Resident training in pediatric critical care transport medicine: a survey of pediatric residency programs

OBJECTIVE: The Accreditation Council for Graduate Medical Education (ACGME) Program Requirement for Pediatrics includes specific objectives that pediatric residents participate in both the pre-hospital care of acutely ill or injured patients and the stabilization and transport of patients to critical care areas. Previously, residents were often included as the physician component for many pediatric critical care transport teams. Subsequent regionalization of transport services and development of nurse-only transport teams prompted us to determine the current level of resident participation in pediatric critical care transport as well as how individual residency programs were meeting the educational objectives. METHODS: A questionnaire was mailed to each pediatric residency program listed in the 1996-1997 GME Directory. Information was obtained regarding the size of the hospital and the residency program, the presence of a pediatric critical care transport team, the number of annual transports, and transport team leader. In addition, the use of pediatric residents for transports was ascertained, as well as their specific role, training requirements, and method of evaluation. RESULTS: Data were received from 138 programs for a return rate of 65%. Eighty percent of programs offered a pediatric critical care transport service. Nurse-led teams were used for 51% of NICU and 44% of PICU transports. Of the 82 NICU and 84 PICU teams that used residents, the majority used them as team leaders (60% and 70%; respectively) with only the minority requiring that they be at the PL-3 year or greater. The training and/or certification required for resident participation in transports varied among programs, with 85% requiring completion of a NICU or PICU rotation, and 94% requiring NRP or PALS certification. Programs that did not allow resident participation provided exposure to Transport Medicine by various mechanisms, including lectures and emergency department (ED) rotations. CONCLUSION: Pediatric resident participation in critical care transport varies widely among pediatric critical care transport teams. The degree to which residents participate in the transport team would appear to have diminished in comparison to previous studies. Transport teams often use other resources, such as nurses, fellows, or attendings, to lead their transport teams. Pediatric resident exposure to and participation in Transport Medicine varies among programs, as do the methods used to prepare residents for their experience.     

The training of pediatric residents in the care of acutely ill and injured children

OBJECTIVES: To describe the current educational experience of pediatric residents in pediatric emergency care, to identify areas of variability between residency programs, and to distinguish areas in need of further improvement. DESIGN: A 63-item survey mailed to all accredited pediatric residency training program directors in the United States and Puerto Rico. SETTING AND PARTICIPANTS: Pediatric residency programs and their directors. MAIN OUTCOME MEASURES: Primary training settings, required and elective rotations related to the care of the acutely ill and injured child, supervision of care, procedural and technical training, and didactic curriculum in pediatric emergency medicine (PEM). RESULTS: One hundred fifty-three (72%) of 213 residency programs responded. One hundred nine (71%) were based at general or university hospitals, the remaining 44 (29%) were based at freestanding children's hospitals. Residents most commonly saw patients in pediatric emergency departments (54%), followed by acute care clinics (21%), general emergency departments (21%), and urgent care clinics (5%). The mean number of weeks of PEM training required was 11, but varied widely from 0 to 36 weeks. Forty programs (27%) required their residents to spend 4 or fewer weeks rotating in an emergency department setting. The best predictor of the number of weeks spent in emergency medicine was residency program size, with small programs requiring fewer weeks (7 weeks for small [1-8 postgraduate year 1 residents] vs 13 for medium [9-17 postgraduate year 1 residents] vs 15 for large [> or =18 postgraduate year 1 residents]). Pediatric surgery (18%), orthopedic (8%), anesthesia (6%), and toxicology (4%) rotations were rarely required. Ninety-two percent of the programs had 24-hour on-site attending physician coverage of the emergency department. Supervising physicians varied widely in their training and included PEM attendings and fellows, general emergency medicine attendings, and general pediatric attendings. Small programs were less likely to have PEM coverage (57% at small vs 95% at large) and more likely to have general emergency medicine coverage (79% at small vs 29% at large). Reported opportunities to perform procedures were uniformly high and did not differ by program size or affiliated fellowship. Residency program directors were uniformly confident in their residents' training in medical resuscitation, critical care, emergency care, airway management, and minor trauma. Thirty-seven percent of all respondents were not confident in their residents' training in major trauma. Most programs reported that they had a didactic PEM curriculum (77%), although the number of hours devoted to the lectures varied substantially. CONCLUSIONS: Wide variability exists in the amount of time devoted to emergency medicine within pediatric residency training curricula and in the training background of attendings used to supervise patient care and resident education. Nevertheless, pediatric residency training programs directors feel confident in their residents training in most topics related to PEM. Residents' training in major trauma resuscitation was the most frequently cited deficiency.     

