A Survey Assessment of Perceived Importance and Methods of Maintenance of Critical Procedural Skills in Pediatric Emergency Medicine.

OBJECTIVE: The aim of this study was to delineate pediatric emergency medicine provider opinions regarding the importance of, and to ascertain existing processes by which practitioners maintain, the following critical procedural skills: oral endotracheal intubation, intraosseous line placement, pharmacologic and electrical cardioversion, tube thoracostomy, and defibrillation. METHODS: A customized survey was administered to all members of the Listserv for the American Academy of Pediatrics Section on Emergency Medicine. Perceived importance of maintaining critical pediatric procedural skills was measured using a 5-point Likert-type scale. Secondary outcomes included presence and type of mandatory training, availability of on-site backup, and perceived barriers to maintenance of skills. RESULTS: Two hundred sixty-two members (25%) responded representing 106 different institutions, 70% of freestanding children's hospitals that received graduate medical education payments in 2014, and 68% of pediatric emergency medicine fellowship programs. More than 90% of respondents felt it was either very or extremely important to maintain competency for 5 of the 6 critical procedures, but no more than 49% of respondents felt that clinical care alone provided opportunity to maintain skills. The proportion of respondents indicating no mandatory training for each critical procedural skill was as follows: oral endotracheal intubation (23%), intraosseous line placement (30%), pharmacologic cardioversion (32%), electrical cardioversion (32%), tube thoracostomy (40%), and defibrillation (32%). CONCLUSIONS: Critical procedural skills are perceived by emergency providers who care for children as extremely important to maintain. Direct care of pediatric patients likely does not provide sufficient opportunity to maintain these skills. There are widespread deficiencies relating to mandatory maintenance of critical procedural skill training.

Performance of International Medical Graduates in Pediatric Residency: A Study of Peer and Faculty Perceptions.

BACKGROUND: International medical graduates (IMGs) constitute approximately 25% of the US pediatric workforce. Their recruitment into US residency training raises concerns regarding their competence, although this has not been formally studied. Cincinnati Children's Hospital has systematically recruited IMGs over the past 16 years. This study evaluates perceptions of IMG performance by faculty and US graduate (USG) peers. METHODS: We surveyed IMG, USG, and faculty groups, including current and former trainees, assessing perceived IMG performance compared with that of USGs in terms of clinical knowledge/skills, resource utilization, communication, public health knowledge and efficiency, and overall impact on the program. RESULTS: Overall perceived performance was within 1 standard deviation of expected USG performance. IMGs outperformed USGs in clinical knowledge/skills and resource utilization but underperformed in communication, public health knowledge, and efficiency. Significant differences were noted in communication with patients and public health knowledge; IMGs ranked their performance significantly lower than USGs/faculty ranked their performance. Overall impact was perceived positively, including an increased interest in global health in among USGs. CONCLUSIONS: Carefully recruited IMGs are perceived to perform nearly equal to their USG peers, and their presence is perceived as positive to a major pediatric residency program. Specific domains for educational interventions are identified for programs wishing to expand IMG recruitment.

An International Survey of Corticosteroid Use for the Management of Low Cardiac Output Syndrome.

OBJECTIVE: Limited evidence exists on use of corticosteroids in low cardiac output syndrome following cardiac surgery. We sought to determine physicians' practices and beliefs with regard to corticosteroids therapy for low cardiac output syndrome. DESIGN: Multinational internet-based survey. SETTING: Pediatric Cardiac Intensive Care Society member database. SUBJECTS: Pediatric cardiac intensive care physicians. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We received 188 responses from 85 centers throughout the world including 57 U.S. congenital heart centers, eight Canadian centers, and 20 international centers. The majority of respondents (51%) reported performing at least 200 bypass cases per year and had separate dedicated cardiac ICUs (57%). Most physicians (89%) rarely or never prescribe corticosteroids for mild low cardiac output syndrome (single vasoactive agent and mildly decreased perfusion), whereas 94% of those surveyed sometimes or always administer corticosteroids to patients with severe low cardiac output syndrome (two or more vasoactive agents and persistent hypotension). Hydrocortisone was the most commonly used corticosteroids (88%), but there was no consensus on dosage used. There was a variable approach to cortisol level measurement and cortisol stimulation testing to inform therapy with corticosteroids. A majority of respondents (75%) stated that they would be willing to randomize patients with severe low cardiac output syndrome into a trial of corticosteroids efficacy. CONCLUSIONS: Our survey demonstrates considerable practice variability with regard to the type of patients in whom corticosteroids are administered, adrenal axis testing is performed, and dosage of hydrocortisone used. The majority of physicians, however, stated their willingness to randomize patients with severe low cardiac output syndrome in a corticosteroids trial. This survey identified multiple areas for future research on use of corticosteroids for low cardiac output syndrome.

