Angelo P. Giardino

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.

Qualitative research methods for medical educators.

This paper provides a primer for qualitative research in medical education. Our aim is to equip readers with a basic understanding of qualitative research and prepare them to judge the goodness of fit between qualitative research and their own research questions. We provide an overview of the reasons for choosing a qualitative research approach and potential benefits of using these methods for systematic investigation. We discuss developing qualitative research questions, grounding research in a philosophical framework, and applying rigorous methods of data collection, sampling, and analysis. We also address methods to establish the trustworthiness of a qualitative study and introduce the reader to ethical concerns that warrant special attention when planning qualitative research. We conclude with a worksheet that readers may use for designing a qualitative study. Medical educators ask many questions that carefully designed qualitative research would address effectively. Careful attention to the design of qualitative studies will help to ensure credible answers that will illuminate many of the issues, challenges, and quandaries that arise while doing the work of medical education.

Racial and Ethnic Disparities in Indicators of a Primary Care Medical Home for Children

OBJECTIVE Racial/ethnic disparities in access to care across a broad range of health services have been well established. In adults, having a medical home has been shown to reduce disparities. The objective of this study was to assess the extent to which children of different race/ethnicities receive primary care consistent with a medical home. METHODS We conducted a secondary analysis of 84 101 children, ages 0-17, from the 2003-2004 National Survey of Childrens Health, a nationwide household survey. The primary independent variable was race/ethnicity of the child. The main dependent variable was a medical home as defined by the American Academy of Pediatrics. Multiple logistic regression was conducted to investigate associations between race/ethnicity and having a medical home. RESULTS The odds of having a medical home were lower for non-Hispanic black (odds ratio [OR] 0.76, 95% confidence interval [95% CI] 0.69-0.83), Hispanic (OR 0.80, 95% CI 0.72-0.89), and other (OR 0.77, 95% CI 0.69-0.87) children compared with non-Hispanic white children after adjusting for sociodemographic variables. Specific components of a medical home for which minority children had a lower odds (P < .01) of having compared with white children included having a personal provider, a provider who always/usually spent enough time with them, and a provider who always/usually communicated well. CONCLUSIONS Minority children experienced multiple disparities compared with white children in having a medical home. Study of individual medical home components has the potential to identify specific areas to improve disparities.

Healthcare utilization and expenditures for low income children with sickle cell disease

While multiple studies have examined the healthcare burden of sickle cell disease (SCD) in adults, few have specifically focused on healthcare utilization and expenditures in children. The objective of this study was to characterize the healthcare utilization and costs associated with the care of low‐income children with SCD in comparison to other children of similar socioeconomic status.

Association of medical home care and disparities in emergency care utilization among children with special health care needs.

OBJECTIVE The aim of this study was to determine whether having a medical home is associated with a reduction of racial/ethnic disparities in emergency care utilization by children with special health care needs (CSHCN). METHODS We conducted a secondary analysis of 35 301 children, aged 0 to 17, from the 2005-2006 National Survey of Children with Special Health Care Needs. The primary dependent variable was emergency care utilization, defined as 1 or more emergency care encounters in the last 12 months. The primary independent variables were race/ethnicity and type of care (medical home, usual source of care, no medical home/no usual source of care). Multiple logistic regression was conducted to investigate associations between race/ethnicity, type of care, and emergency care utilization. RESULTS Analysis of type of care and its interactions with race/ethnicity showed that non-Hispanic black children with a medical home had higher odds (odds ratio [OR] 1.26, 95% confidence interval [CI] 1.03-1.54) of emergency care utilization compared with non-Hispanic white children with a medical home. The odds of having 1 or more emergency care visits were higher for non-Hispanic black children (OR 1.38, 95% CI 1.22-1.56) compared with non-Hispanic white children after controlling for sociodemographic variables. Having a medical home was associated with lower odds of emergency care utilization (OR 0.81, 95% CI 0.72-0.90) compared with having neither a medical home nor a usual source of care. CONCLUSIONS Emergency care utilization for CSHCN differed significantly according to race/ethnicity. Having a medical home may be associated with a reduction in disparities in this fragile population.

