Workflow Analysis Driven Recommendations for Integration of Electronically-Enhanced Sexually Transmitted Infection Screening Tools in Pediatric Emergency Departments.

Adolescents are disproportionately affected by sexually transmitted infections (STIs). Failure to diagnose and treat STIs in a timely manner may result in serious sequelae. Adolescents frequently access the emergency department (ED) for care. Although ED-based STI screening is acceptable to both patients and clinicians, understanding how best to implement STI screening processes into the ED clinical workflow without compromising patient safety or efficiency is critical. The objective of this study was to conduct direct observations documenting current workflow processes and tasks during patient visits at six Pediatric Emergency Care Applied Research Network (PECARN) EDs for site-specific integration of STI electronically-enhanced screening processes. Workflow observations were captured via TaskTracker, a time and motion electronic data collection application that allows researchers to categorize general work processes and record multitasking by providing a timestamp of when tasks began and ended. Workflow was captured during 118 patient visits across six PECARN EDs. The average time to initial assessment by the most senior provider was 76 min (range 59-106 min, SD = 43 min). Care teams were consistent across sites, and included attending physicians, advanced practice providers, nurses, registration clerks, technicians, and students. A timeline belt comparison was performed. Across most sites, the most promising implementation of a STI screening tool was in the patient examination room following the initial patient assessment by the nurse.

A Survey of Return Visits to the Pediatric Emergency Department: The Caretakers' Perspective.

OBJECTIVE: Approximately 5% of children return to the emergency department within 72 hours of a first evaluation. Previous literature has focused on healthcare utilization and the use of return visits as a quality metric. The goal of this study was to quantify reasons for return visits from the caretaker perspective. METHODS: Caretaker surveys were developed based on previously identified themes from focus groups. When considering reasons for return, multiple answers were allowed. Surveys were administered to a convenience sample of eligible caretakers who returned to the emergency department within 72 hours between June and August 2013. Caretakers were excluded if the return was scheduled or for an unrelated complaint. RESULTS: Of the 306 eligible caretakers, 83 (27%) participated. A majority returned because of continued (92%) or worsening symptoms (70%). More than half returned because they did not know how to help their child at home (60%), they did not understand their child's illness (59%), and/or they did not expect the persistence of symptoms (58%). Overall, caretakers felt more testing (55%), treatments (45%), medications (41%), and information (28%) should have been provided at the initial visit. Caretakers of children admitted at the second visit were significantly more dissatisfied with care at the first visit (P = 0.05). CONCLUSIONS: The most commonly reported reasons for pediatric return visits were continued symptoms and lack of illness understanding. We plan to use these data to develop targeted interventions to decrease the perceived need for return visits.

Caretakers' Perspectives on Return Pediatric Emergency Department Visits: A Qualitative Analysis of Focus Groups.

OBJECTIVES: Approximately 5% of pediatric patients return to the emergency department (ED) within 72 hours of initial evaluation. The goal of this study was to identify reasons for return visits from the caretaker perspective. METHODS: Two parent focus groups were conducted in November 2012. Parents were excluded from participation if the return visit was unrelated to the initial visit or the child was asked to return (e.g., wound check). The focus groups were audiotaped, transcribed, and analyzed using a thematic content analysis approach. RESULTS: A total of 13 parents participated. Children were 10 months to 11 years of age (median, 3.1 years). Primary symptoms and diagnoses were related to respiratory (n = 6); gastrointestinal (n = 2); dermatologic (n = 2); musculoskeletal (n = 2); and ear, nose, throat and mouth diseases (n = 1). Return visits occurred 12 to 50 hours (median, 24 hours) after the initial visit. Reasons for return visits were divided into 4 domains: (1) the caretaker's response to the initial visit (e.g., dissatisfaction with medical staff, medical care, or information provided), (2) the child's illness (e.g., continued, worsening, or concerning symptoms), (3) the nature of the ED itself (e.g., subspecialist availability, convenient hours), and (4) follow-up care (e.g., lack of appointments with primary physicians or subspecialists). CONCLUSIONS: Several of the reasons parents identify for return visits are within the locus of control of the ED, and several could be addressed by improving regional health care coordination. Surveys based on these themes will quantitate the reasons for return visits and prioritize future strategies to address the perceived need for return visits.

