Charles J. Schubert

Characteristics of nonurgent emergency department use in the first 3 months of life

Objectives To determine the characteristics of nonurgent emergency department (ED) visits in the first 3 months of life. Methods The study cohort consisted of full-term newborns admitted to and discharged from one newborn nursery from September 1, 1992, to May 1, 1994. All visits in the first 90 days of life to one large urban ED were analyzed to determine whether they were nonurgent, based on history of present illness and final diagnosis or disposition. The principal outcomes of interest were the frequency and pattern of nonurgent ED visits. Risk factors for nonurgent ED use were also studied. Results A total of 2137 patients with 965 ED visits were analyzed; 20.4% of the patients had nonurgent visits, and 60.1% of all visits were nonurgent. Of all patients with nonurgent visits, 24.1% had more than one. Younger maternal age, Medicaid, maternal parity, and nonwhite race all resulted in increased nonurgent ED use. One third of all ED visits were made when the primary care physician’s offices were open, and 57.6% of these visits were nonurgent. Conclusions Maternal and economic factors affected nonurgent ED utilization. Other critical factors still need to be explored. Interventions focused on decreasing nonurgent ED use in early infancy should be targeted at patients with the identified risk factors.

Global health education in US pediatric residency programs

BACKGROUND AND OBJECTIVE: Despite the growing importance of global health (GH) training for pediatric residents, few mechanisms have cataloged GH educational opportunities offered by US pediatric residency programs. We sought to characterize GH education opportunities across pediatric residency programs and identify program characteristics associated with key GH education elements. METHODS: Data on program and GH training characteristics were sought from program directors or their delegates of all US pediatric residency programs during 2013 to 2014. These data were used to compare programs with and without a GH track as well as across small, medium, and large programs. Program characteristics associated with the presence of key educational elements were identified by using bivariate logistic regression. RESULTS: Data were collected from 198 of 199 active US pediatric residency programs (99.5%). Seven percent of pediatric trainees went abroad during 2013 to 2014. Forty-nine programs (24.7%) reported having a GH track, 66.1% had a faculty lead, 58.1% offered international field experiences, and 48.5% offered domestic field experiences. Forty-two percent of programs reported international partnerships across 153 countries. Larger programs, those with lead faculty, GH tracks, or partnerships had significantly increased odds of having each GH educational element, including pretravel preparation. CONCLUSIONS: The number of pediatric residency programs offering GH training opportunities continues to rise. However, smaller programs and those without tracks, lead faculty, or formal partnerships lag behind with organized GH curricula. As GH becomes an integral component of pediatric training, a heightened commitment is needed to ensure consistency of training experiences that encompass best practices in all programs.

Burden of Rotavirus Disease Among Children Visiting Pediatric Emergency Departments in Cincinnati, Ohio, and Oakland, California, in 1999–2000

OBJECTIVE. We assessed the incidence of rotavirus disease requiring an emergency department visit among children <5 years of age. METHODS. We conducted active surveillance for acute gastroenteritis in pediatric emergency departments in Cincinnati, Ohio, and Oakland, California, from March 1999 to May 2000, among children 2 weeks to 59 months of age with acute diarrhea and/or vomiting. We obtained clinical and demographic information from participants and tested their stool specimens for rotavirus. RESULTS. Approximately 9% of all emergency department visits at the study sites were attributable to acute gastroenteritis. A total of 1433 children were eligible at the 2 sites; 85% were enrolled and 68% provided a stool specimen. Overall, rotavirus was detected in specimens from 27% of children (30% in Cincinnati and 24% in Oakland). Rotavirus detection was higher in bulk stools, compared with rectal swabs, at both Cincinnati (37% vs 23%) and Oakland (46% vs 18%). Patients with rotavirus had more-severe disease than did those with nonrotavirus gastroenteritis. We estimated that the mean annual incidence of emergency department visits attributable to rotavirus was 12 cases per 1000 children in Cincinnati and 15 cases per 1000 children in Oakland. Through extrapolation, we estimated that rotavirus infection causes ∼260 910 emergency department visits per year among US children. CONCLUSION. Active surveillance demonstrated that the burden of laboratory-confirmed rotavirus disease treated in emergency department settings among US children is substantial and greater than estimated previously.

