Comparison of neonatal nurse practitioners' and pediatric residents' care of extremely low-birth-weight infants

OBJECTIVE: To compare outcomes and charges of health care delivery to extremely low-birth-weight infants by neonatal nurse practitioners (NNP) and pediatric residents. DESIGN: Retrospective cohort study. SETTING: A 56-bed neonatal intensive care unit (NICU) in a university teaching hospital. METHODS: Study population included all infants with birth weights less than 1000 g who were admitted to the NICU during the 2-year period between September 1, 1994, and August 31, 1996. Infants who died earlier than 12 hours of age, or who were admitted after 1 week of age or with major malformations, chromosomal abnormalities, or congenital infections were excluded. There were separate teams of NNPs and residents providing care around the clock. The study group included 201 infants with birth weights of less than 1000 g. The NNP team cared for 94 infants and the resident team cared for 107 infants. MAIN OUTCOME MEASURES: Survival, length of stay, and total charges. RESULTS: Survival to discharge occurred for 71 NNP team infants (76%) and 82 resident team infants (77%) (P =.87). The median total length of stay was 87 days (range, 39-230 days) for NNP team infants and 88 days (range, 41-365 days) for resident team infants (P =.54). There were no significant differences between NNP infants and resident team infants in the prevalence of severe intracranial hemorrhage, threshold retinopathy of prematurity, or chronic lung disease at 36 weeks postconceptual age. Median total NICU hospital charges were $141,624 (range, $52,020-$693,018) for NNP team infants and $139,388 (range, $50,178-$990,865) for resident team infants (P =.89). There were no significant differences between NNP team infants and resident team infants in NICU charges for laboratory, radiology, or pharmacy services. CONCLUSION: Neonatal nurse practitioners and pediatric residents provided comparable patient care to extremely low-birth-weight infants, with similar outcomes and similar charges.     

Intraosseous access in the setting of pediatric critical care transport.

OBJECTIVE: To demonstrate safety and efficacy of intraosseous needle placement among health care provider groups in the setting of pediatric critical care transport. DESIGN: Retrospective chart review. SETTING: Pediatric critical care transports to a pediatric intensive care unit. PATIENTS: Children undergoing pediatric critical care transport between January 1, 2000, and March 31, 2002, requiring intraosseous access before arrival to the pediatric intensive care unit. INTERVENTIONS: Intraosseous access placed for emergent vascular access. MEASUREMENTS AND MAIN RESULTS: During the study period, the transport team performed 1,792 transports and identified 47 patients requiring 58 intraosseous placements. These were placed by emergency medical technician-paramedics (18%), referring emergency medicine physicians (42%), and the transport team members (40%). The intraosseous needles were placed with a mean of 1.2 attempts per placement and a first attempt success rate of 78%. Main site of placement was the proximal anterior tibia (95%). Access was maintained for a mean of 5.2 hrs. The intraosseous needle was used for fluids, medications, and laboratory studies. Admitting diagnoses included respiratory distress (28%), cardiopulmonary arrest (26%), neurologic insults (17%), dehydration (15%), sepsis (11%), and other (3%). Ages ranged from 3 wks to 14 yrs (mean 2.2 yrs) and weights from 2.1 to 60 kg (mean 12.3 kg). Complications were noted in seven of 58 (12%), all limited to local edema or infiltration. CONCLUSIONS: Intraosseous placement is frequently needed in the care of critically ill pediatric patients before they reach the pediatric intensive care unit. We have demonstrated that intraosseous needles can be placed safely with similar rates of success when comparing different provider groups. Emergency medical technician-paramedics, emergency medicine physicians, and pediatric critical care transport teams should be familiar with intraosseous placement.     

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.     

Pediatric critical care transport survey: team composition and training, mobilization time, and mode of transportation

A survey was conducted to determine the current standard of care with regard to team composition and training, mobilization time, and vehicle use for pediatric critical care transport. An evaluation of 30 pediatric referral centers revealed that 60% provide a critical care transport team. Of those teams, the mean number of transports per year was 304. Response time ranged from 10 to 90 minutes. All teams included a physician all or most of the time; 100% of teams included a critical care nurse, and 50% always included a respiratory therapist. Ambulances alone are used in 28% of systems, with the remainder using combinations of ambulances, helicopters, and fixed wing aircraft. A proposal is presented for future standards in pediatric critical care transport with regard to the factors discussed.     

