distributed an electronic survey to the 1,505 resident members of the National Med-Peds Resident Association. In addition to sociodemographic data, participants reported their career plans, how well their residency prepared them for various aspects of practice, and their perceptions of PHM fellowship and its effect on their career choices. RESULTS: Among the 228 participants, the most planned careers were combined hospital medicine (36.8%, 84/228), combined subspecialty practice (32.5%, 74/228), and primary care (31.1%, 71/228). Residents felt well prepared for patient care and significantly more prepared for inpatient practice than for primary care. Participants rated the potential disadvantages of PHM fellowship as major deterrents and did not view the possible advantages as strong incentives. Among those who had considered a hospital medicine careers, 91.2% (186/203) were less likely to pursue PHM after its certification as a subspecialty. CONCLUSION: Med-peds residents have a wide range of career interests but fellowship has made them less likely to pursue PHM careers. These findings emphasize the importance of addressing the needs of med-peds trained providers as PHM certification pathways and fellowship curricula develop to avoid adverse effects on the workforce.

A Dedicated Fracture Reduction Room: A Cost-Effective Alternative to the Operating Room.

INTRODUCTION: Charges, procedural efficiency, return to activity, and complications after closed treatment of fractures performed in an operating room (OR) versus closed reduction in a dedicated fracture reduction room (FRR) were compared. METHODS: Patients with closed fractures of the forearm who underwent closed reduction in the year before (OR), and after implementation of the FRR, were retrospectively reviewed. Charges, American Society of Anesthesiologists class, sex, age, length of follow-up, prior reduction, fracture location/displacement, time from injury to procedure, procedural time, time to return to activity, and complications were recorded. RESULTS: Eighteen patients met the inclusion criteria in the FRR group (13 men, 5 women), and 22 in the OR group (18 men, 4 women). No notable differences in age, sex, follow-up, American Society of Anesthesiologists class, fracture location/displacement, incidence of prior reduction, or time to return to activity were observed. Two (9.5%) complications occurred in the FRR group versus 7 (32%) in the OR group, P > 0.05. No anesthesia complications were present. Patients treated in the FRR incurred charges of $5,299 ± $1,289 versus $10,455 ± $2,290 in the OR, P < 0.001. Total time of visit in the FRR was ∼30% less than the OR, P < 0.001. No notable delay in treatment was observed. DISCUSSION: In the era of finite resources and value-based care, implementation of a FRR resulted in safe, cost-effective, and increased procedural efficiency.

Voluntary Medical Incident Reporting Tool to Improve Physician Reporting of Medical Errors in an Emergency Department.

INTRODUCTION: Medical errors are frequently under-reported, yet their appropriate analysis, coupled with remediation, is essential for continuous quality improvement. The emergency department (ED) is recognized as a complex and chaotic environment prone to errors. In this paper, we describe the design and implementation of a web-based ED-specific incident reporting system using an iterative process. METHODS: A web-based, password-protected tool was developed by members of a quality assurance committee for ED providers to report incidents that they believe could impact patient safety. RESULTS: The utilization of this system in one residency program with two academic sites resulted in an increase from 81 reported incidents in 2009, the first year of use, to 561 reported incidents in 2012. This is an increase in rate of reported events from 0.07% of all ED visits to 0.44% of all ED visits. In 2012, faculty reported 60% of all incidents, while residents and midlevel providers reported 24% and 16% respectively. The most commonly reported incidents were delays in care and management concerns. CONCLUSION: Error reporting frequency can be dramatically improved by using a web-based, user-friendly, voluntary, and non-punitive reporting system.

Admission rapid thrombelastography can replace conventional coagulation tests in the emergency department: experience with 1974 consecutive trauma patients.

