Analysis of education and previous nursing experience of certified PNPs in the United States.

BACKGROUND: Educational programs to prepare nurse practitioners (NPs) were historically built upon foundational nursing experience. Originally prepared as certificate programs in 1965, the educational requirements for nurse practitioners (NPs) rapidly shifted from certificate programs to the Master's degree (DellaBella, 2015; Fairman, 2008). As Doctor of Nursing Practice (DNP) degree programs increase in number, it is unknown whether this foundational nursing experience has changed, or if it differs by certification type for pediatric nurse practitioners (PNPs). This study aimed to evaluate the educational preparation and prior nursing experience of primary care and acute care certified PNPs. METHODS: A national survey of members of the Pediatric Nurse Practitioner Certification Board (N = 17,530) was completed (Mudd et al., 2022). A sub-analysis of this data was conducted (n = 1974). RESULTS: There was no statistical evidence among either primary or acute care PNPs of an association between previous nursing experience and type of degree preparation (Master's or DNP). There was only a weak association between educational preparation and experience among acute care nurse practitioners. Most respondents were prepared at the Master's level, and 85% of all respondents had >1 year of nursing experience prior to returning for additional PNP education. DISCUSSION: This study adds to the literature as it describes the educational preparation and foundational nursing experience of primary and acute care PNPs. It can serve as a benchmark as the move to the DNP continues for Advanced Practice Registered Nurse preparation.

Utilizing Telepresence Robots for Multiple Patient Scenarios in an Online Nurse Practitioner Program.

Simulation has been utilized widely in nurse practitioner programs for competency development and training. With the growing number of online educational programs, innovative solutions need to be developed to assess student competency for a variety of clinical situations and scenarios. An innovative method is the implementation of telepresence robots for multiple patient scenarios in a simulated environment. This article demonstrates the use of multiple patient scenarios using telepresence robots in an online post master's acute care pediatric nurse practitioner program.

A Multi-Institutional Simulation Boot Camp for Pediatric Cardiac Critical Care Nurse Practitioners.

OBJECTIVES: Assess the effect of a simulation "boot camp" on the ability of pediatric nurse practitioners to identify and treat a low cardiac output state in postoperative patients with congenital heart disease. Additionally, assess the pediatric nurse practitioners' confidence and satisfaction with simulation training. DESIGN: Prospective pre/post interventional pilot study. SETTING: University simulation center. SUBJECTS: Thirty acute care pediatric nurse practitioners from 13 academic medical centers in North America. INTERVENTIONS: We conducted an expert opinion survey to guide curriculum development. The curriculum included didactic sessions, case studies, and high-fidelity simulation, based on high-complexity cases, congenital heart disease benchmark procedures, and a mix of lesion-specific postoperative complications. To cover multiple, high-complexity cases, we implemented Rapid Cycle Deliberate Practice method of teaching for selected simulation scenarios using an expert driven checklist. MEASUREMENTS AND MAIN RESULTS: Knowledge was assessed with a pre-/posttest format (maximum score, 100%). A paired-sample t test showed a statistically significant increase in the posttest scores (mean [SD], pre test, 36.8% [14.3%] vs post test, 56.0% [15.8%]; p < 0.001). Time to recognize and treat an acute deterioration was evaluated through the use of selected high-fidelity simulation. Median time improved overall "time to task" across these scenarios. There was a significant increase in the proportion of clinically time-sensitive tasks completed within 5 minutes (pre, 60% [30/50] vs post, 86% [43/50]; p = 0.003] Confidence and satisfaction were evaluated with a validated tool ("Student Satisfaction and Self-Confidence in Learning"). Using a five-point Likert scale, the participants reported a high level of satisfaction (4.7 ± 0.30) and performance confidence (4.8 ± 0.31) with the simulation experience. CONCLUSIONS: Although simulation boot camps have been used effectively for training physicians and educating critical care providers, this was a novel approach to educating pediatric nurse practitioners from multiple academic centers. The course improved overall knowledge, and the pediatric nurse practitioners reported satisfaction and confidence in the simulation experience.

Factors associated with poor controller medication use in children with high asthma emergency department use.