Global health training in pediatric residency: a qualitative analysis of faculty director insights

ObjectiveInterest and participation in global health (GH) has been growing rapidly among pediatric residents. Residency programs are responding by establishing formal GH programs. We sought to define key insights in GH education from pediatric residency programs with formal GH tracks.MethodsSeven model pediatric residency programs with formal GH training were identified in 2007. Faculty directors representing 6 of these programs participated in expert interviews assessing 6 categories of questions about GH tracks: understanding how GH tracks establish partnerships with global sites; defining organizational and financing structure of GH tracks; describing resident curriculum and pre-trip preparation; describing clinical experiences of residents in GH tracks; defining evaluation of residents and GH tracks; and defining factors that affect development and ongoing implementation of GH tracks. Data were analyzed using qualitative methodology.ResultsAll programs relied on faculty relationships to establish dynamic partnerships with global sites. All programs acknowledged resident burden on GH partners. Strategies to alleviate burden included improving resident supervision and providing varying models of GH curricula and pre-trip preparation, generally based on core residency training competencies. Support and funding for GH programs are minimal and variable. Resident experiences included volunteer patient care, teaching, and research. Commitment of experienced faculty and support from institutional leadership facilitated implementation of GH programs.ConclusionsDirectors of 6 model GH programs within pediatric residencies provided insights that inform others who want to establish successful GH partnerships and resident training that will prepare trainees to meet global child health needs.     

National trends in pediatric resident recruitment.

Primary care residency programs throughout the nation are having increasing difficulty recruiting sufficient residents. Only 65% of pediatric residency positions are filled with medical graduates from the United States. We sent a questionnaire to pediatric residency program directors throughout the country to assess what changes pediatric programs had implemented in response to matching concerns. Forty-one percent had recruited non-house officer professionals to perform resident-type work. Such professionals included osteopathic and/or foreign-trained physicians (55%) and moonlighters (49%). House staff work hours had been reduced in 35% of programs and on-call frequency in 33%. Sixty-one percent had made significant changes in their recruiting practices in the past 5 years that are described herein. Annual recruiting budgets varied from nothing to over $75,000. This survey reveals widespread reduction in resident work load and increased intensity in the recruiting process throughout the country.     

The state of pediatric interfacility transport: consensus of the second National Pediatric and Neonatal Interfacility Transport Medicine Leadership Conference

Interfacility transport of pediatric and neonatal patients for advanced or specialty medical care is an integral part of our medical delivery system. Assessment of current services and planning for the future are imperative. As part of this process, the American Academy of Pediatrics and the Section on Transport Medicine held the second National Pediatric and Neonatal Transport Leadership Conference in Chicago in June 2000. Ninety-nine total participants, representing 25 states and 5 international locations, debated and discussed issues relevant to the developing specialty of pediatric transport medicine. These topics included: 1) the role of the medical director, 2) benchmarking of neonatal and pediatric transport programs, 3) clinical research, 4) accreditation, 5) team configuration, 6) economics of transport medicine in health care delivery, 7) justification of transport teams in institutions, and 8) international transport/extracurricular transport opportunities. Insights and conclusions from this meeting of transport leaders are presented in the consensus statement.     

Training in community pediatrics: a national survey of program directors.