OBJECTIVE: Injury and shock lead to alterations in conventional coagulation tests (CCTs). Recently, rapid thrombelastography (r-TEG) has become recognized as a comprehensive assessment of coagulation abnormalities. We have previously shown that admission r-TEG results are available faster than CCTs and predict pulmonary embolism. We hypothesized that r-TEGs more reliably predict blood component transfusion than CCTs. METHODS: Consecutive patients admitted between September 2009 and February 2011 who met the highest-level trauma activations were included. All had admission r-TEG and CCTs. We correlated r-TEG values [activated clotting time (ACT), r, k, α, maximal amplitude (MA), LY30] with their corresponding CCTs [prothrombin time (PT)/activated partial thromboplastin time (aPTT), international normalized ratio (INR), platelet count and fibrinogen] for transfusion requirements. Charges were calculated for each test. Demographics, vital signs, and injury severity were recorded. RESULTS: We studied 1974 major trauma activations. The median injury severity score was 17 [interquartile range 9-26]; 25% were in shock; 28% were transfused; and 6% died within 24 hours. Overall, r-TEG correlated with CCTs. When controlling for age, injury mechanism, weighted-Revised Trauma Score, base excess and hemoglobin, ACT-predicted red blood cell (RBC) transfusion, and the α-angle predicted massive RBC transfusion better than PT/aPTT or INR (P < 0.001). The α-angle was superior to fibrinogen for predicting plasma transfusion (P < 0.001); MA was superior to platelet count for predicting platelet transfusion (P < 0.001); and LY-30 (rate of amplitude reduction 30 minutes after the MA is reached) documented fibrinolysis. These correlations improved for transfused, shocked or head injured patients. The charge for r-TEG ($317) was similar to the 5 CCTs ($286). CONCLUSIONS: The r-TEG data was clinically superior to results from 5 CCTs. In addition, r-TEG identified patients with an increased risk of early RBC, plasma and platelet transfusions, and fibrinolysis. Admission CCTs can be replaced with r-TEG.

The current medical practice of the pediatric orthopaedic surgeon in North America.

Musculoskeletal disorders in children are common and comprise 20% to 30% of the complaints observed by primary care physicians. Most primary care physicians prefer to refer patients with pediatric musculoskeletal conditions to the pediatric orthopaedic surgeon; most of whom are treated nonoperatively. Pediatric orthopaedic surgeons are well trained to provide efficient, cost-effective, and definitive quality care. This article supports the supposition that pediatric orthopaedic surgeons are the primary care physicians for children with musculoskeletal disorders. This article focuses on the primary clinical responsibilities of the pediatric orthopaedic surgeon, describes the value of this practice, and contrasts their responsibilities from that of other orthopaedic subspecialties.

Assessment of wavelet analysis of gait in children with typical development and cerebral palsy.

The objective of this study was to examine the use of the continuous wavelet transform (CWT) on surface electromyographic (sEMG) signals acquired from the lower extremity muscles during gait in children with typical development (TD) and cerebral palsy (CP). This was done to explore the possibility of developing a quantitative assessment scale of motor function based on time-frequency information. An initial study was conducted on retrospective gait data from three children, matched in gender and in anthropometric variables but with differing levels of walking ability. EMG data were extracted from five lower extremity muscles to assess the degrees of differentiation. The data were processed using the CWT to derive an average scalogram, from which the instantaneous mean frequency (IMNF) was calculated. Principal component analysis was used to assess the differences between the curves. Preliminary results indicated that for select lower extremity muscles, there was a significant deviation in the IMNF curves in the child with CP as compared to the child with TD. Furthermore, as motor impairment increased, total percent explained variance to the TD curves decreased. This suggests that it might be possible to derive a physiologically based quantitative index for assessing motor function and for assessing clinical treatments in CP using the wavelet analysis.

Illustrating the coupled human-environment system for vulnerability analysis: three case studies.

The vulnerability framework of the Research and Assessment Systems for Sustainability Program explicitly recognizes the coupled human-environment system and accounts for interactions in the coupling affecting the system's responses to hazards and its vulnerability. This paper illustrates the usefulness of the vulnerability framework through three case studies: the tropical southern Yucatán, the arid Yaqui Valley of northwest Mexico, and the pan-Arctic. Together, these examples illustrate the role of external forces in reshaping the systems in question and their vulnerability to environmental hazards, as well as the different capacities of stakeholders, based on their access to social and biophysical capital, to respond to the changes and hazards. The framework proves useful in directing attention to the interacting parts of the coupled system and helps identify gaps in information and understanding relevant to reducing vulnerability in the systems as a whole.