Do Adolescents With Higher Knowledge of HIV Have Lower Sexual Risk Behaviors?

OBJECTIVES: Human immunodeficiency virus (HIV) remains a leading cause of morbidity and mortality in the United States, and adolescents account for a disproportionate number of new cases. We aimed to assess knowledge of HIV in relation to sexual risk behaviors among adolescents seeking care in our pediatric emergency department and to assess sources of HIV knowledge among this population. METHODS: Adolescents aged 14 to 21 years who presented to the pediatric emergency department participated in a questionnaire assessing HIV knowledge, sexual risk behaviors, and sources of HIV knowledge. For purposes of statistical analysis, patients were divided into a high-score (greater than or equal to the median score) or low-score (less than the median score) group based on the HIV-Knowledge Questionnaire 18 portion of the survey. RESULTS: A total of 240 adolescents were enrolled. Of those, 112 patients scored higher than or equal to the median HIV-Knowledge Questionnaire 18 score of 11. High-scoring knowledge was independently associated with patients 18 years or older (P = 0.001), any lifetime sexual activity (odds ratio [OR], 2.18; 95% confidence interval [CI], 1.30-3.67; P = 0.003), previous testing for HIV (OR, 2.40; 95% CI, 1.40-4.11; P = 0.002), and an "expert" source (school-based or medical professionals) as their primary source of knowledge (OR, 1.88; 95% CI, 1.05-3.41; P = 0.034). Age of first sexual encounter, number of partners, and condom use were not significantly associated with knowledge score. CONCLUSIONS: Education from "expert" sources is important in providing adolescents with accurate information. However, education alone is unlikely to change sexual practices. A more comprehensive approach to HIV prevention is needed to decrease HIV transmission among this patient population.

Family-Centered Pediatric Emergency Care: A Framework for Measuring What Parents Want and Value.

OBJECTIVE: To identify and describe dimensions of family-centered care important to parents in pediatric emergency care and compare them to those currently defined in the literature. METHODS: A qualitative study was conducted involving 8 focus groups with parents who accompanied their child to an emergency department visit at a large tertiary-care pediatric health system. Participants were identified using purposive sampling to achieve representation across demographic characteristics including child's race, insurance status, severity, and participant's relationship to child. Focus groups were segmented by patient age and presence of a chronic condition. They were moderated by a facilitator experienced in health-related topics. A 6-member multidisciplinary team completed a content analysis. RESULTS: Sixty-eight parents participated. They were female (77%); aged 20 to 29 years (19%), 30 to 39 years (47%), more than 40 years (31%); black (44%), white (52%); and married (50%). Their child's characteristics were: public insurance (52%); black (46%), white (46%); and admitted as an inpatient (46%). The analysis resulted in 8 dimensions: 1) emotional support; 2) coordination; 3) elicit and respect preferences, and involve the patient and family in care decisions; 4) timely and attentive care; 5) information, communication, and education; 6) pain management; 7) safe and child-focused environment; and 8) continuity and transition. Compared to those published in the literature, the most notable differences were combining involving family and respect for preferences into a single dimension, and separating physical comfort into 2 dimensions: pain management and safe/child-focused environment. CONCLUSIONS: The resulting dimensions provide a framework for measuring and improving the delivery of family-centered pediatric emergency care.

Defining the Simulation Technician Role: Results of a Survey-Based Study.

