Chris Kennedy

Validation and Refinement of the Difficult Intravenous Access Score: A Clinical Prediction Rule for Identifying Children With Difficult Intravenous Access

OBJECTIVES The difficult intravenous access (DIVA) score, a proportionally weighted four-variable (vein palpability, vein visibility, patient age, and history of prematurity) clinical rule, has been developed to predict failure of intravenous (IV) placement in children. This study sought to externally validate and refine the DIVA score. METHODS Patients undergoing peripheral IV placement by pediatric emergency department (ED) nurses were enrolled. The outcome of interest was defined as failure of cannulation on first attempt. Proposed refinement predictor variables include history of newborn intensive care unit (NICU) stay, operator experience characteristics (years since graduation, years of pediatric nursing experience, and IVs started per month), and skin shade. Adjusted multivariate models were constructed using logistic regression. Receiver operating characteristic (ROC) curves were constructed and areas under the curve (AUC) calculated for each model. RESULTS A total of 366 subjects were enrolled (mean age = 5.4 years, SD ± 5.6 years) and of them, 118 (32.2%) subjects failed the first IV attempt. The original four-variable model tested in this data set resulted in an AUC of 0.72 (95% confidence interval [CI] = 0.67 to 0.78). Patients with a DIVA score of 4 or greater had more than 50% likelihood of failed first IV attempt. A three-variable rule (vein palpability, vein visibility, and patient age) was evaluated and found to possess similar discriminating ability (AUC = 0.72, 95% CI = 0.67 to 0.78). CONCLUSIONS This study validated the previously derived four-variable DIVA score. A simpler three-variable rule was as predictive of failed IV placement on first attempt as the four-variable rule. Validation in nonpediatric EDs is needed to thoroughly evaluate generalizability.

A randomized clinical trial of oral transmucosal fentanyl citrate versus intravenous morphine sulfate for initial control of pain in children with extremity injuries.

Background: Extremity injury is a common condition that requires pain management in an emergency department. In pediatric patients, the most frequently used method of pain control is intravenous (IV) morphine sulfate. Oral transmucosal fentanyl citrate (OTFC) is a potential alternative to morphine, which may obviate the need to place an IV before addressing pain. Objective: To compare OTFC with IV morphine for sedation and analgesia during initial evaluation of children with deformity of an extremity and suspected fracture. Design/Methods: A randomized controlled trial of OTFC versus IV morphine in which 8- to 18-year-olds presenting to pediatric tertiary care emergency department with extremity deformity and suspected fracture were eligible. Only those with visual analog scale (VAS) (0 = no pain, 100 = worst pain imaginable) score equal to or greater than 50/100, and American Society of Anesthesia I or II qualified. Patients were excluded if history of loss of/altered level of consciousness, multiple traumatic injuries, or if patient had received prior medication for pain control. All patients enrolled were randomly assigned to receive either IV morphine (0.1 mg/kg) or OTFC (10-15 μg/kg). Patients rated pain intensity using VAS; scores were recorded before medicating and at 15-minute intervals after the medication was given. Adverse events such as emesis, pruritus, and respiratory depression were recorded. Results: A total of 87 patients were enrolled in study (OTFC, 47; morphine, 40). There are no significant differences between the 2 groups when comparing sex, age, weight, and pretreatment VAS score (P > 0.05). Although the VAS scores were not significantly different before medicating the patient, an analysis of variance shows that there was a significant difference (P > 0.05) in VAS scores at 30 minutes. The differences persisted for every 15 minutes through the 75 minutes of monitoring. There was no statistically significant difference between the 2 groups when comparing the number of adverse events (P = 0.23). Conclusions: The use of OTFC can provide improved pain control when compared with IV morphine. The pain reduction starts 30 minutes after initiation of medication, and the effect is seen as far as 75 minutes after the initiation of analgesic medication. The study size was too small to make any statements concerning adverse effects; thus, further studies with larger sample sizes are needed to determine the use of OTFC.

Evaluation of a curriculum for intimate partner violence screening in a pediatric emergency department.