BACKGROUND: Understanding health and social factors associated with controller medication use in children with high-risk asthma may inform disease management in the home and community. OBJECTIVE: To examine health and social factors associated with the Asthma Medication Ratio (AMR), a measure of guideline-based care and controller medication use, in children with persistent asthma and frequent emergency department (ED) use. METHODS: Study questionnaires, serum allergen sensitization, salivary cotinine, and pharmacy record data were collected for 222 children enrolled from August 2013 to February 2016 in a randomized clinical trial that tested the efficacy of an ED- and home-based intervention. Logistic regression was used to examine factors associated with an AMR greater than 0.50, reflecting appropriate controller medication use. RESULTS: Most children were male (64%), African American (93%), Medicaid insured (93%), and classified as having uncontrolled asthma (44%). Almost half (48%) received non-guideline-based care or low controller medication use based on an AMR less than 0.50. The final regression model predicting an AMR greater than 0.50 indicated that children receiving specialty care (odds ratio [OR], 4.87; 95% confidence interval [CI], 2.06-11.50), caregivers reporting minimal worry about medication adverse effects (OR, 0.50; 95% CI, 0.25-1.00), positive sensitization to ragweed allergen (OR, 3.82; 95% CI, 1.63-8.96), and negative specific IgE for dust mite (OR, 0.33; 95% CI, 0.15-0.76) were significantly associated with achieving an AMR greater than 0.50. CONCLUSION: Clinical decision making for high-risk children with asthma may be enhanced by identification of sensitization to environmental allergens, ascertaining caregiver's concerns about controller medication adverse effects and increased referral to specialty care. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01981564.

Caregiver perception of asthma management of children in the context of poverty.

OBJECTIVE: Low-income caregivers of young children with high-risk asthma experience social stressors and illness-related demands that may impede effective home asthma management. Knowledge of the caregiving experience in the context of poverty is limited. METHODS: Convenience sampling methods were used to recruit low-income caregivers of children aged 7-12 years, who are frequently in the Emergency Room (ED) for uncontrolled asthma. Thirteen caregivers participated in focus groups that were designed to elicit reflections on asthma home and community management from the caregiver perspective. A grounded theory approach was used in the open coding of transcript data from three focus groups, as well as to revise and reorganize emerging themes and sub-themes. RESULTS: Participants (Mean age = 33.9 years) were predominantly the biological mother (92.3%), single (84.6%), and impoverished (69.2% reported annual household income ≤ $30,000). Their children (Mean age = 7.8 years) were African-American (100%), enrolled in Medicaid (92.3%), averaged 1.38 (SD = 0.7) ED visits over the prior 3 months, resided in homes with at least one smoker (61.5%), and nearly all (84.6%) experienced activity limitations due to asthma. Five themes emerged in the analysis: intensive caregiving role, complex and shared asthma management responsibility, parental beliefs and structural barriers to guideline-based care, lack of control over environmental triggers, and parent advocacy to improve child asthma care and outcomes. CONCLUSIONS: Caregivers managing a child with high-risk asthma in the context of poverty indicate the need for ongoing asthma education, increased sensitivity to the complexity of home asthma management, and family-centered interventions that enhance communication and collaboration between caregivers and providers.

Evaluation of a Nurse-Initiated Acute Gastroenteritis Pathway in the Pediatric Emergency Department.

PROBLEM: Acute gastroenteritis (AGE) is a common illness treated in the emergency department. Delays in initiating rehydration for children with mild or moderate dehydration from AGE can lead to prolonged ED visits and increased resource utilization that do not provide prognostic value or support family-centered care. The purpose of this quality improvement project was to promote early oral rehydration therapy (ORT) for persons with AGE in an attempt to reduce unnecessary resource utilization and length of stay (LOS). METHODS: This prospective quality improvement project used a nurse-initiated waiting room ORT pathway for patients 6 months to 21 years of age who presented to the emergency department with diarrhea with or without vomiting. Outcomes related to nurse-initiated ORT, intravenous fluid use, laboratory studies or diagnostic imaging, and LOS were measured before and after implementation. RESULTS: Of 643 patients for whom the pathway was initiated, 392 received nurse-initiated care. The proportion of intravenous fluid use was 10.2% lower (odds ratio [OR], 0.43; 95% confidence interval [CI], 0.27-0.68) and laboratory test ordering was 7.4% lower (OR, 0.64; 95% CI, 0.43-0.94) in patients receiving nurse-initiated care. Time to discharge after provider examination was 46 minutes faster in the nurse-initiated care group (P < .001), resulting in an overall LOS reduction by 40 minutes (P < .001). IMPLICATIONS FOR PRACTICE: Nurse autonomy in using an AGE pathway facilitates evidence-based practice, improves ED efficiency, and decreases resource utilization and LOS. Future research should focus on family satisfaction and ED revisits within 72 hours of discharge.