Use of Quality-Improvement Methods to Improve Timeliness of Analgesic Delivery

OBJECTIVES: Despite its high prevalence, pain often is poorly managed in the emergency department. We used improvement science and quality-improvement methods to reduce delays associated with opioid delivery for children presenting to the emergency department with clinically apparent extremity fractures. METHODS: On the basis of a review of the literature, interviews with key stakeholders, expert consensus, and reviews of isolated examples of patients receiving timely analgesics, a multidisciplinary improvement team identified a set of operational factors, or key drivers, believed to be critical to the performance of appropriate initial pain management for children presenting to the emergency department with acute extremity injury. These key drivers focused the development of an intervention. RESULTS: The intervention, termed the orthopedic evaluation process, addressed all 4 identified key drivers simultaneously by standardizing triage decisions, activating necessary health care providers, aligning the care delivery need with necessary resources, and allowing parallel-task completion between physicians and nursing staff. After implementation of this process, 95% of the patients with long-bone extremity fractures treated with intravenous opioids received a first dose within 45 minutes of arrival, compared with a preintervention baseline average of 20%. CONCLUSIONS: By applying quality-improvement and process improvement methodology, we identified key drivers for the rapid delivery of systemic opioids to patients with clinically apparent extremity fractures and significantly improved the timeliness of analgesic delivery for this subgroup of patients.

Vaginal discharge as an indicator of gonorrhea and Chlamydia infection in girls under 12 years old.

Cultures for sexually transmitted diseases (STDs) are frequently obtained as part of an evaluation for alleged sexual abuse, but the prevalence of STDs in abused children is very low. Furthermore, STDs in children may not be identified if the clinician does not maintain a high index of suspicion in the symptomatic child. A retrospective review was done to study the symptoms and presenting complaints of girls under 12 with gonorrhea and chlamydia infections and to examine the prevalence of STDs in asymptomatic girls. The charts of 622 patients were reviewed. All patients were females under 12, Tanner I or II, who were initially seen for evaluation of sexual abuse or who were diagnosed with an STD. During the study period, 28 girls were found to have STDs. Twenty-two of these girls had vaginal gonorrhea; vaginal chlamydia was diagnosed in eight. Twenty-three of the 28 girls (82%) with an STD were initially seen and cultured for a chief complaint of vaginal discharge. Of the 581 patients who were cultured for evaluation of abuse, only five STDs were diagnosed (0.7%). All 22 girls with gonorrhea had a vaginal discharge on examination. Of the eight girls with chlamydia, two also had vaginal gonorrhea. Of the six who had chlamydia without gonorrhea, asymptomatic infection was common; four gave histories of discharge but only one had a discharge on examination. Our review indicates that girls under 12 who present for evaluation of vaginal discharge may have an STD and should be cultured for gonorrhea and chlamydia whether or not sexual abuse is suspected. In girls alleging sexual abuse and who are asymptomatic, vaginal gonorrhea and chlamydia infection are uncommon.

The Resident Decision-Making Process in Global Health Education Appraising Factors Influencing Participation

The globalization of pediatric graduate medical education is ongoing; thus, this study was conducted to begin to explore the nature of resident interest in global health (GH) training and to further identify potentially modifiable factors influencing participation in away rotations. The authors surveyed all residents at Cincinnati Children’s Hospital Medical Center to identify factors influencing participation in education efforts and away rotations. With a participation rate of 79.4% (n = 143), 5 key factors emerged as most significant in the decision-making process amid all participants. Among residents who had previous experience, 82.1% were interested in participating in an away elective compared with 58.3% of those without experience (P = .002). Residents with previous experience abroad were also more likely to plan to integrate GH into their careers (61.7% vs 26.7%, P < .0001). This article describes specific obstacles to resident participation in GH education and documents the association between previous experience and significant interest in long-term involvement.

Global health opportunities within pediatric subspecialty fellowship training programs: surveying the virtual landscape

BackgroundThere is growing interest in global health among medical trainees. Medical schools and residencies are responding to this trend by offering global health opportunities within their programs. Among United States (US) graduating pediatric residents, 40% choose to subspecialize after residency training. There is limited data, however, regarding global health opportunities within traditional post-residency, subspecialty fellowship training programs. The objectives of this study were to explore the availability and type of global health opportunities within Accreditation Council for Graduate Medical Education (ACGME)-accredited pediatric subspecialty fellowship training programs, as noted by their online report, and to document change in these opportunities over time.MethodsThe authors performed a systematic online review of ACGME-accredited fellowship training programs within a convenience sample of six US pediatric subspecialties. Utilizing two data sources, the American Medical Association-Fellowship and Residency Electronic Interactive Database Access (AMA-FREIDA) and individual program websites, all programs were coded for global health opportunities and opportunity types were stratified into predefined categories. Comparisons were made between 2008 and 2011 using Fisher exact test. All analyses were conducted using SAS Software v. 9.3 (SAS Institute Inc., Cary, NC).ResultsOf the 355 and 360 programs reviewed in 2008 and 2011 respectively, there was an increase in total number of programs listing global health opportunities on AMA-FREIDA (16% to 23%, p=0.02) and on individual program websites (8% to 16%, p=0.004). Nearly all subspecialties had an increased percentage of programs offering global health opportunities on both data sources; although only critical care experienced a significant increase (p=0.04, AMA-FREIDA). The types of opportunities differed across all subspecialties.ConclusionsGlobal health opportunities among ACGME-accredited pediatric subspecialty fellowship programs are limited, but increasing as noted by their online report. The availability and types of these opportunities differ by pediatric subspecialty.

