Audrey Z. Paul

Point-of-care ultrasonography by pediatric emergency medicine physicians

Emergency physicians have used point-of-care ultrasonography since the 1990s. Pediatric emergency medicine physicians have more recently adopted this technology. Point-of-care ultrasonography is used for various scenarios, particularly the evaluation of soft tissue infections or blunt abdominal trauma and procedural guidance. To date, there are no published statements from national organizations specifically for pediatric emergency physicians describing the incorporation of point-of-care ultrasonography into their practice. This document outlines how pediatric emergency departments may establish a formal point-of-care ultrasonography program. This task includes appointing leaders with expertise in point-of-care ultrasonography, effectively training and credentialing physicians in the department, and providing ongoing quality assurance reviews.

Impact of Just-in-Time and Just-in-Place Simulation on Intern Success With Infant Lumbar Puncture.

BACKGROUND AND OBJECTIVE: Simulation-based skill trainings are common; however, optimal instructional designs that improve outcomes are not well specified. We explored the impact of just-in-time and just-in-place training (JIPT) on interns’ infant lumbar puncture (LP) success. METHODS: This prospective study enrolled pediatric and emergency medicine interns from 2009 to 2012 at 34 centers. Two distinct instructional design strategies were compared. Cohort A (2009–2010) completed simulation-based training at commencement of internship, receiving individually coached practice on the LP simulator until achieving a predefined mastery performance standard. Cohort B (2010–2012) had the same training plus JIPT sessions immediately before their first clinical LP. Main outcome was LP success, defined as obtaining fluid with first needle insertion and <1000 red blood cells per high-power field. Process measures included use of analgesia, early stylet removal, and overall attempts. RESULTS: A total of 436 first infant LPs were analyzed. The LP success rate in cohort A was 35% (13/37), compared with 38% (152/399) in cohort B (95% confidence interval for difference [CI diff], −15% to +18%). Cohort B exhibited greater analgesia use (68% vs 19%; 95% CI diff, 33% to 59%), early stylet removal (69% vs 54%; 95% CI diff, 0% to 32%), and lower mean number of attempts (1.4 ± 0.6 vs 2.1 ± 1.6, P < .01) compared with cohort A. CONCLUSIONS: Across multiple institutions, intern success rates with infant LP are poor. Despite improving process measures, adding JIPT to training bundles did not improve success rate. More research is needed on optimal instructional design strategies for infant LP.

Withholding or Termination of Resuscitation in Pediatric Out-of-Hospital Traumatic Cardiopulmonary Arrest

This multiorganizational literature review was undertaken to provide an evidence base for determining whether recommendations for out-of-hospital termination of resuscitation could be made for children who are victims of traumatic cardiopulmonary arrest. Although there is increasing acceptance of out-of-hospital termination of resuscitation for adult traumatic cardiopulmonary arrest when there is no expectation of a good outcome, children are routinely excluded from state termination-of-resuscitation protocols. The decision to withhold resuscitative efforts in a child under specific circumstances (decapitation or dependent lividity, rigor mortis, etc) is reasonable. If there is any doubt as to the circumstances or timing of the traumatic cardiopulmonary arrest, under the current status of limiting termination of resuscitation in the field to persons older than 18 years in most states, resuscitation should be initiated and continued until arrival to the appropriate facility. If the patient has arrested, resuscitation has already exceeded 30 minutes, and the nearest facility is more than 30 minutes away, involvement of parents and family of these children in the decision-making process with assistance and guidance from medical professionals should be considered as part of an emphasis on family-centered care because the evidence suggests that either death or a poor outcome is inevitable.

Point-of-Care Ultrasonography by Pediatric Emergency Physicians

Point-of-care ultrasonography is increasingly being used to facilitate accurate and timely diagnoses and to guide procedures. It is important for pediatric emergency physicians caring for patients in the emergency department to receive adequate and continued point-of-care ultrasonography training for those indications used in their practice setting. Emergency departments should have credentialing and quality assurance programs. Pediatric emergency medicine fellowships should provide appropriate training to physician trainees. Hospitals should provide privileges to physicians who demonstrate competency in point-of-care ultrasonography. Ongoing research will provide the necessary measures to define the optimal training and competency assessment standards. Requirements for credentialing and hospital privileges will vary and will be specific to individual departments and hospitals. As more physicians are trained and more research is completed, there should be one national standard for credentialing and privileging in point-of-care ultrasonography for pediatric emergency physicians.