An innovative curriculum for primary care neonatology

This article describes the design of an innovative curriculum for pediatric residency newborn nursery rotation. In 1989, the Accreditation Committee for Graduate Medical Education added the requirement of newborn care to pediatric residency training; in 1996, the Accreditation Committee for Graduate Medical Education expanded that requirement. Specifically, certification required 4 weeks of newborn care, separate from any neonatal intensive care experience, and with at least 2 weeks in a newborn nursery. In response, we designed a structured newborn nursery curriculum for our pediatric residency training program. Three areas of focus were identified, from which the content and the strategies for teaching were derived. The areas of focus were (1). primary care, (2). confluence of levels of care that arise in newborn care, and (3). limitations and advantages of the structure and the environment of the rotation. The curriculum was implemented on a pediatric level 1 (PL-1) rotation entitled "primary care neonatology."     

International electives at the university of Minnesota global pediatric residency program: opportunities for education in all Accreditation Council for Graduate Medical Education competencies

PurposeGlobally competent pediatricians are in demand because of the increasing numbers of children from immigrant families living in the United States and the shortages of health care workers in low-income countries where the majority of the worlds' children live. This study sought to better understand the educational outcomes of international electives taken by pediatric residents training in global health.MethodsThirty-two pediatric residents who participated in an international elective as part of a global health curriculum completed reflective essays which were analyzed for themes from 2006 to 2010. During the first-order analysis, the emergent themes mapped to the Accreditation Council for Graduate Medical Education (ACGME) competencies. In response, a second-order analysis re-examined the essays with an additional researcher to support categorization consistent with the ACGME competencies.ResultsMore than 90% of essays described experiences related to medical knowledge, patient care and systems-based practice. More than 50% included reflections on practice-based learning and improvement, professionalism, and interpersonal and communication skills. Residents also described the impact on their personal and professional development.ConclusionInternational electives can provide educational opportunities for residents to develop competency in each of the 6 ACGME domains and to reevaluate their life purpose and career goals. In addition to opportunities to increase their medical knowledge, patient care and communication skills, residents find international electives rich learning environments for systems-based practice, practice-based learning/improvement, and professionalism, domains that can be challenging to teach. These findings support the importance of international electives in global health in meeting core requirements in residency training.     

How are pediatric training programs preparing residents for practice?

The majority of pediatric residents continue to choose a career in practice on completion of their training. Despite knowing residents' career preferences, many training programs have focused on inpatient tertiary care at the expense of primary care. Perhaps this reflects service needs and the significant technology and extensive information resulting in the growth of pediatric subspecialties. To determine the spectrum of didactic and clinical experiences pediatric training programs offer residents to prepare them for managing a practice, we conducted a survey of pediatric training program directors in 1988. Although the majority of residency programs have a practice management curriculum, the number of hours devoted to this area is minimal. In addition, a significant number of residents are not experiencing a community office rotation. This survey indicates the need to develop a practice management curriculum if trainees are to be prepared for choosing the right career and for being competitive in practice.     

Not Throwing Away My Shot: Leveraging a Peer Vaccination Workshop to Increase Residents’ Immunization Skills

ObjectiveThe Accreditation Council for Graduate Medical Education (ACGME) requires that pediatric residents demonstrate competence administering immunizations. Despite mandatory simulation training, less than half our residents reported immunization competence. All residents need to receive their influenza vaccination, but schedule restrictions present logistical challenges. We implemented a peer influenza immunization workshop and assessed the impact on resident immunization competence compared to simulation-only training.MethodsProspective cohort study at a pediatric residency program in a tertiary academic center. We implemented an annual influenza immunization workshop including immunization education, simulated practice, and peer influenza immunization. We compared workshop participation to simulation-only training on resident confidence immunizing, number of immunizations logged, and ACGME survey results for immunization skills.ResultsIn 2019, 80% (N = 59) of residents participated in the workshop. Participants were more likely to report confidence in immunization skills than nonparticipants (P = .001). Resident-administered immunizations increased from 1 in the 3 years preceding workshop implementation to 74 during the 2019 to 2020 academic year. Significantly, more ACGME survey respondents reported preparedness to immunize after workshop implementation (P = .02).ConclusionsImplementation of an influenza immunization workshop provides an innovative opportunity to increase resident preparedness performing an ACGME-required procedure while also helping ensure programs remain compliant with influenza requirements.     