OBJECTIVE: To describe the spectrum of residency training in community-based settings, assess the extent of resident education on community pediatrics topics, and determine whether educational activities vary by program size or availability of primary care tracks. METHODS: Survey of US pediatric residency program directors from May-September 2002. A 10-item self-administered questionnaire assessed the programs' extent of resident involvement in 15 selected community-based settings and inclusion of didactic or practical education regarding 13 community health topics. RESULTS: Of 168 programs surveyed (81% response rate), 40% were small (< or =30 residents), 35% were medium (31-50 residents), 25% were large (>50 residents), and 15% had primary care tracks. Frequently required community-based settings included schools (69%), child protection teams (62%), day care centers (57%), and home visiting (48%). Of 15 community-based settings, 28% required involvement in fewer than 4, 41% required involvement in 4-6, and 31% required involvement in 7 or more. More than two-thirds offered didactic teaching and practical experience on issues related to managed care, cultural competency, and the mental health and social service systems. There were no differences in the number of required community-based settings by program size or presence of primary care tracks. CONCLUSIONS: Most pediatric residency programs require exposure to community-based settings and provide education on various community health topics. Ongoing challenges include continued implementation amid work duty hour limitations, best practice models for practical implementation of community-based experience into residency training, and the impact of such training on future involvement in the community and physician practice.     

Home visits by pediatric residents. A valuable educational tool.

OBJECTIVE--To establish how many pediatric residency programs offer home visits, to assess the feasibility of making home visits as part of pediatric training, and to determine whether residents perceive home visits as worthwhile learning experiences. DESIGN--A questionnaire was mailed to all medical school pediatric departments in the United States and Puerto Rico to determine the prevalence of home visits during residency training. To study the feasibility of residents making home visits, a pilot program was instituted. PARTICIPANTS--Fourteen pediatric residents participated in the study. Each resident visited a house, trailer, apartment, or shelter for the homeless that was within a 20-minute radius from the medical center. To determine the educational value of home visits, each resident wrote a one-page report immediately on his or her return to the hospital. After about 6 months, all participating residents completed a questionnaire retrospectively evaluating their home visits. SELECTION PROCEDURES--Interns who were neither on-call nor postcall the day of the visits were invited to participate. Patients were selected because they were homebound (eg, ventilator-dependent), had missed follow-up appointments, or had transportation difficulties. RESULTS--Thirteen percent of the pediatric residency programs surveyed currently include home visits. In all 14 of the pilot visits, the home was located without difficulty and the patient was at home. In each case, the family welcomed the visit. All the pediatric residents believed that the home visit was a worthwhile learning experience. CONCLUSIONS--Although very few programs (13%) currently offer home visits as part of pediatric residency training, such visits are feasible within a large urban area. Residents are enthusiastic about seeing how and where their patients live, and consider home visits a worthwhile learning experience.     

Oncology patients in a pediatric intensive care unit--a 7-year experience

BACKGROUND: As a result of improved therapeutic and diagnostic modalities the survival rate of children with neoplastic disease has increased dramatically. The consequences of these scientific advances have led to increased malignancy-related critical complications requiring the expertise of intensive care practitioners. PATIENTS: From all children admitted to the pediatric intensive care unit (PICU) of the Martin-Luther University Halle those with hematologic-oncologic condition were evaluated. RESULTS: From 4068 PICU admissions 196 (4.8%) oncologic patients were identified. Most of them were admitted for postoperative care, monitoring or intervention. 24 patients were admitted because of severe disease or treatment related complications. 14 out of 24 (58%) patients died on PICU. Mortality was significant higher in a subgroup requiring mechanical ventilation or suffering from sepsis. All patients but two with multi-organ system failure (> or = 2 organs) died. CONCLUSIONS: Children with neoplastic disease can benefit from pediatric intensive care unit (PICU) support. Successful treatment of life-threatening complications requires a close cooperation of pediatric oncology and PICU. Further studies are necessary to improve therapeutic strategies in oncology patients requiring PICU admission.     

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.     

Excess morbidity associated with interhospital transport.