Parental decision making associated with pediatric emergency department use for asthma.

BACKGROUND: Disadvantaged minority children are disproportionately affected by asthma. This group is also known to frequently use the emergency department (ED) for asthma care. Understanding decisions for use of the ED is important to prevent high cost. OBJECTIVE: To examine caregiver factors associated with the decision to use the ED for asthma care in inner-city children with asthma. METHODS: One hundred fifty participants in a randomized clinical trial testing the effectiveness of a home-based asthma intervention were enrolled, and questionnaires were administered to caregivers during the child's ED asthma visit. Sociodemographics, health characteristic data, and caregiver interview data were examined to ascertain factors that affected caregiver decision making to use the ED for asthma care. A cluster analysis was performed to correlate caregiver reasons for the decision to use the ED for asthma care. RESULTS: Three clusters emerged for decision making: urgency, preference for the use of the ED, and access to care issues. The perception of urgency was the most common reason reported by caregivers (91%) followed by reporting a preference for the ED for care (37%) and reporting access to care issues (31%). Access to care was primarily attributable to the inability to get a same-day appointment with their primary care practitioner (24%). CONCLUSION: The caregiver factors involved in the decision to use the ED can provide a basis for further intervention and investigation. Such factors include caregiver asthma home management, improvement in relationships with primary care practitioners, and access to care-related issues.

Evaluating the Practice of Pediatric Nurse Practitioners: Is It Time for Dual Primary and Acute Care Preparation?

This survey aimed to evaluate contemporary pediatric nurse practitioner (PNP) practice as it relates to the competencies of both the primary and acute care population focus and settings of practice to guide curriculum revisions. The design of the study was a cross-sectional survey of PNPs certified by the Pediatric Nursing Certification Board. There were 2,265 surveys completed. Regardless of the certification type, PNPs report providing care across settings and integrating the competencies of both the primary and acute care PNP into practice. This warrants further consideration by programs to prepare future PNPs for dual primary and acute care certification.

Sleep disturbance and psychological distress among hospitalized children in India: Parental perceptions on pediatric inpatient experiences.

PURPOSE: Investigate parental perceptions of children's sleep disturbance and psychological distress associated with an inpatient stay in a low-resource hospital setting. DESIGN AND METHODS: Demographic and validated survey instruments were adapted for administration to parents of children in the medical wards of a tertiary hospital in India. Parents proficient in English, Hindi, Tamil, or Telugu with a child age 4-12 years admitted for at least 48 h were eligible to participate. All respondents completed the Factors Affecting Sleep Disturbance Scale, Sleep Duration Questionnaire, Sleep Disturbance Scale, and Kessler Psychological Distress Scale. Data analysis entailed descriptive statistics, correlations, and multivariate regressions to analyze relationships across responses on demographics, sleep disturbance, and psychological distress. RESULTS: Among 105 parents with hospitalized children, most had children 4-6 years old (54%), including 65% boys and 35% girls. Parents reported that their children slept overnight in the hospital for a mean of 8.3 ± 1.6 h. Children 4-6 year old (relative risk ratio [RRR] = 0.63, p = .004), dyspnea (RRR = 8.73, p = .04), previous hospitalization (RRR = 9.17, p = .03), nighttime procedures (RRR = 2.97, p = .03, and missing home (RRR = 6.78, p < .001) were the factors affecting sleep. Factors affecting psychological distress was nighttime medication administration (RRR = 4.92, p = .01). Sleep disturbances correlated with psychological distress (r = 0.56; p < .01). CONCLUSION: Sleep disturbance and associated psychological distress in hospitalized children were widely reported by parents queried in this low-resource hospital setting. PRACTICAL IMPLICATIONS: Nurses can lead efforts in ameliorating sleep in hospitalized children, including partnering with stakeholders on measures to reduce sleep disruption. Child-centered interventions may improve sleep hygiene and decrease psychological distress among children.

Rapid Cycle Deliberate Practice to Facilitate "Nano" In Situ Simulation: An Interprofessional Approach to Just-in-Time Training.