Changes in pediatric residents' perceptions of their continuity experience during their training: a national study.

OBJECTIVE: To determine how pediatric residents' perceptions of continuity clinic experiences vary by level of training, after controlling for the effect of continuity setting. METHOD: Cross-sectional survey of pediatric and combined pediatric trainees in US residency programs. RESULTS: Survey responses were received from 1355 residents in 36 training programs. Residents' continuity experiences were in hospital-based and community settings. Numbers of patients seen increased between PGY-1 and PGY-3 years, but not in the PGY-4 and PGY-5 years. Compared to PGY-1 residents, PGY-2 and PGY-3 residents were more likely to report more encounters with established patients, but were not more likely to feel like the primary care provider. There were no significant differences by training level in terms of involvement in panel patients' laboratory results, hospitalizations, or telephone calls, although nursery involvement decreased with increasing training level. Autonomy was directly related to training level. The perception of having the appropriate amount of exposure to practice management issues was low for all respondents. CONCLUSIONS: Residents perceived that they had greater autonomy and continuity with patients as they become more senior, yet they were not more likely to feel like the primary care provider. Lack of increased involvement in key patient care and office responsibilities across training years may reflect a need for changes in resident education. These data may be helpful in formulating recommendations to program directors with regard to determining which Accreditation Council for Graduate Medical Education competencies should be emphasized and evaluated in the continuity experience.     

Death and the pediatric house officer revisited

Thirty-six third-year pediatric residents at four Western university training programs were interviewed individually and retrospectively about the magnitude of their clinical experience in managing the treatment of chronically ill and dying children, as well as the psychosocial educational curriculum of their training program as it pertained to these experiences. The residents managed an average of 35 dying children during their first 2 1/2 years of pediatric residency. They imparted the news of a potentially fatal disease to an average of 33 families during this same time span. There was a disparity between the magnitude of the clinical experience and the time and emphasis on these issues in the residency curriculum. The implications of these findings for an improved educational curriculum in the psychosocial care of dying children are discussed.     

人工智能快速全基因组自动分析系统在新生儿/儿童重症监护室的应用

新生儿重症监护室及儿童重症监护室患儿是遗传性疾病的高发人群,对遗传性疾病早期快速的病因诊断并针对性给予干预措施可以降低患儿病死率或不同程度改善预后.全基因组测序(whole exome sequencing,WGS)因涵盖点突变、拷贝数、内含子区域的各种结构及重组变异等更为全面的信息,已成为遗传性疾病有力的诊断工具之一...     

A nationwide survey of behavioral pediatric residency training

This survey assessed the prevalence of behavioral pediatric residency training in the U.S., the professional background of faculty, training methods utilized, curriculum content, and barriers to expansion of behavioral training. Questionnaires were returned by 60% of 246 accredited pediatric residency programs; of these, 49% had a "formal" behavioral training program, 38% offered some training, and 13% offered none. Formal programs identified 419 faculty members involved in teaching behavioral pediatrics to residents: physicians (48%), psychologists (21%), social workers (19%), nurses (8%), other (4%). Mandatory training was more frequent than elective training; continuous training was more likely than block rotations to be mandatory. "Inadequate funding" and "lack of appropriately trained faculty" were most frequently cited as barriers to expansion of the teaching of behavioral pediatrics.     

数字视频脑电图在儿科重症监护室的应用

儿科重症监护室(NICU、PICU)的患儿常存在各种原因导致脑损伤,数字视频脑电图检查可为病因诊断、病情变化监测、评估、预后等提供帮助,现将数字视频脑电图在 NICU 和 PICU 中常见疾病中的应用进行综述。     

Using a Modified Delphi Methodology to Identify Essential Telemedicine Skills for Pediatric Residents

ObjectiveTelemedicine use in pediatrics increased during the coronavirus disease-2019 (COVID-19) pandemic. Despite rapid uptake by pediatric residency programs, consensus on essential telemedicine skills for pediatric residents is lacking. We used a modified Delphi methodology to identify essential telemedicine skills and behaviors for pediatric residents.MethodsA focused literature search was performed to identify items for review by pediatric telemedicine experts. A modified Delphi methodology consisting of iterative rounds of anonymous surveys was conducted until consensus for each item was reached. Consensus was defined as >80% of experts identifying a topic as “very important.” All items were mapped to one of the Accreditation Council for Graduate Medical Education (ACGME) core competencies.ResultsSeventeen pediatric telemedicine skills and behaviors achieved a consensus of “very important.” Most items mapped to the ACGME core competency domains of interpersonal and communication skills and professionalism.ConclusionsThere was a high degree of agreement among pediatric telemedicine experts on the importance of 17 telemedicine skills and behaviors for pediatric trainees. These skills can inform pediatric telemedicine curricula and provide validity evidence for pediatric telemedicine assessment tools.     

