A Quality Improvement Project to Optimize Fluoride Varnish Use in a Pediatric Outpatient Clinic with Multiple Resident Providers.

The pediatric clinic at Kapi'olani Medical Center provides dental varnish to prevent decay. A chart review (conducted August 1-31, 2017) revealed that only 49.6% of eligible children received varnish. Among those who did not receive varnish, no explanation was provided in 83.9% of the charts. This quality improvement project was designed to increase delivery and documentation of dental varnish. The participants were 14-15 pediatric and psychiatry residents (11 present for all cycles). Cycle 1 interventions were a 5-minute resident educational session on the importance and process of fluoride varnish, and visual reminders on all order entry computers in the clinic. Cycle 2 intervention consisted of a prompt added to the clinic's default well child visit templates requiring notation of whether varnish was given and a reason if not. Data for cycle 2 was collected over 6 weeks as some residents chose to use their own templates, serving as an unplanned comparison group. Application of varnish increased to 77.7% (P < .001) after cycle 1, and was statistically unchanged for cycle 2 (74% (P = .24)). Documentation of reason for lack of varnish was missing in 80% (P = .59) after cycle 1 and 17 % (P < .001) after cycle 2 (with prompt). In the cycle 2 comparison group using their own templates, the varnish application rate was 71% (P < .001) with no explanation for lack of varnish 84% of the time (P = .95). Brief educational interventions may result in increased use of fluoride varnish in resident-based clinics. Task based prompts or stop measures in electronic medical record templates can improve documentation, which can inform efforts to improve varnish application.

Perspectives of Chuukese patients and their health care providers on the use of different sources of interpreters.

BACKGROUND: Immigrants from Chuuk, a Pacific Island nation in Micronesia, are a growing population of limited-English speakers in Hawai'i. The purpose of this study was to examine the perspectives of Chuukese patients and their physicians in Honolulu, Hawai'i on interpreter services. METHODS: An anonymous multiple choice survey was distributed to potential patients through a Chuukese community group and to physicians through the Hawai'i Residency Programs to examine the following sources of interpreters: Family member or friend, telephone interpreter, or professional in-person interpreter. Statistical significance of cross-tabulated responses was analyzed using Fisher's exact test. RESULTS: 114 surveys from health care providers and 95 surveys from Chuukese community members were analyzed after exclusion criteria. Using a family member or friend was the method most frequently used by physicians (78%) and Chuukese patients (71%). Telephone interpreters were used the least by physicians (6%) and Chuukese patients (2%) and both rated it poorly in terms of comfort and ease of use. Physicians rated professional in-person interpreters as the best method (67%) while Chuukese patients rated using a family member or friend as the best method (61%), especially among those who reported a lower English proficiency (P = .04) and who lived in Hawai'i for fewer years (P > .01). DISCUSSION: The preference of Chuukese patients for using a family member or friend as interpreter differs from national standards which promote the use of a professional interpreter. Given the preference of both physicians and Chuukese patients for in-person interpreters over telephone interpreters, there is a need for increased training and hiring of in-person interpreters.

An evaluation of mother-centered anticipatory guidance to reduce obesogenic infant feeding behaviors.

OBJECTIVE: To evaluate the effect of 2 anticipatory guidance styles (maternal focused [MOMS] and infant focused [Ounce of Prevention]) directed at mothers of infants aged newborn to 6 months on their infant feeding behaviors at 1 year compared with routine advice as outlined in Bright Futures (BF). METHODS: This is a cluster randomized trial. A total of 292 mother/infant dyads were enrolled at their first well-child visit to 3 urban pediatric clinics in Columbus, Ohio. Intervention-specific brief advice and 1-page handouts were given at each well visit. In addition to infant weights and lengths, surveys about eating habits and infant feeding practices were completed at baseline and 12 months. RESULTS: Baseline data revealed a group with high rates of maternal overweight (62%) and obesogenic habits. At 12 months, the maternal-focused group gave their infants less juice (8.97 oz vs 14.37 oz, P < .05), and more daily servings of fruit (1.40 vs 0.94, P < .05) and vegetables (1.41 vs 1.03, P < .05) compared with BF mothers. Ounce of Prevention mothers also gave less juice (9.3 oz, P < .05) and more fruit servings (1.26 P < .05) than BF. CONCLUSIONS: Brief specific interventions added to well-child care may affect obesogenic infant feeding behaviors of mothers and deserves further study as an inexpensive approach to preventing childhood obesity.

