Development of a Quality Improvement Curriculum in a Pediatric Emergency Medicine Fellowship.

Quality improvement (QI) is a science of systematic analysis and improvement of health care delivery systems. Working knowledge of QI models is imperative to professional development of future pediatric emergency medicine practitioners. The Accreditation Council for Graduate Medical Education has established a list of QI and patient safety expectations for trainees. In order to address educational needs in this area, we have created a novel QI curriculum for pediatric emergency medicine fellows that include didactic sessions, active participation in QI projects, and mentorship by QI faculty. As a part of the curriculum, fellows are required to participate in variety of QI and patient safety activities, such as Morbidity and Mortality conferences, QI and Patient Case Review committees, and Clinical Care Guideline work groups. As a measure of success, fellows who have participated in this curriculum have shared their successful QI work at the local and national levels. This goal of this report is to share our experience in order to provide other institutions a framework for their own curriculum development.

Milestones comparisons from residency to pediatric emergency medicine fellowship: Resetting expectations.

BACKGROUND: Pediatric emergency medicine (PEM) fellowships accept trainees who have completed a residency in either emergency medicine (EM) or pediatrics and have adopted 17 subcompetencies with accompanying set of milestones from these two residency programs. This study aims to examine the changes in milestone scores among common subcompetencies from the end of EM or pediatrics residency to early PEM fellowship and evaluates time to reattainment of scores for subcompetencies in which a decline was noted. METHODS: This is a national, retrospective cohort study of trainees enrolled in PEM fellowship programs from July 2014 to June 2018. PEM fellowship program directors voluntarily submitted deidentified milestone reports within the study time frame, including end-of-residency reports. Descriptive analyses of milestone scores between end of residency and PEM fellowship were performed. RESULTS: Forty-eight U.S. PEM fellowship programs (65%) provided fellowship milestone data on 638 fellows, 218 (34%) of whom also had end-of-residency milestone scores submitted. Of 218 fellows eligible for analysis, 210 (96%) had completed a pediatrics residency and eight (4%) had completed an EM residency. Pediatric-trained fellows had statistically significant decreases in mean milestone scores in all 10 shared subcompetencies. Reattainment of milestone scores across all common subcompetencies for both EM and pediatric-trained PEM fellows occurred by the end of fellowship. CONCLUSIONS: This study demonstrated declines in milestone scores from the end of primary residency training in pediatrics to early PEM fellowship in shared subcompetencies, which may suggest that performance expectations are reset at the beginning of PEM fellowship. Changes in subcompetency milestone anchors to provide subspecialty-specific context may be needed to more accurately define skills acquisition in the residency-to-fellowship transition.

Impact of a Dedicated Teaching Attending Experience on a Required Emergency Medicine Clerkship.

INTRODUCTION: One published strategy for improving educational experiences for medical students in the emergency department (ED) while maintaining patient care has been the implementation of dedicated teaching attending shifts. To leverage the advantages of the ED as an exceptional clinical educational environment and to address the challenges posed by the rapid pace and high volume of the ED, our institution developed a clerkship curriculum that incorporates a dedicated clinical educator role - the teaching attending - to deliver quality bedside teaching experiences for students in a required third-year clerkship. The purpose of this educational innovation was to determine whether a dedicated teaching attending experience on a third-year required emergency medicine (EM) clerkship would improve student-reported clinical teaching evaluations and student-reported satisfaction with the overall quality of the EM clerkship. METHODS: Using a five-point Likert-type scale (1 - poor to 5 - excellent), student-reported evaluation ratings and the numbers of graduating students matching into EM were trended for 10 years retrospectively from the inception of the clerkship for the graduating class of 2009 through and including the graduating class of 2019. We used multinomial logistic regression to evaluate whether the presence of a teaching attending during the EM clerkship improved student-reported evaluation ratings for the EM clerkship. We used sample proportion tests to assess the differences between top-box (4 or 5 rating) proportions between years when the teaching attending experience was present and when it was not. RESULTS: For clinical teaching quality, when the teaching attending is present the estimated odds of receiving a rating of 5 is 77.2 times greater (p <0.001) than when the teaching attending is not present and a rating of 4 is 27.5 times greater (p =0.0017). For overall clerkship quality, when the teaching attending is present, the estimated odds of receiving a rating of 5 is 13 times greater (p <0.001) and a rating of 4 is 5.2 times greater (p=0.0086) than when the teaching attending is not present. CONCLUSION: The use of a dedicated teaching attending shift is a successful educational innovation for improving student self-reported evaluation items in a third-year required EM clerkship.