Barriers to pediatric injury prevention counseling

OBJECTIVES: Physicians cite numerous barriers to incorporating injury prevention counseling into routine care. Health behavior models suggest that beliefs about barriers are associated with physician characteristics. This study explores associations between physician characteristics and physician perceptions of barriers. METHODS: Self administered structured questionnaires were sent to all five North Carolina (United States) pediatric residency programs. A total of 160 (72%) physicians training in pediatrics or medicine-pediatrics in these programs replied. Associations between perceived barriers and knowledge, gender, training, experience, and correlation between perceived barriers and other physician beliefs about injury prevention counseling, were measured. RESULTS: Although most residents believed that talking to parents about injury prevention during routine visits was important, they felt they lacked time, did not think to ask parents about injury prevention, or had more important things to do. The more importance residents placed on asking parents about hazards, the less the extent to which barriers were perceived (r = 0.32). Barriers were perceived to a greater extent by residents who thought their preceptors did not expect them to counsel about injury prevention (r = 0.28), lacked confidence that their counseling helped parents (r = 0.32), or felt uncomfortable counseling parents about injury prevention (r = 0.18). Knowledge, residency year, training, and previous experience with injury were not related to perceived barriers. CONCLUSIONS: Residency programs should teach the importance of injury prevention; provide opportunities for residents to become comfortable talking with parents about this; and train residents in the appropriate use of counseling as one strategy for addressing injury prevention.     

Sedation, analgesia, and neuromuscular blockade in the pediatric intensive care unit: survey of fellowship training programs.

OBJECTIVE: To survey current sedation, analgesia, and neuromuscular blockade practices in pediatric critical care fellowship training programs in the United States. DESIGN: Questionnaire survey sent by all program directors. The survey could be submitted either via a Web site, fax, or mail. SETTING: University school of medicine. SUBJECTS: Fifty-nine pediatric critical care fellowship training program directors in the United States, listed on the Accreditation Council for Graduate Medical Education Web site. INTERVENTIONS: Survey. MEASUREMENTS AND MAIN RESULTS: The response rate was 59.3% (35 questionnaires). Midazolam, lorazepam, morphine, and fentanyl are the most frequently used drugs in pediatric intensive care units for analgesia and sedation. Most pediatric intensive care units surveyed have a written sedation policy (66%). The majority of units responding to the survey (85.7%) routinely use a scoring system to assess agitation and pain in children, with the most common being the COMFORT score. All of the pediatric intensive care units surveyed reported weaning drugs slowly to try to prevent drug withdrawal. Movement disorders related to prolonged sedation and analgesia seem to be more common than is reported in the literature, with 65.7% of units reporting cases. There is good consensus on the indications for neuromuscular blockade, with vecuronium being the most popular drug. CONCLUSIONS: When compared with a similar survey from 1989, this survey suggests that pediatric critical care units with fellowship training programs have made some changes in their approach to sedation and analgesia over the past decade. More fellowship directors report the use of sedation protocols and better recognition, prevention, and management of drug withdrawal. Similar analgesic, sedative, and neuromuscular blocking drugs are being used but some more commonly than a decade ago.     

PICU患儿的睡眠障碍

睡眠障碍在PICU患儿中普遍存在,多种因素可使重症患儿出现睡眠障碍,对疾病恢复、远期预后均可能产生影响。目前对危重患儿睡眠障碍尚缺乏系统的研究,PICU中可用的睡眠评估工具有限,多元化促进睡眠管理方案可能对改善睡眠有效。     

Growth, development, and failure to thrive: factors that underlie the availability of pediatric critical care facilities in the United States.