Evaluation and management of children and adolescents with acute mental health or behavioral problems. Part I: Common clinical challenges of patients with mental health and/or behavioral emergencies

This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have fi led confl ict of interest statements with the American Academy of Pediatrics. Any confl icts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication. Clinical reports from the American Academy of Pediatrics benefi t from expertise and resources of liaisons and internal (AAP) and external reviewers. However, clinical reports from the American Academy of Pediatrics may not refl ect the views of the liaisons or the organizations or government agencies that they represent. The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffi rmed, revised, or retired at or before that time. DOI: 10.1542/peds.2016-1570

Handoffs: Transitions of care for children in the emergency department

Transitions of care (ToCs), also referred to as handoffs or sign-outs, occur when the responsibility for a patient’s care transfers from 1 health care provider to another. Transitions are common in the acute care setting and have been noted to be vulnerable events with opportunities for error. Health care is taking ideas from other high-risk industries, such as aerospace and nuclear power, to create models of structured transition processes. Although little literature currently exists to establish 1 model as superior, multiorganizational consensus groups agree that standardization is warranted and that additional work is needed to establish characteristics of ToCs that are associated with clinical or practice outcomes. The rationale for structuring ToCs, specifically those related to the care of children in the emergency setting, and a description of identified strategies are presented, along with resources for educating health care providers on ToCs. Recommendations for development, education, and implementation of transition models are included.

Death of a Child in the Emergency Department

The American Academy of Pediatrics, American College of Emergency Physicians, and Emergency Nurses Association have collaborated to identify practices and principles to guide the care of children, families, and staff in the challenging and uncommon event of the death of a child in the emergency department in this policy statement and in an accompanying technical report.

Pediatric Medication Safety in the Emergency Department

Pediatric patients cared for in emergency departments (EDs) are at high risk of medication errors for a variety of reasons. A multidisciplinary panel was convened by the Emergency Medical Services for Children program and the American Academy of Pediatrics Committee on Pediatric Emergency Medicine to initiate a discussion on medication safety in the ED. Top opportunities identified to improve medication safety include using kilogram-only weight-based dosing, optimizing computerized physician order entry by using clinical decision support, developing a standard formulary for pediatric patients while limiting variability of medication concentrations, using pharmacist support within EDs, enhancing training of medical professionals, systematizing the dispensing and administration of medications within the ED, and addressing challenges for home medication administration before discharge. abstract

Impact of a Child Life and Music Therapy Procedural Support Intervention on Parental Perception of Their Child's Distress During Intravenous Placement

Objectives Child life specialists and music therapists have a unique and integral role in providing psychosocial care to pediatric patients and families. These professionals are trained to provide clinical interventions that support coping and adjustment and reduce the risk of psychological trauma related to hospital visits and health care encounters. The researchers devised a multimodal approach using a combined child life and music therapy intervention to address procedure-related distress in patients receiving intravenous (IV) placement in the pediatric emergency department. The aim of this study was to investigate the efficacy of this collaborative intervention by evaluating parental perception of their childs distress. Methods This study was a prospective analysis investigating the impact of a child life and music therapy intervention on children aged 4 to 11 years old receiving an IV placement in the pediatric emergency department. Efficacy was evaluated by comparing scores between a 4-question pretest and subsequent 4-question posttest that asked the childs parent to evaluate how they anticipated their child would respond to the procedure, and then to evaluate how they perceived their child to have responded after the procedure. Qualitative data were collected in the form of open-ended comments, which were accommodated at the end of the posttest. Data were analyzed by the Cochran-Mantel-Haenszel method for testing repeated ordinal responses and the PROC GENMOD procedure in the SAS system software. Results A total of 41 participants were enrolled in this study. Results of the statistical analysis revealed significant differences between all pre- and posttest scores (P < 0.05), and significant likelihood that the patient would improve relative to the 4 questions, as a result of the child life and music therapy intervention. Conclusions Improvement was demonstrated across all 4 questions, suggesting that the child life and music therapy intervention supported healthy, adaptive coping and helped to minimize distress experienced by patients during IV placement. These results underscore the importance and potential clinical impact of child life psychological preparation and psychotherapy-based music therapy interventions in reducing distress in pediatric patients during common medical procedures.

Evaluation and Monitoring of a Child With Hydrocarbon Pneumonitis Using Point-of-Care Lung Ultrasound in the Pediatric Emergency Department

Abstract A well-appearing 3-year-old boy presented to the pediatric emergency department 2 hours after a presumed hydrocarbon ingestion. He was referred to the emergency department by his pediatrician after consultation with the local poison control center after possibly ingesting ylang ylang (Cananga odorata) fragrance oil. The child was asymptomatic with a normal physical examination. Point-of-care lung ultrasound identified focal hydrocarbon pneumonitis in the right lung and demonstrated resolution of these findings. Utilization of point-of-care ultrasound resulted in a shorter emergency department length of stay and the avoidance of radiation exposure from serial chest x-rays.