Job market survey of recent pediatric emergency medicine fellowship graduates.

OBJECTIVES: The American Academy of Pediatrics Section of Emergency Medicine's Subcommittee on Administration developed a survey tool targeting recent pediatric emergency medicine (PEM) fellowship graduates to assess the current PEM job market in a variety of areas including (1) the new positions accepted, (2) perspectives of fellowship training, and (3) the relationship between PEM and general emergency medicine practice. METHODS: The 40-question internet-based survey was developed through www.surveymonkey.com. Solicitations to PEM fellowship graduates who completed training between the years 2000 and 2005 were sent via the Section of Emergency Medicine member e-mail list as well as the PEM LISTSERV. Data collection occurred from April to May 2005. RESULTS: Of 125 survey respondents, 89% completed a 3-year pediatrics residency plus a 3-year PEM fellowship. Offers to graduates of positions with research expectations outnumbered clinical positions, 3:2, with an average of 5 total positions offered per respondent. Thirty-four percent remained at the institution of fellowship graduation, and 71% accepted faculty appointments with medical school affiliation. Seventy percent of work time was spent on clinical duties and 10% on research. Most felt better prepared in the areas of clinical training and teaching than in the areas of research and administration. Additional general emergency medicine exposure was not desired. Half of the respondents felt that a 2-year fellowship program would have met their career goals. CONCLUSIONS: Recent PEM fellowship graduates felt that job availability was good and were satisfied with their new positions. Respondents perceived better fellowship training in clinical and teaching aspects than in research and administration. New positions were heavily clinical and matched career goals.

A clinical decision rule for cranial computed tomography in minor pediatric head trauma.

OBJECTIVES: To develop a sensitive clinical decision rule with a high negative predictive value for the use of cranial computed tomography (CT) in minor pediatric head trauma, to identify clinical features predictive of neurosurgical intervention, and to assess clinicians' predictive abilities to determine the presence or absence of intracranial injury based on history and physical examination alone. DESIGN: Prospective observational study. SETTING: Four level I pediatric trauma centers. PARTICIPANTS: One thousand patients younger than 21 years with minor head trauma undergoing cranial CT. MAIN OUTCOME MEASURE: Intracranial injury as demonstrated by CT and neurosurgical intervention. RESULTS: Of 1000 patients in the study, the mean age was 8.9 years, and 64.1% were male; 6.5% (65 of 1000) had positive findings on CT, and 9.2% (6 of 65) of these required neurosurgical intervention. Recursive partitioning identified the following variables in the decision rule: dizziness, skull defect, sensory deficit, mental status change, bicycle-related injury, age younger than 2 years, Glasgow Coma Scale score less than 15, and evidence of a basilar skull fracture. For detection of intracranial injury, the decision rule had a sensitivity of 95.4% (95% confidence interval [CI], 86.2%-98.8%), a specificity of 48.9% (95% CI, 46.6%-52.1%), and a negative predictive value of 99.3% (95% CI, 98.1%-99.8%). CONCLUSIONS: We developed a sensitive clinical decision rule with a high NPV for detection of intracranial injury in minor pediatric head trauma. If validated, this rule could provide a useful adjunct to the physician's clinical assessment by reducing variations in practice and unnecessary cranial CT.