OBJECTIVE. We sought to describe the assessment of course participant changes in attitudes, self-efficacy, and behaviors after completion of the Its Time to Ask training curriculum for screening for intimate partner violence (IPV) in a pediatric emergency department (PED). METHODS. A 22-item Likert scale questionnaire was administered at baseline (before training), after training, and at 6-month follow-up to PED employee participants in a 2-hour IPV education program. Mean participant responses were compared between baseline/posttraining and baseline/6-month follow-up. Participants also completed a course-satisfaction survey. RESULTS. A total of 79 PED staff completed the baseline questionnaire before the training. Eighty-seven participants completed the posttraining questionnaire, and 48 completed the 6-month follow-up questionnaire. Participants had consistent, positive changes in attitudes after training that persisted at the 6-month follow-up for 5 items on the questionnaire. Attitudes that did not change showed baseline means already in disagreement with questionnaire statements. Participants reported significant, positive changes for all 7 self-efficacy statements at 1 or both of the posttraining evaluations. The only changes in behavior were observed at 6 months. The majority of participants were satisfied with the training and would recommend it to colleagues. CONCLUSIONS. Significant, self-reported changes in attitudes, self-efficacy, and behaviors/clinical practice regarding screening for IPV in a PED can be achieved through participation in a brief training curriculum.

Interexaminer agreement in physical examination for children with suspected soft tissue abscesses.

Objective: This study aimed to measure interexaminer agreement for physical examination (PE) findings in children with a suspected soft tissue abscess. Methods: A prospective study was conducted from March 1 to July 31, 2007, at an urban, tertiary care childrens hospital emergency department. Children presenting to the emergency department with a suspected local skin abscess were independently examined by 2 physicians. Interrater agreement of 7 PE findings for children with a suspected soft tissue abscess was assessed. Interrater agreement was calculated for the diagnosis of the lesion and decision to incise and drain. Results: A total of 105 paired observations were completed by a total of 27 physicians. The patients examined were aged 2 weeks to 18 years, with a mean age of 80 months. Lesions were most frequently encountered on the buttocks (38%). Incision and drainage was attempted in 75% of cases, with purulent material obtained in 92% of all attempts. Interrater agreement was substantial for erythema (&kgr; = 0.66) and size of the lesion (intraclass correlation coefficient = 0.78), moderate for drainage (&kgr; = 0.57) and tenderness (&kgr; = 0.40), fair for fluctuance (&kgr; = 0.35), and poor for warmth (&kgr; = 0.15) and showed no agreement for induration (&kgr; = −0.08). There was moderate agreement on diagnosing the lesion as an abscess (&kgr; = 0.48) and determination if the lesion required incision and drainage (&kgr; = 0.44). Conclusions: Interexaminer agreement of examination findings and diagnosis of an abscess was fair to moderate, implying a lack of precision of PE as the primary means for diagnosis. Future studies of diagnostic adjuncts, such as bedside ultrasonography, may lead to improved management of soft tissue infections in children.

911 (nueve once): Spanish-speaking parents' perspectives on prehospital emergency care for children.

Racial, ethnic and language-based disparities occur throughout the US health system. Pediatric prehospital emergency medical services are less likely to be used by Latinos. We identified perceptions of and barriers to prehospital pediatric emergency care (911) access among Spanish-speaking parents. A qualitative study involving six focus groups was conducted. Spanish-speaking parents participated with a bilingual moderator. Topics discussed included experiences, knowledge, beliefs, fears, barriers, and improvement strategies. All groups were audiotaped, transcribed, and reviewed for recurring themes. Forty-nine parents participated. Though parents believed 911 was available to all, many were uncertain how to use it, and what qualified as an emergency. Barriers included language discordance, fear of exposing immigration status, and fear of financial consequences. Parents strongly desired to learn more about 911 through classes, brochures, and media campaigns. Prehospital emergency care should be available to all children. Further quantitative studies may help solidify the identified barriers and uncover areas needing improvement within Emergency Medical Systems. Addressing barriers to 911 use in Spanish-speaking communities could improve the equity of health care delivery, while also decreasing the amount of non-emergency 911 use.

Council of Pediatric Subspecialties (CoPS): The First Five Years

The Council of Pediatric Subspecialties (CoPS) was founded in September 2006 largely due to concerns about the nonuniformity of the fellowship application process. Working with the pediatric subspecialty community, CoPS has been successful in promoting a uniform process with many more pediatric fellowship programs now using a matching program and the Electronic Residency Application Service. More important, the organization has created a bidirectional network of communication among the pediatric subspecialties and has used this to accomplish a great deal more than improving the entry of residents into subspecialty training. CoPS has provided a united voice for the subspecialties in response to the Institute of Medicine’s Duty Hours report, participated in the development of educational conferences geared toward the subspecialist, promoted careers in the subspecialties, and worked with other pediatric organizations to advocate for improved health care for children. This article highlights CoPS’ many achievements and describes the methods it used to accomplish them, illustrating how pediatric subspecialists can develop a communication network and use this to work together to achieve common goals.

