Daniel A. Rauch

Child life services

Child life programs have become standard in most large pediatric centers and even on some smaller pediatric inpatient units to address the psychosocial concerns that accompany hospitalization and other health care experiences. The child life specialist focuses on the strengths and sense of well-being of children while promoting their optimal development and minimizing the adverse effects of children’s experiences in health care or other potentially stressful settings. Using play and psychological preparation as primary tools, child life interventions facilitate coping and adjustment at times and under circumstances that might prove overwhelming otherwise. Play and age-appropriate communication may be used to (1) promote optimal development, (2) present information, (3) plan and rehearse useful coping strategies for medical events or procedures, (4) work through feelings about past or impending experiences, and (5) establish therapeutic relationships with children and parents to support family involvement in each child’s care, with continuity across the care continuum. The benefits of this collaborative work with the family and health care team are not limited to the health care setting; it may also optimize reintegration into schools and the community.

Pediatric Hospitalists: Report of a Leadership Conference

OBJECTIVES. To summarize a meeting of academic pediatric hospitalists and to describe the current state of the field. METHODS. The Ambulatory Pediatric Association sponsored a meeting for academic pediatric hospitalists in November 2003. The purpose of the meeting was to discuss and to define roles of academic pediatric hospitalists, including their roles as clinicians, educators, and researchers, and to discuss organizational issues and unique hospitalist issues within general academic pediatrics. Workshops were held in the areas of organization and administration, academic life, research, and education. A literature review was also conducted in the areas discussed. RESULTS. More than 130 physicians attended. Thirteen workshops were held, and all information was summarized in large-group sessions for all attendees. CONCLUSIONS. Pediatric hospital medicine is a rapidly growing field, with an estimated 800 to 1000 pediatric hospitalists currently practicing. Initial work has defined the clinical environment and has begun to stake out a unique knowledge and skill set. The Pediatric Hospitalists in Academic Settings conference demonstrated the audience for additional development and the resources to move forward.

Peripheral Difficult Venous Access in Children

Early identification of DVA is the first step in optimizing patient care. The consensus panel described DVA as a clinical condition in which multiple attempts and/or special interventions are anticipated or required to achieve and maintain peripheral venous access. Special interventions are defined as the use of any technique or hospital resource with the potential to improve peripheral IV insertion success rates. These include traditional methods of enhancing the visibility and palpability of peripheral veins (eg, warming the catheter site to induce vasodilation); advanced visualization technologies such as ultrasound, transillumination, and nearinfrared lighting; and enlisting designated IV specialists and/or hospital staff with extensive experience in starting pediatric IVs. Some children may need more invasive interventions such as intraosseous (IO) infusion, a peripherally inserted central catheter, or a central venous catheter (CVC) to achieve parenteral access. There is a dearth of clinical evidence on the incidence of DVA in pediatric patients. Studies of IV insertion success rates indicate that 5% to 33% of children require more than 2 needle sticks to achieve IV access. Even when interventions such as transillumination and ultrasound are used, up to 15% of children still require more than 2 attempts to establish venous access. A recent prospective analysis of 593 insertion attempts in centers with pediatric hospitalist services showed that successful placement Establishing peripheral intravenous (IV) access in pediatric patients can be challenging. Clinical studies show that only 53% to 76% of children are successfully cannulated on the first attempt. Multiple failed attempts are painful and upsetting for the child and distressing for family members and caregivers, yet there are no guidelines or consensus statements on the recognition and management of this problem. In January 2008, a panel of physicians and nurses specializing in emergency medicine, anesthesia, critical care, and hospital medicine convened to discuss peripheral difficult venous access (DVA) in children. Daniel Rauch, MD, FAAP, and Laura L. Kuensting, MSN(R), RN, CPNP, cochaired the roundtable discussion, which was made possible by a grant from Baxter Healthcare, Inc. The main objectives of the meeting were to estimate the frequency of DVA in pediatric patients; describe its clinical and emotional impact on the patient, the patient’s family, and clinicians; develop terminology that accurately describes the condition; review the factors that help identify children with DVA; and