A prospective study was performed to determine whether excess morbidity occurred in critically ill and injured pediatric patients during interhospital transport compared with morbidity in a control group. Control observations were made during the first 2 hours of pediatric intensive care unit (PICU) care of patients emergently admitted from within the same institution and not requiring interhospital transport. The first 2 PICU hours of control patients corresponded to the interval of transport in those who required interhospital transfer. Transport care was provided by nonspecialized teams from referring hospitals. Morbidity occurred in 20.9% of 177 transported patients, exceeding the morbidity rate of 11.3% in 195 control patients (P < .05). The difference in morbidity was due to intensive care-related adverse events (eg, plugged or dislodged endotracheal tubes, loss of intravenous access) in 15.3% and 3.6% of transported and control patients, respectively (P < .05). Physiologic deterioration occurred at similar rates of 7.9% and 8.7% in transported and control patients, respectively (P > .05). Slightly greater pre-ICU severity of illness in transported than control patients (median Pediatric Risk of Mortality Score = 10 and 7, respectively, P < .05) and greater pre-ICU therapy relative to severity (P < .05) in control patients are potential confounding sources of the morbidity differences. If patients are stratified into subgroups of similar pre-ICU severity, an excess of intensive care-related adverse events in transported patients remains evident in the severe subgroup (P < .05). Further investigation is warranted to determine whether specialized transport teams can reduce the excess morbidity associated with interhospital transport of critically ill and injured pediatric patients.     

Research exposure during pediatric residency: influence on career expectations

OBJECTIVES: To examine pediatric residents' research experiences during residency and to explore whether residents' attitudes toward research are related to their decision to pursue subspecialty fellowships. STUDY DESIGN: A national random sample of 500 PL-3 pediatric residents completing training in 2001 was surveyed. Responses were obtained from 318 residents (64%). Resident research experiences and perceived competence were compared for residents planning to pursue subspecialty training (34%) and residents who were not (66%). RESULTS: Residents interested in a subspecialty were more likely to have had formal research training (39% vs 27%) and to have assisted on a research project (26% vs 14%) during residency. Upon residency completion, residents in both groups rated their knowledge of most research skills as being fair or poor. A favorable rating toward research was the strongest predictor of whether residents have subspecialty rather than general pediatrics as their future clinical goal (OR=3.7). CONCLUSIONS: Given residents' limited research exposure and the strong association found between residents' research attitudes and their plans to pursue subspecialty training, serious consideration should be given to the possible benefits of research promotion programs, which may lead to increased resident interest in pediatric fellowships and pediatric research.     

Evidence-based medicine in pediatric residency programs: where are we now?

BACKGROUND: Evidence-based medicine (EBM) integrates the best research evidence with clinical expertise and patient values to optimize clinical outcomes for our patients. OBJECTIVE: To examine incorporation of EBM into journal club (JC) and other venues within pediatric residency programs. DESIGN/METHODS: A 30-question confidential survey was designed to determine how residents are taught and practice EBM. The survey was sent to the chief resident (CR) at all North American pediatric residency programs (N = 192). Nonrespondents were sent surveys 4 and 8 weeks later. RESULTS: The response rate was 80% (n = 153). Pediatric residency programs varied in size from 12 to 132 residents from responses in 39 states. Most programs (97%, confidence interval [CI], 92-99) used EBM. JC (89%, CI, 83-93), noontime lectures (62%, CI, 54-70), and morning report (61%, CI, 53-69) were the most common venues used to teach EBM. JC (58%, CI, 50-66), morning report (11%, CI, 6-17), and resident workshop (11%, CI, 6-17) were the most effective venues to teach EBM, although resident workshops were as effective as JC to teach EBM in programs offering workshops (38% each, CI, 21-56). Most CRs felt confident in their ability to practice EBM (56%, CI, 48-64), but few CRs felt that their program could teach EBM (7%) or evaluate EBM effectiveness (20%). CONCLUSIONS: EBM is common throughout pediatric residencies. JC was the most effective venue in which to teach EBM, unless a workshop was offered. Most CRs thought it was important to teach EBM, but did not feel confident in their program's ability to teach EBM.     

Variables predicting the need for a pediatric critical care transport team.

To determine when a pediatric critical care transport team is required to transport a patient to a referral center, this cross-sectional study evaluated 369 consecutive pediatric transports by stepwise multiple logistic regression analysis of six variables: age, vital signs, seizure activity, current endotracheal intubation, respiratory distress, and respiratory diagnosis. Models were developed for three outcome variables: 1) Major procedures were required in 8.9% of cases. The predicted probability of needing a major procedure was increased for intubated patients (probability of 12.9%), patients less than 1 year of age with unstable vital signs (12.9%), and patients meeting both these criteria (23.2%). 2) A posttransport assessment of need for a physician on the team was positive in 43% of cases. The probability of needing a physician was increased for intubated patients (probability of 68.8%), patients less than 1 year of age with unstable vital signs (58.7%), and patients meeting both these criteria (79.9%). 3) Category 1 drugs, ie, medications requiring ICU monitoring, were used in 19% of transports. The probability of this occurring was increased for intubated patients with stable vital signs (probability of 24.7%) and for intubated patients with unstable vital signs (41.4%). None of the other pretransport variables, alone or in pairs, was a significant predictor of any of the three outcome variables. The data indicate that intubation, age, and vital sign status can be used in predicting whether a transport team is needed.     