OBJECTIVE: Pediatric intensive care units (PICUs) have grown in number and size over time in aggregate across the United States, but the factors promoting such changes have not been well characterized. This study was conducted to explore the establishment, expansion, and closure of PICUs. DESIGN: A cross-sectional in-depth telephone interview survey of executive hospital administrators. SETTING: Fourteen institutions representing four newly established PICUs, two PICU expansions, and eight PICU closures. MEASUREMENTS AND MAIN RESULTS: Officials' comments indicate that the establishment of PICUs is driven primarily by the need to care for patients requiring intensive cardiorespiratory monitoring and/or postoperative surgical care and to respond to the needs of outlying community hospitals. The main factors that drive PICU expansion are institutional growth in pediatric subspecialist medical and surgical support for critically ill patients and the need to match increases in demand and patient volume experienced by existing PICUs. With regard to PICU closures, competition from other institutions within the same market for patients and subspecialty care providers, lower-than-expected volumes of patients, and/or negative financial margins were cited as key factors. CONCLUSIONS: This study provides new insight into decision-making that influences the availability of critical care services for children. The establishment, expansion, and closure of PICUs are driven predominantly by local demand for pediatric critical care services, whereas availability of subspecialists as well as competition between PICUs within the same market affect the long-term sustainability of such services.     

Assessing pediatric senior residents' training in resuscitation: fund of knowledge, technical skills, and perception of confidence

OBJECTIVE: To describe pediatric housestaff knowledge, experience, confidence in pediatric resuscitations and their ability to perform important resuscitation procedures during the usual training experience. DESIGN AND PARTICIPANTS: Cohort study of PGY-3 level residents in a ACGME accredited pediatric residency training program at a large, tertiary care children's hospital. METHODS: Fund of knowledge was assessed by administering the standardized test from the Pediatric Advanced Life Support (PALS) Course in addition to a supplemental short answer test requiring clinical problem-solving skills. Procedural skills were evaluated through observation of the resident performing four procedures during a skills workshop using a weighted step-wise grading sheet. Resident experience and confidence was quantified using an anonymous survey. RESULTS: Ninety-seven percent of residents participated. Residents achieved high scores on the standardized PALS test (93.2%+/-5.5), but performed less well when answering more complicated questions (60.0%+/-9.9) on the short answer test. No resident was able to successfully perform both basic and advanced airway skills, and only 11% successfully completed both vascular skills. Although residents were overall confident in their resuscitation skills, performance in the skill workshop revealed significant deficits. For example, only 18% performed ancillary airway maneuvers properly. None of the residents performed all four skills correctly. Experience in both real and mock resuscitations was infrequent. Residents reported receiving feedback on their performance less than half of the time. Over 89% of them felt that resuscitation knowledge and skill were important for their future chosen career. CONCLUSION: Pediatric residents infrequently lead or participate in real or mock resuscitations. Although confident in performing many of the necessary resuscitation skills, few residents performed critical components of these skills correctly. Current pediatric residency training may not provide sufficient experience to develop adequate skills, fund of knowledge, or confidence needed for resuscitation.     

Breastfeeding education and support services offered to pediatric residents in the US

ObjectiveThe American Academy of Pediatrics (AAP) encourages pediatricians to support the practice of breastfeeding and residency educators to develop formal curricula in breastfeeding education. Few studies, however, describe breastfeeding education or support services currently provided to pediatric residents in the United States. The goals of this study were to investigate breastfeeding training offered during 3-year pediatric residency programs and to describe residency programs’ policies and services for residents who breastfeed.MethodsWe conducted a cross-sectional study using a Web-based survey of pediatric program directors regarding breastfeeding education and support services for residents.ResultsSeventy percent of program directors (132 of 189) completed the survey, with 77.3% of respondents (n = 102) estimating the amount of breastfeeding education offered to their pediatric residents. Residents are provided with a median total of 9.0 hours of breastfeeding training over 3 years, primarily in continuity clinic and in lectures and rounds with attendings. At the programs’ primary teaching hospitals, breastfeeding residents are provided breastfeeding rooms (67.0%), breast pumps (75.3%), and breast milk storage facilities (87.6%). Only 10 programs reported having an official policy to accommodate breastfeeding residents.ConclusionsPediatric residents receive approximately 3 hours of breastfeeding training per year. In addition, there is less than universal implementation by residency programs of AAP recommendations for supporting breastfeeding in the workplace. Pediatric residency programs should find ways to improve and assess the quality of breastfeeding education and workplace support to better role model this advocacy standard.