Burnout in pediatric residents over a 2-year period: a longitudinal study.

OBJECTIVE: Burnout is a work-related syndrome characterized by emotional exhaustion (EE), depersonalization (DP), and lack of personal accomplishment (PA). We hypothesized that the transition into an environment of high physical, intellectual, and emotional demands of the medical profession would lead to an increase in the prevalence of burnout in pediatric residents, which would remain high throughout residency. METHODS: The Maslach Burnout Inventory (MBI) was administered to pediatric residents at Lucile Packard Children's Hospital 6 times between February 2010 and February 2012. These times corresponded to the start of residency, mid-intern year, end-intern year, mid-junior year, end-junior year, and mid-senior year. RESULTS: Mean values of burnout components changed significantly between the start of residency and mid-intern year. EE increased from 15.8 to 24.5 (P < .001), DP increased from 4.5 to 9.2 (P < .001), and PA decreased from 40.2 to 38.3 (P = .04). Similarly, the prevalence of burnout increased from 17% to 46% (P = .012), or 2% to 24% (P = .002) using more restrictive criteria, between the start of residency and mid-intern year. Significant changes in mean scores or prevalence of burnout were not found between any other consecutive times throughout residency. CONCLUSIONS: This longitudinal study documented a significant increase in the components of burnout among pediatric residents between the start of residency and mid-intern year, which persisted through the PGY2 and PGY3 years. Further studies are warranted to identify correlates of resident burnout and to develop preventative strategies to reduce its occurrence.

Alternative activation in systemic juvenile idiopathic arthritis monocytes.

Systemic juvenile idiopathic arthritis (SJIA) is a chronic autoinflammatory condition. The association with macrophage activation syndrome, and the therapeutic efficacy of inhibiting monocyte-derived cytokines, has implicated these cells in SJIA pathogenesis. To characterize the activation state (classical/M1 vs. alternative/M2) of SJIA monocytes, we immunophenotyped monocytes using several approaches. Monocyte transcripts were analyzed by microarray and quantitative PCR. Surface proteins were measured at the single cell level using flow cytometry. Cytokine production was evaluated by intracellular staining and ELISA. CD14(++)CD16(-) and CD14(+)CD16(+) monocyte subsets are activated in SJIA. A mixed M1/M2 activation phenotype is apparent at the single cell level, especially during flare. Consistent with an M2 phenotype, SJIA monocytes produce IL-1ß after LPS exposure, but do not secrete it. Despite the inflammatory nature of active SJIA, circulating monocytes demonstrate significant anti-inflammatory features. The persistence of some of these phenotypes during clinically inactive disease argues that this state reflects compensated inflammation.

Effect of procedure simulation workshops on resident procedural confidence and competence.

BACKGROUND: Pediatrics residents perform a limited number of some procedures in the clinical setting and may benefit from procedure simulation workshops. OBJECTIVE: To examine (1) the number and types of procedures performed by pediatrics residents in the clinical setting, (2) the relationship between the number of procedures performed and self-reported procedural confidence and competence, and (3) the effect of a procedure simulation workshop on self-reported procedural confidence and competence. METHODS: Pediatrics residents at Lucile Packard Children's Hospital at Stanford attended a half-day procedure workshop, rotating between 6 procedure simulation stations: vascular access, airway management, bladder catheterization, chest tube placement, lumbar puncture, and umbilical lines. Residents completed a survey immediately before and after the workshop to self-assess procedural confidence and competence. RESULTS: Seventy-two residents participated in a procedure workshop. The average number of procedures performed increased significantly from intern to junior to senior year. A positive correlation was found between number of procedures performed and preworkshop confidence (P < .001, R (2)  =  0.86) and competence (P < .001, R (2)  =  0.88). For each procedure assessed, completion of the procedure simulation workshop resulted in a statistically significant (P < .001) increase in self-perceived confidence (14%-131%; average, 48%) and competence (12%-119%; average, 50%). Statistically significant (P < .05) increases remained when results for interns, juniors, and seniors were examined separately. CONCLUSION: Procedure simulation workshops improve resident self-reported procedural confidence and competence, particularly for procedures that are least performed.