Pediatric radiologist-driven didactics for a pediatric residency program: a quality initiative

Background

Pediatric residents exhibit knowledge gaps in appropriateness of imaging utilization.

Objective

This study evaluates the value of radiologist-driven imaging education in a pediatric residency program. The primary goals of this educational program were to provide pediatric residents with resources such as the American College of Radiology Appropriateness Criteria, support optimal resource utilization and patient care, increase resident understanding of radiation risk, and determine the value of integrating radiologists into pediatric education.

Materials and methods

A needs assessment was performed in which the chief residents of a large pediatric program were surveyed. The consensus of chief residents was that a four-part lecture series delivered by a pediatric radiology fellow would be beneficial to the pediatric residents. Topics included general radiation risk as well as basic imaging topics in the chest, abdomen, neurological system, extremities and vasculature. Each lecture integrated appropriate ordering, ALARA (As Low As Reasonably Achievable)/Image Gently, and basic image interpretation. Residents were asked, using a Likert scale, to rate their understanding of radiation risk, the ACR Appropriateness Criteria, and other topics of interest before and after each lecture. Pediatric residents were given a 10-item quiz before and after the lecture series to assess their knowledge regarding the best test to order in clinical scenarios.

Results

The average pre-lecture score for knowledge of radiation risk was 3.27 (95% confidence interval [CI]: 3.02–3.51) out of 5, which improved to 4.27 (95% CI: 4.09–4.57) post-lecture. There was an increase in understanding of ACR appropriateness, with pre-lecture rating of knowledge increasing from 1.91 (95% CI 1.54–2.29) out of 5 to 3.61 (95% CI 3.33–3.90) post-lecture. The residents averaged 82.7% (95% CI 77.3%–88.1%) on the appropriateness pre-test and 93.8% (95% CI 90.3%–97.2%) on the post-test. Residents provided positive feedback upon conclusion of the program and reported a beneficial effect on their education.

Conclusion

A radiologist-driven lecture series in a pediatric residency can improve resident understanding of appropriate ordering practices and radiation risk. Radiologist participation in pediatric residency training is well-received.

     

Development and evaluation of high-fidelity simulation case scenarios for pediatric resident education.

OBJECTIVE: Pediatric residency programs need objective methods of trainee assessment. Patient simulation can contribute to objective evaluation of acute care event management skills. We describe the development and validation of 4 simulation case scenarios for pediatric resident evaluation. METHODS: We created 4 pediatric simulation cases: apnea, asthma, supraventricular tachycardia, and sepsis. Each case contains a scenario and an unweighted checklist. Case and checklist development began by reaching expert consensus about case content followed by 92 pilot simulation sessions used for content revision and rater training. After development, 54 first-and second-year pediatric residents participated in 108 simulation test cases to assess the validity of data from these tools for our population. We report outcomes for interrater reliability, discriminant validity, and the impact of potential confounding factors on validity estimates. RESULTS: Interrater reliability (kappa) ranged from 0.75 to 0.87. There were statistically and educationally significant differences in summary scores between first-and second-year residents for 3 of the 4 cases. Neither previous simulation exposure nor the order in which the cases were performed were found to be significant factors by multivariate analysis. CONCLUSIONS: Simulation can be used to reliably measure and discriminate resident competencies in acute care management. Rigorous measurement development work is difficult and time-consuming. Done correctly, measurement development yields tangible and lasting benefits for trainees, faculty, and residency programs. Development studies that use systematic procedures and large trainee samples at multiple sites are the best approach to creating measurement tools that yield valid data.