Transcutaneous bilirubin measurement methods in neonates and its utility for emergency department use.

Transcutaneous bilirubin measurements correlate with serum bilirubin measurements in neonates. They permit rapid measurements but do not provide fractionation information. Background information of bilirubin measurements is reviewed. The role of transcutaneous bilirubin measurements in the emergency department is reviewed.

Recruitment and retention strategies in longitudinal clinical studies with low-income populations.

BACKGROUND: Conducting longitudinal research studies with low-income and/or minority participants present a unique set of challenges and opportunities. PURPOSE: To outline the specific strategies employed to successfully recruit and retain participants in a longitudinal study of nutritional anticipatory guidance during early childhood, conducted with a low-income, ethnically diverse, urban population of mothers. METHODS: We describe recruitment and retention efforts made by the research team for the 'MOMS' Study (Making Our Mealtimes Special). The 'multilayered' approach for recruitment and retention included commitment of research leadership, piloting procedures, frequent team reporting, emphasis on participant convenience, incentives, frequent contact with participants, expanded budget, clinical staff buy-in, a dedicated phone line, and the use of research project branding and logos. RESULTS: Barriers to enrollment were not encountered in this project, despite recruiting from a low-income population with a large proportion of African-American families. Process evaluation with clinic staff demonstrated the perception of the MOMS staff was very positive. Participant retention rate was 75% and 64% at 6 months and 12 months post-recruitment, respectively. We attribute retention success largely to a coordinated effort between the research team and the infrastructure support at the clinical sites, as well as project branding and a dedicated phone line. CONCLUSIONS: Successful participant recruitment and retention approaches need to be specific and consistent with clinical staff buy in throughout the project.

Anticipatory guidance for prevention of childhood obesity: design of the MOMS project.

The prevalence of childhood overweight and obesity in the United States has increased by more than 100% since 1971. Primary care clinicians have a unique opportunity to influence child health during the first year of life via anticipatory guidance (AG). However, little is known about whether AG regarding feeding and meal structure is effective in promoting optimal nutrition and eating behaviors. The purpose of this project, "Making our Mealtimes Special" (MOMS), was to assess 2 distinct methods of pediatric AG during infancy versus a "usual care" condition, with the ultimate goal of prevention of childhood overweight and obesity. The purpose of this article is to describe the ( a) study design and rationale, (b) implementation plan, (c ) assessment of outcomes, and (d) population enrolled. This project will generate important information on the usefulness of nutritional AG during the first year of life in promoting healthy eating behaviors during early childhood.

Staying smoke free: an intervention to prevent postpartum relapse.

This pilot study evaluated the effectiveness of a nurse-delivered home-visiting program during the postpartum period that included a low-intensity smoking relapse-prevention intervention. A prospective two-group design was used. Participants were women who had quit smoking during their pregnancy. They were invited to participate during postpartum hospitalization on a university hospital postpartum ward. A brief intervention during postpartum hospitalization, a home visit, and two follow-up phone calls over a 1- to 2-month period were compared with a routine home visit without any prescribed focus on tobacco use. The main outcome was biochemically verified smoking abstinence at 3 and 6 months postenrollment. Abstinence was defined as a salivary cotinine level of 14 ng/ml or less. At 3 months postenrollment, 26.4% of the intervention group were classified as abstinent, compared with 12.4% of the comparison group (OR = 2.4, 95% CI = 1.16-4.98). At 6 months, the proportion of the intervention group categorized as abstinent was 21.5%, compared with 10.2% of comparison group participants (OR = 2.5, 95% CI = 1.13-5.71). Greater than three times as many in the intervention group remained abstinent at both times (18.2%), compared with the comparison group (5.2%; OR = 2.4, 95% CI = 1.16-4.93). The effectiveness of this brief, low-cost, and potentially replicable intervention in improving the rate of persistent postpartum smoke-free status for women who quit smoking during pregnancy is encouraging. A randomized trial of the approach is warranted.