Parenting stress in US families: implications for paediatric healthcare utilization

OBJECTIVE According to family stress models, parental responses to stress disrupt interactions between parent and child and may lead to parental inability to seek timely medical care for their child. The objective of this study was to quantitatively assess the relationship between high parenting stress and child healthcare utilization. METHODS We used the 2003-2004 National Survey of Childrens Health to determine the prevalence of parenting stress in US families and associated socio-demographic variables. We used weighted logistic regression to investigate associations between parenting stress and healthcare utilization, controlling for other parental psychosocial and socio-demographic variables. The primary independent variables were parenting stress, parental mental health, parental coping and social support. The main dependent variables were emergency care, sick visits to primary care and preventive care in the past 12 months. RESULTS Nationally, 13% of children lived in households with at least one parent experiencing high parenting stress. Socio-demographic variables associated with the highest odds of parenting stress included Black race, special needs status and non-English primary language. Parents with high parenting stress had a higher odds (adjusted odds ratio 1.24, 95% confidence interval 1.10-1.41) of seeking emergency care for their children compared with parents with low parenting stress, controlling for other parental psychosocial factors and socio-demographic variables. CONCLUSIONS Having a parent who is experiencing high parenting stress is associated with greater utilization of paediatric emergency care. Interventions targeted at parenting stress may provide families with needed support and reduce unnecessary emergency care utilization.

Collection of Forensic Evidence From Pediatric Victims of Sexual Assault

OBJECTIVE: To determine the time period after sexual assault of a child that specimens may yield evidence using DNA amplification. Secondary questions included the comparative laboratory yields of body swabs versus other specimens, and the correlation between physical findings and laboratory results. PATIENTS AND METHODS: Data from evidence-collection kits from children 13 years and younger were reviewed. Kits were screened for evidence using traditional methods, and DNA testing was performed for positive specimens. Laboratory data were compared with historical information. RESULTS: There were 277 evidence-collection kits analyzed; 151 were collected from children younger than 10; 222 kits (80%) had 1 or more positive laboratory screening test, of which 56 (20%) tested positive by DNA. The time interval to collection was <24 hours for 30 of the 56 positive kits (68% positives with a documented time interval), and 24 (43% of all positive kits) were positive only by nonbody specimens. The majority of children with DNA were aged 10 or older, but kits from 14 children younger than 10 also had a positive DNA result, of which 5 were positive by a body swab collected between 7 and 95 hours after assault. Although body swabs were important sources of evidence for older children, they were significantly less likely than nonbody specimens to yield DNA among children younger than 10 (P = .002). There was no correlation between physical findings and laboratory evidence. CONCLUSIONS: Body samples should be considered for children beyond 24 hours after assault, although the yield is limited. Physical examination findings do not predict yield of forensic laboratory tests.

An ethnographic study of attending rounds in general paediatrics: understanding the ritual.

Medical Education 2010: 44: 1105–1116

Predictors of direct costs of diabetes care in pediatric patients with type 1 diabetes

Ying AK, Lairson DR, Giardino AP, Bondy ML, Zaheer I, Haymond MW, Heptulla RA. Predictors of direct costs of diabetes care in pediatric patients with type 1 diabetes.

Sedation for pediatric CT scanning: is radiology becoming a drug-free zone?

Introduction: Cooperation for a diagnostic study is a frequent indication for pediatric procedural sedation. This study examines the continued need for sedation in the era of fast helical computerized tomography (CT) scanners. Methods: Medical records of children younger than 72 months undergoing CT scans were systematically reviewed to identify the use of procedural sedation to complete their diagnostic studies. Statistical analysis was through ANOVA and regression modeling. Results: A total of 104 patients underwent 122 CT studies. Requests originated from 3 sources: 59.8% ED (n = 73), 38.5% Neonatal Intensive Care Unit (n = 47), and 1.6% Pediatric Ward (n = 2). Studies performed included: 79.5% head/facial (n = 97), 15.6% abdomen/pelvis (n = 19), and 5.9% other (n = 6). The mean ages of all study patients was 23.4 (±2.4) months with a median of 14 months. Only 8.6% patients (n = 9) received any sedation. The mean age of sedated patients was 18.8 (±2.7) months with a median of 21 months. With the exception of one 4-month-old, all other sedated children were between 12 and 30 months. Sedative use occurred in 36.4% of patients in this age group, which was significantly greater than the remainder of the study group (OR 56.5, 95% CI 9-1091, P < 0.001) Sedative agents used included: diphenhydramine (4), pentobarbital (1), propofol (1), ketamine (1), midazolam (1), diphenhydramine/pentobarbital (1). Conclusions: Procedural sedation is infrequently used in infants and young children undergoing helical CT studies.