Evaluating the Performance of Medical Educators: A Novel Analysis Tool to Demonstrate the Quality and Impact of Educational Activities

Purpose Traditional promotion standards rely heavily on quantification of research grants and publications in the curriculum vitae. The promotion and retention of educators is challenged by the lack of accepted standards to evaluate the depth, breadth, quality, and impact of educational activities. The authors sought to develop a practical analysis tool for the evaluation of educator portfolios (EPs), based on measurable outcomes that allow reproducible analysis of the quality and impact of educational activities. Method The authors, 10 veteran educators and an external expert evaluator, used a scholarly, iterative consensus-building process to develop the tool and test it using real EPs from educational scholars who followed an EP template. They revised the template in parallel with the analysis tool to ensure that EP data enabled valid and reliable evaluation. The authors created the EP template and analysis tool for scholar and program evaluation in the Educational Scholars Program, a three-year national certification program of the Academic Pediatric Association. Results The analysis tool combines 18 quantitative and 25 qualitative items, with specifications, for objective evaluation of educational activities and scholarship. Conclusions The authors offer this comprehensive, yet practical tool as a method to enhance opportunities for faculty promotions and advancement, based on well-defined and documented educational outcome measures. It is relevant for clinical educators across disciplines and across institutions. Future studies will test the interrater reliability of the tool, using data from EPs written using the revised template.

Inpatient staffing within pediatric residency programs: Work hour restrictions and the evolving role of the pediatric hospitalist

OBJECTIVE In October 2010, the Accreditation Council for Graduate Medical Education (ACGME) mandated new standards that will further restrict resident work hours. There is growing concern surrounding the impact these restrictions will have on the staffing of inpatient services. The objective of this study was to survey the landscape of pediatric resident coverage of noncritical care inpatient teaching services prior to the implementation of these guidelines. In addition, we sought to explore how changes in work hour restrictions might affect the role of pediatric hospitalists in training programs. METHODS In January 2010, an institutional review board (IRB)-approved electronic survey was sent to 196 US residency training programs via the Association of Pediatric Program Directors (APPD) listserve. RESULTS One hundred twenty responses were received representing 5201 pediatric residents. Of the programs that responded, 84% have hospitalists. At programs with hospitalists (n = 97), 24% have pediatric hospitalist attendings in-house at night. Nearly a quarter of responding programs (22%) reported having no attending physicians in-house at night. At the time of our survey, 31% of programs anticipated the addition of 24-hour in-house hospitalist coverage within the next 5 years. When the additional work hour restrictions are implemented, 70% of programs anticipated the need to add additional hospitalist coverage at night. CONCLUSIONS Significant variation exists in how pediatric teaching services provide overnight coverage. While hospitalists are prevalent in pediatric training programs (84% overall, 67% day only), their role in direct patient care during the overnight hours has been limited thus far. New work hour restrictions will promote the need for more hospitalists.

Guiding Principles for Pediatric Hospital Medicine Programs

Pediatric hospital medicine programs have an established place in pediatric medicine. This statement speaks to the expanded roles and responsibilities of pediatric hospitalists and their integrated role among the community of pediatricians who care for children within and outside of the hospital setting.

Lessons from pediatrics residency program directors' experiences with work hour limitations in New York State.

Purpose To evaluate the impact of residency work hour limitations on pediatrics residency programs in New York State, and to learn lessons that can be used nationally with the implementation of the Accreditation Council of Graduate Medical Educations similar rules. Method A three-page questionnaire was mailed to all pediatrics residency program directors in New York. The questionnaire assessed methods used to accommodate the work hour limitations and perceptions of the limitations’ effects. Results Twenty-one program directors responded (68%). Only large programs used night floats and night teams to meet work hour requirements. Programs of all sizes and in all settings used cross coverage and sent residents home immediately post call. About half of the programs hired additional nonresident staff, usually nurse practitioners, physician assistants, and/or attendings. The most frequently reported effects were decreases in the amount of time residents spent in inpatient settings, patient continuity in inpatient settings, flexibility of residents’ scheduling, and increased logistical work needed to maintain continuity clinic. A summary of advice to other program directors was “be creative” and “be flexible.” Conclusions New Yorks pediatrics residency programs used a variety of mechanisms to meet work hour restrictions. Smaller programs had fewer methods available to them to meet such restrictions. Although the logistical work needed to maintain continuity clinic increased greatly, continuity and outpatient settings themselves were not greatly affected by work hour limitations. Inpatient settings were more affected and experienced much more in the way of change.