The Pediatric Subspecialty Match: Past, Present, and Future.

T he Council of Pediatric Subspecialties (CoPS) was formed in 2006 to facilitate communication and collaboration among pediatric subspecialty organizations. One of its first undertakings was an assessment of the pediatric subspecialty application process. At the time, pediatric residents felt pressured into choosing a subspecialty early in training, with many starting the application process before the end of their first year of residency. In addition, most subspecialties did not have a standard application process, resulting in significant variation in the information requested by individual programs. In 2007, CoPS created a task force to evaluate these issues. After weighing the pros and cons of unifying the application process and surveying 1244 fellows, the task force made 2 recommendations: (1) all subspecialties were requested to use the Electronic Residency Application Service (ERAS); and (2) they were encouraged to consolidate their match dates to one of 2 options through the National Resident Matching Program (NRMP). These suggested match dates were in late spring (13 months prior to starting fellowship) and late fall (7 months prior to starting fellowship). Through continued dialogue and with the encouragement of CoPS, subspecialties gradually adopted these recommendations. In 2006, only 4 subspecialties used ERAS and 6 subspecialties participated in a match. By 2011, 14 subspecialties were using ERAS, with an even distribution between the 2 recommended match dates. Nonetheless, pediatric trainees continued to express concern over the early timing of the spring match, for which applications are typically submitted in early December of the second year of residency. For those in the Accelerated Research Pathway applying to subspecialties in the

Essentials of PEM Fellowship Part 2: The Profession in Entrustable Professional Activities

Abstract This article is the second in a 7-part series that aims to comprehensively describe the current state and future directions of pediatric emergency medicine (PEM) fellowship training from the essential requirements to considerations for successfully administering and managing a program to the careers that may be anticipated upon program completion. This article describes the development of PEM entrustable professional activities (EPAs) and the relationship of these EPAs with existing taxonomies of assessment and learning within PEM fellowship. It summarizes the field in concepts that can be taught and assessed, packaging the PEM subspecialty into EPAs.

0162 Development of a field assessment conditioning tool (FACT) – an exploration of the role of healthcare advocacy

Background We have designed an assessment instrument, to empower health care advocacy by trauma team members and managers.1 The context of the assessment is the readiness of hospitals to receive traumatically injured children, as trauma is the leading cause of mortality in infants and children.2 The instrument is to be used by the healthcare professionals that constitute or manage trauma teams, and highlights a series of trauma team hospital interactions and performances. The instrument enables the description, reflection, evaluation and eventual improvement of team – hospital interactions by health advocacy. Methodology We have run unannounced fully immersive in-situ/point of care paediatric trauma simulations in a major paediatric trauma centre, once a month, for over 24 months, to date. We tested the instrument (Field Assessment Conditioning Tool (FACT)) utilising high fidelity patient simulators as surrogates for real children presenting to trauma bays. These were followed by semi-structured interviews with both trauma team members and trauma governance board administrators. Results Four themes emerged from interviews: The support for a more holistic approach to evaluating and assessing both the organisation’s and trauma team’s readiness to receive paediatric trauma. The support for harnessing internal expertise of all team members to evaluate quality of trauma care. The FACT provides a language to describe, evaluate quality and potentially invoke changes. Perceived usefulness by all of the staff (team members and governance boards) will determine to a large extent to which the FACT will be used. Potential impact Assessing all aspects of medical performance is complex and requires a programme of assessment incorporating both psychometric measurements instruments and framework tools. This is especially important to support the role of health advocates. Preliminary data from the FACT implementation and evaluation contributes to the conceptual validity of this approach to assessment. References MacKinnon RJ, Kennedy C, Doherty C, Shepherd M, Cole J, Stenfors-Hayes T, on behalf of the INSPIRE Trauma Outreach. Fitness for purpose study of the Field Assessment Conditioning Tool (FACT): a research protocol. Med Educ Train BMJ Open 2015;5:e006386 doi:10.1136/bmjopen-2014-006386 Centers for Disease Control and Prevention. National Center for Health Statistics. VitalStats. http://www.cdc.gov/nchs/vitalstats.htm. [accessed April 20, 2013]