BACKGROUND: Simulation is increasingly used to identify latent threats to patient safety, such as delays in recognition and management of time-sensitive conditions. The Rapid Cycle Deliberate Practice teaching method may facilitate "nano" (brief) in situ simulation training in a critical care setting to improve multidisciplinary team performance of time-sensitive clinical tasks. OBJECTIVE: To determine whether nano-in situ simulation training with Rapid Cycle Deliberate Practice can improve pediatric intensive care unit team proficiency in identifying and managing postoperative shock in a pediatric cardiac patient. METHODS: A quality improvement educational project was conducted involving nano-in situ simulation sessions in a combined pediatric and pediatric cardiac intensive care unit. The Rapid Cycle Deliberate Practice method was used with an expert-driven checklist for 30-minute simulation scenarios. RESULTS: A total of 23 critical care providers participated. The proportion of time-sensitive tasks completed within 5 minutes increased significantly from before to after training (52% [13 of 25] vs 100% [25 of 25]; P ≤ .001). Using a 5-point Likert scale, with higher scores indicating higher levels, the participants reported high degrees of performance confidence (mean, 4.42; SD, 0.20) and satisfaction with the simulation experience (mean, 4.96; SD, 0.12). CONCLUSION: The Rapid Cycle Deliberate Practice method was used to facilitate nano-in situ simulation training and identify areas requiring additional education to improve patient safety. In situ simulation can educate providers in a cost-effective and timely manner.

Urgent Care Utilization in a Pediatric Population With Private Health Insurance.

INTRODUCTION: Pediatric urgent care (UC) utilization patterns have been studied in Medicaid enrollees, but not in those with private insurance. METHODS: Utilization patterns of UC at a suburban pediatric primary care practice with patients with private health insurance were reviewed. Descriptive data were obtained. RESULTS: Three hundred twenty-five charts were reviewed. Most UC visits were for children under 6 years of age (59.7%), a diagnosis of fever (12.2%), and with low severity illness (57.8%). Seventy percent occurred during weekdays and during times when the primary care practice was open. Most children (67.4%) had a diagnostic test performed at UC and 42.2% received a prescription for antibiotics. DISCUSSION: Primary care providers should target caregiver education on low acuity conditions and consider process improvements to accommodate urgent visits. While pediatric UC benchmarks are needed, data suggests that general UCs are at risk for overprescribing antibiotics compared to national ambulatory averages.

Children with poorly controlled asthma: Randomized controlled trial of a home-based environmental control intervention.

BACKGROUND: Few trials have tested targeted environmental control (EC) interventions based on biomarkers of second hand smoke (SHS) exposure and allergen sensitization in reducing asthma emergency department (ED) visits in children with poorly controlled asthma. METHODS: Overall, 222 children with poorly controlled asthma were randomized into a home-based EC intervention (INT) or control (CON) group and followed for ED visits over 12 months. All children received allergen-specific IgE serologic testing and SHS exposure biomarker testing to inform the EC intervention. Pharmacy data was examined for asthma medication fills. Cox proportional hazards and multivariate regression models were performed to examine factors associated with repeat ED visits. RESULTS: There was no difference in increased risk of >1 ED visit at 12 months between INT and CON groups. Most children (75%) had moderate/severe persistent asthma. Over half (56%) had SHS exposure and 83% tested positive for >1 allergen sensitization. Among children without SHS exposure, the median time to first recurrent ED visit differed by group (CON: 195; INT: >365 days) after adjusting for child age, allergic sensitization, medication fills prior to baseline, controller medication use, and the interaction between group status and SHS exposure. Children who had positive allergic sensitizations, younger, had increased controller medication use and randomized to the CON group and had no SHS exposure had increased risk for a repeat ED visit over 12 months. CONCLUSIONS: In this study, a home-based EC intervention was not successful in reducing asthma ED revisits in children with poorly controlled asthma with SHS exposure. Allergic sensitization, young age, and increased controller medication use were important predictors of asthma ED visits.

Improving Care of Inner-City Children with Poorly Controlled Asthma: What Mothers Want You to Know.

INTRODUCTION: Low-income caregiver perspectives on asthma management are understudied but may illuminate strategies to improve care delivery and child outcomes. METHOD: Purposive sampling methods were used to recruit 15 caregivers of children with frequent asthma emergency department visits. Interviews explored how poverty and stress affect asthma management. Grounded theory coding techniques were used to analyze the data. RESULTS: Participants were the biological mother (100%) and were poor (75% had mean annual income ≤ $30,000). Their children (mean age = 6.9 years) were African American (100%), enrolled in Medicaid (100%), and averaged 1.5 emergency department visits over the prior 3 months. Four themes emerged: (a) Deplorable Housing Conditions, (b) Allies and Adversaries in School-Based Asthma Management, (c) Satisfaction With Asthma Health Care Delivery, and (d) Prevalent Psychological Distress. DISCUSSION: Impoverished caregivers of children with frequent asthma emergency department visits describe stress that is multifaceted, overwhelming, and difficult to eradicate. Their experiences underscore the need for improved school-based asthma management and family-centered approaches to health care delivery.