Building Sustainable Partnerships to Strengthen Pediatric Capacity at a Government Hospital in Malawi

Introduction To achieve sustained reductions in child mortality in low- and middle-income countries, increased local capacity is necessary. One approach to capacity building is support offered via partnerships with institutions in high-income countries. However, lack of cooperation between institutions can create barriers to successful implementation of programs and may inadvertently weaken the health system they are striving to improve. A coordinated approach is necessary. Background Three U.S.-based institutions have separately supported various aspects of pediatric care at Kamuzu Central Hospital (KCH), the main government referral hospital in the central region of Malawi, for several years. Within each institution’s experience, common themes were recognized, which required attention in order to sustain improvements in care. Each recognized that support of clinical care is a necessary cornerstone before initiating educational or training efforts. In particular, the support of emergency and acute care is paramount in order to decrease in-hospital mortality. Through the combined efforts of Malawian partners and the US-based institutions, the pediatric mortality rate has decreased from >10 to <4% since 2011, yet critical gaps remain. To achieve further improvements, representatives with expertise in pediatric emergency medicine (PEM) from each US-based institution hypothesized that coordinated efforts would be most effective, decrease duplication, improve communication, and ensure that investments in education and training are aligned with local priorities. Call to action Together with local stakeholders, the three US-based partners created a multi-institutional partnership, Pediatric Alliance for Child Health Improvement in Malawi at Kamuzu Central Hospital and Environs (PACHIMAKE). Representatives from each institution gathered in Malawi late 2016 and sought input and support from local partners at all levels to prioritize interventions, which could be collectively undertaken by this consortium. Long- and short-term goals were identified and approved by local partners and will be implemented through a phased approach. Conclusion The development of a novel partnership between relevant stakeholders in Malawi and US-based partners with expertise in PEM should help to further decrease pediatric mortality through the coordinated provision of acute care expertise and training as well as investment in the development of educational, research, and clinical efforts in PEM at KCH.

Implementing and evaluating an injury prevention curriculum within a pediatric residency program.

BACKGROUND Many pediatric residency programs struggle to incorporate injury prevention training into their curricula. OBJECTIVE To analyze whether a 2-week injury prevention course helps pediatric residents to learn and retain more information than their peers who receive the standard education on injury prevention topics. METHODS A mandatory 2-week injury prevention course is provided for all interns at Cincinnati Childrens Hospital Medical Center (CCHMC). Residents at CCHMC, completed a 50-question test on basic injury prevention topics at intern orientation and at the end of their first and third years of training. A control group of two intern classes from comparable childrens hospitals who did not receive the injury prevention course were given the identical test at similar time periods. Data were analyzed using SPSS, and t tests were used to calculate and compare the mean percent change in test scores. RESULTS Seventy-six pediatric interns were enrolled (33 intervention and 43 controls). After internship, posttests were obtained on 29 (88%) intervention residents and 38 (88%) controls. On completing residency, posttests were received from 16 (48%) CCHMC residents and 22 (51%) controls. There was no difference in demographics or prior injury prevention training between the groups at study enrollment. A total of 63.6% of controls reported receiving injury prevention training by the end of their residency. There was a significant difference in the improvement of mean test scores between the intervention and control groups after internship (14.1% vs. 3.2%; p < 0.001) and again after the third year (11.9% vs. 5.5%; p = 0.02). CONCLUSIONS An injury prevention curriculum for pediatric residents can significantly increase and sustain their fund of knowledge on these important topics.

National Landscape of Interventions to Improve Pediatric Resident Wellness and Reduce Burnout

From the Department of Pediatrics, Division of Emergency Medicine, University of Pittsburgh, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, Pa (Dr Wilson); Department of Pediatrics and Center for Integrative Health and Wellness (Dr Kemper), Department of Pediatrics and Nephrology (Dr Mahan), Nationwide Children’s Hospital, Columbus, Ohio; Department of Pediatrics, Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio (Dr Schubert); Department of Neonatology and Pediatrics, University of Washington, Seattle Children’s Hospital (Dr Batra); Department of Pediatrics, Duke University Medical Center, Durham, NC (Dr Staples); Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Md (Dr Serwint); and Department of Medicine, University of Arizona College of Medicine, Tucson, Ariz (Dr McClafferty) The authors have no conflicts of interest to disclose. Address correspondence to Paria M. Wilson, MD, MEd, Division of Emergency Medicine, Children’s Hospital of Pittsburgh of UPMC, 4401 Penn Ave, AOB Suite 2400, Pittsburgh, PA 15224 (e-mail: paria.wilson@gmail.com).