INTRODUCTION: In health care simulation, simulation technicians perform multiple tasks to support various educational offerings. Technician responsibilities and the tasks that accompany them seem to vary between centers. The objectives were to identify the range and frequency of tasks that technicians perform and to determine if there is a correspondence between what technicians do and what they feel their responsibilities should be. We hypothesized that there is a core set of responsibilities and tasks for the technician position regardless of background, experience, and type of simulation center. METHODS: We conducted a prospective, survey-based study of individuals currently functioning in a simulation technician role in a simulation center. This survey was designed internally and piloted within 3 academic simulation centers. Potential respondents were identified through a national mailing list, and the survey was distributed electronically during a 3-week period. RESULTS: A survey request was sent to 280 potential participants, 136 (49%) responded, and 73 met inclusion criteria. Five core tasks were identified as follows: equipment setup and breakdown, programming scenarios into software, operation of software during simulation, audiovisual support for courses, and on-site simulator maintenance. Independent of background before they were hired, technicians felt unprepared for their role once taking the position. Formal training was identified as a need; however, the majority of technicians felt experience over time was the main contributor toward developing knowledge and skills within their role. CONCLUSIONS: This study represents a first step in defining the technician role within simulation-based education and supports the need for the development of a formal job description to allow recruitment, development, and certification.

Evaluation of regional hospitals' use of children in disaster drills.

OBJECTIVE: Describe the prevalence of pediatric casualties in disaster drills by community hospitals and determine if there is an association between the use of pediatric casualties in disaster drills and the proximity of a community hospital to a tertiary children's hospital. DESIGN: Survey, descriptive study. SETTING: Tertiary children's hospital and surrounding community hospitals. PARTICIPANTS: Hospital emergency management personnel for 30 general community hospitals in the greater Cincinnati, Ohio region. INTERVENTIONS: None MAIN OUTCOME MEASURE(S): The utilization of pediatric casualties in community hospital disaster drills and its relationship to the distance of those hospitals from a tertiary children's hospital. RESULTS: Sixteen hospitals reported a total of 57 disaster drills representing 1,309 casualties. The overwhelming majority (82 percent [1,077/1,309]) of simulated patients from all locations were 16 years of age or older. Those hospitals closest to the children's hospital reported the lowest percentage of pediatric patients (10 percent [35/357]) used in their drills. The hospitals furthest from the children's hospital reported the highest percentage of pediatric patients (32 percent [71/219]) used during disaster drills. CONCLUSIONS: The majority of community hospitals do not incorporate children into their disaster drills, and the closer a community hospital is to a tertiary children's hospital, the less likely it is to include children in its drills. Focused effort and additional resources should be directed toward preparing community hospitals to care for children in the event of a disaster.

Injury prevention in the emergency department: a caregiver's perspective.

BACKGROUND: Emergency medicine physicians and their staff care for high-risk injured patients, making the emergency department (ED) an appropriate place to discuss injury prevention (IP). OBJECTIVE: To determine family receptiveness to and short-term effectiveness of IP information delivery during an ED visit. METHODS: A cross-sectional survey was conducted in an urban pediatric ED. Caregivers of children younger than 15 years, with any chief complaint, were approached to participate. The survey consisted of caregiver's background, IP information received by their primary care pediatrician, and their wishes for receiving IP information in the ED. At survey completion, participants were given an age-appropriate IP handout. Follow-up phone surveys were made at 2 weeks to determine caregiver satisfaction and any self-reported IP changes made. RESULTS: Two hundred fifty-one caregivers were approached. Two hundred forty-six (98%) were interested in receiving IP information in the ED, and 217 (86%) consented to participate. Ninety-three percent felt that the ED should provide IP information; 83% believed it should be offered even if it prolonged their ED visit. There was no significant difference among participants with regard to who should provide the information or how it should be provided. One hundred thirty (60%) of 217 completed the follow-up survey. Ninety-seven percent felt that the IP information was useful, and 63% kept the handout in a retrievable place. Twenty-eight percent of caregivers who completed the follow-up survey reported to change their safety behavior as a result of their ED encounter. CONCLUSIONS: Many families surveyed in an urban pediatric ED wished for IP information in the ED setting. A simple IP intervention in an ED setting may encourage families to practice safer behaviors for their children.