Very Poorly Controlled Asthma in Urban Minority Children: Lessons Learned.

BACKGROUND: Very poorly controlled (VPC) asthma in children is associated with ongoing acute exacerbations but factors associated with VPC are understudied. OBJECTIVE: To examine the risk factors associated with VPC asthma in urban minority children. METHODS: This descriptive study examined asthma control levels (well-controlled [WC], not well-controlled [NWC], and VPC) at baseline and 6 months in children participating in an ongoing randomized controlled trial of an emergency department/home environmental control intervention. Data collection occurred during the index emergency department visit and included allergen-specific IgE and salivary cotinine testing and caregiver interview of sociodemographic and child health characteristics. Follow-up data were collected at 6 months. Unadjusted analyses examined the association of sociodemographic and health characteristics by level of asthma control. Multivariate analysis tested significant factors associated with VPC asthma at 6 months. RESULTS: At baseline most children were categorized with VPC asthma (WC, 0%; NWC, 47%; VPC, 53%) and rates of VPC minimally improved at 6 months (WC, 13%; NWC, 41%; VPC, 46%). Risk for VPC asthma was twice as likely in children with allergic rhinitis (odds ratio [OR], 2.42), having 2 or more primary care provider asthma visits within the past 3 months (OR, 2.77), or caregiver worry about medication side effects (OR, 2.13) and 3 to 4 times more likely when asthma control was assessed during the fall or spring season (OR: fall, 3.32; spring, 4.14). CONCLUSIONS: Improving asthma control in low-income, high-risk children with VPC asthma requires treatment of comorbidities, attention to caregiver medication beliefs, and adept use of stepwise therapy.

Asthma Home Management in the Inner-City: What can the Children Teach us?

OBJECTIVE: Knowledge of asthma home management from the perspective of poor, minority children with asthma is limited. METHOD: Convenience sampling methods were used to recruit families of low-income children who are frequently in the emergency department for uncontrolled asthma. Thirteen youths participated in focus groups designed to elicit reflections on asthma home management. Data were analyzed using grounded theory coding techniques. RESULTS: Participants (Mean age = 9.2 years) were African American (100%), enrolled in Medicaid (92.3%), averaged 1.4 (standard deviation = 0.7) emergency department visits over the prior 3 months, and resided in homes with at least 1 smoker (61.5%). Two themes reflecting multifaceted challenges to the development proper of self-management emerged in the analysis. DISCUSSION: Findings reinforce the need to provide a multipronged approach to improve asthma control in this high-risk population including ongoing child and family education and self-management support, environmental control and housing resources, linkages to smoking cessation programs, and psychosocial support.

Clinical Practice Guideline for the Treatment of Pediatric Acute Gastroenteritis in the Outpatient Setting.

Acute gastroenteritis (AGE) is a common illness in childhood that usually can be treated in the outpatient setting. Inaccurate assessment or delayed treatment of AGE can lead to an increased risk for invasive interventions. A literature search was conducted using PubMed, CINAHL Plus, the Cochrane Library, and Embase. Results of the query were refined to narrow the focus of relevant studies for the provider caring for dehydrated children in the outpatient setting. Use of clinical dehydration scales to assess the level of dehydration and early initiation of oral rehydration therapy promote optimal patient outcomes. Oral rehydration therapy remains the best means of rehydrating, and ondansetron is a safe and effective adjunct to help children with persistent vomiting. The purpose of this practice guideline is to identify best practices for AGE in children older than 6 months with symptoms for less than 7 days who are being cared for in the outpatient setting.

The cutaneous manifestations and common mimickers of physical child abuse.

The cutaneous manifestations of physical child abuse are some of the most common and easily recognized forms of injury. To make an accurate assessment and diagnosis, it is important to differentiate between inflicted cutaneous injuries and mimickers of physical abuse. Likewise, an understanding of reporting guidelines helps guide practitioners in their decision making.