Process evaluation of a nurse-delivered smoking relapse prevention program for new mothers.

The objective of this study(1) is to evaluate the feasibility, recall, and acceptability of an evidence-based intervention using home-health nurses to provide smoking relapse prevention skills to new mothers. The design of this study is process evaluation. Setting and participants include women who had delivered a normal newborn at a university hospital, who quit smoking during pregnancy, were smoke free for 7 days, and had saliva cotinine of less than or equal to 14 nanogram/ml. The intervention is a multicomponent cognitive-behavioral intervention, including inpatient contact, a home-health visit, and 2 follow-up phone calls. Results are as follows: 121 participants enrolled, and the intervention was implemented in 78 home visits. Nurses discussed tobacco issues for an average of 12.0 min. Almost all participants recalled the home visit; nearly two thirds recalled discussing tobacco use. Only 4% reported negative feelings toward discussing tobacco issues. In 87% of home visits, nurses implemented all 5 intervention components with self-reported nonsmokers. The conclusion is as follows: A nurse-delivered smoking relapse prevention intervention for new mothers was feasible and acceptable.

Precepting genital exams: challenges in implementing a complex educational intervention in the continuity clinic.

BACKGROUND: The female genital exam is often omitted from the routine physical. This limits familiarity with normal findings and represents a missed opportunity to evaluate girls for urogenital abnormalities. Continuity clinic offers an opportunity to develop and test a teaching intervention to address this problem. OBJECTIVE: To describe the effect of precepted genital exams on resident confidence and comfort with the exam as well as knowledge and documentation of genital anatomy. METHODS: A controlled trial was conducted in 10 continuity clinics at Children's Hospital, Columbus, Ohio. Residents in 5 clinics reviewed genital anatomy, exam positions, and documentation examples. They were asked to complete 6 precepted exams of girls aged 1-6 years during well-child care over a 6-month period. Residents were given pre- and posttests assessing knowledge of, confidence, and comfort with the genital exam. Pre- and poststudy genital exam documentation was reviewed. RESULTS: Ninety-seven percent of the intervention group, compared to 73% of the control group, answered 4 or 5 on a 5-point scale of confidence with regard to recognizing a normal exam (5 = highest) following the intervention (P = .01). Ninety-four percent of the intervention group and 64% of the control group answered 4 or 5 with regard to how comfortable they were performing genital exams (P = .01). Knowledge scores and documentation of genital anatomy did not differ between groups. Thirty-two percent of residents had the full intervention. CONCLUSIONS: Resident confidence and comfort increase with precepting. Precepting did not improve knowledge or documentation of genital anatomy. We advocate use of this preliminary data to design and test future educational interventions.

Learning management systems: technology to measure the medical knowledge competency of the ACGME.

AIMS: We report how the learning management system (LMS) Web Course Tools (WebCT) was used to design, implement and evaluate the web-based course "Principles of Ambulatory Paediatrics", taken by paediatric residents during an ambulatory block rotation. This report also illustrates how WebCT can be used to measure the medical knowledge competency required by the Accreditation Council for Graduate Medical Education (ACGME). METHODS: Eighty paediatric residents completed a 1-month outpatient rotation between July 1, 2001 and June 30, 2002. During this rotation residents were required to complete 4 modules in asthma, otitis media, gastroenteritis and fever, respectively. Each module was evaluated using a standard questionnaire. RESULTS: Completion rates for the required modules ranged from 64-72%. Residents in all 3 years of training showed improvement between the pre- and post-test scores for each module, except for postgraduate Year 2 residents in the asthma module. Most residents somewhat agreed, agreed or strongly agreed that the module components were useful and that the experience of completing the modules would improve their ability to take care of patients. CONCLUSIONS: The LMS WebCT is an innovative and adaptable approach for designing a web-based course for primary care education in paediatrics. The LMS addresses the educational needs of both a clinical division and a residency programme. The LMS also provides an information technology infrastructure to measure the medical knowledge competency required by the ACGME.