Changes in inpatient staffing following implementation of new residency work hours.

BACKGROUND In 2011, the Accreditation Council for Graduate Medical Education added additional resident work-hour restrictions that limited the number of hours residents could work, with increased emphasis on attending supervision. OBJECTIVE Our objective was to determine how residency programs have responded to residency work hours, specifically assessing residency night float systems and in-house attending physicians. DESIGN In May 2012, an electronic survey was sent to all US pediatric residency training programs via the Association of Pediatric Program Directors listserv with e-mail reminders to nonresponding programs. We analyzed data to assess the use of resident night float systems, admission caps, and attending physicians in-house at night. RESULTS Out of 198 programs contacted, 152 programs responded (77% response rate). Residency programs utilizing a night float system increased from 43% to 71% after new work hours were implemented. Overall use of resident admission caps did not change significantly. Twenty-three percent of programs increased the number of attending physicians in-house at night; 57% of those programs increased the number of pediatric hospitalist attendings, whereas 37% increased the number of pediatric intensivists. There is a trend toward increased pediatric hospitalist attending in-house 24/7 coverage. Of programs without 24/7 coverage, 26% plan to add coverage within 5 years. Only 12% of programs have no in-house attending coverage at night. CONCLUSIONS Although programs vary in their response to changes in residency work restrictions, they most commonly utilize night float systems and increased the amount of in-house attending coverage at night, especially pediatric hospitalist attendings. Many programs plan to add 24/7 pediatric hospitalist coverage within 5 years.

Medical Staff Appointment and Delineation of Pediatric Privileges in Hospitals

The review and verification of credentials and the granting of clinical privileges are required of every hospital to ensure that members of the medical staff are competent and qualified to provide specified levels of patient care. The credentialing process involves the following: (1) assessment of the professional and personal background of each practitioner seeking privileges; (2) assignment of privileges appropriate for the clinician’s training and experience; (3) ongoing monitoring of the professional activities of each staff member; and (4) periodic reappointment to the medical staff on the basis of objectively measured performance. We examine the essential elements of a credentials review for initial and renewed medical staff appointments along with suggested criteria for the delineation of clinical privileges. Sample forms for the delineation of privileges can be found in the Supplemental tab at http://pediatrics.aappublications.org/content/129/4/797.supplemental. Because of differences among individual hospitals, no 1 method for credentialing is universally applicable. The medical staff of each hospital must, therefore, establish its own process based on the general principles reviewed in this report. The issues of medical staff membership and credentialing have become very complex, and institutions and medical staffs are vulnerable to legal action. Consequently, it is advisable for hospitals and medical staffs to obtain expert legal advice when medical staff bylaws are constructed or revised.

Use of Ketamine in a Pain Management Protocol for Repetitive Procedures

Ketamine has been the focus of recent attention in the literature for its use as an anesthetic and analgesic agent for pediatric procedures.1-3 Its safety profile and adverse effects have been noted. Although current interest in ketamine has been in its use for painful procedures and much of the original human studies were done on children,4 there are a few reports of repeated ketamine administration to pediatric patients. Some of the reports are for radiotherapy5-7 and brief painful procedures associated with chemotherapy such as lumbar punctures.8-11 One early report documents using ketamine for burn care procedures that were painful, repetitive, and hours in duration.12 This report stressed the use of ketamine … Address correspondence to Daniel A. Rauch, MD, Jacobi Medical Center, Department of Pediatrics, Room 803H, 1400 Pelham Pkwy South, Bronx, NY 10461.