Daniel M. Fein

Interns' Success With Clinical Procedures in Infants After Simulation Training

BACKGROUND AND OBJECTIVE: Simulation-based medical education (SBME) is used to teach residents. However, few studies have evaluated its clinical impact. The goal of this study was to evaluate the impact of an SBME session on pediatric interns’ clinical procedural success. METHODS: This randomized trial was conducted at 10 academic medical centers. Interns were surveyed on infant lumbar puncture (ILP) and child intravenous line placement (CIV) knowledge and watched audiovisual expert modeling of both procedures. Participants were randomized to SBME mastery learning for ILP or CIV and for 6 succeeding months reported clinical performance for both procedures. ILP success was defined as obtaining a sample on the first attempt with <1000 red blood cells per high-power field or fluid described as clear. CIV success was defined as placement of a functioning catheter on the first try. Each group served as the control group for the procedure for which they did not receive the intervention. RESULTS: Two-hundred interns participated (104 in the ILP group and 96 in the CIV group). Together, they reported 409 procedures. ILP success rates were 34% (31 of 91) for interns who received ILP mastery learning and 34% (25 of 73) for controls (difference: 0.2% [95% confidence interval: –0.1 to 0.1]). The CIV success rate was 54% (62 of 115) for interns who received CIV mastery learning compared with 50% (58 of 115) for controls (difference: 3% [95% confidence interval: –10 to 17]). CONCLUSIONS: Participation in a single SBME mastery learning session was insufficient to affect pediatric interns’ subsequent procedural success.

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.

Pattern of pain management during lumbar puncture in children.

Background: Although studies have shown that children have similar physiological pain responses as adults, children often receive less pain medication compared with adults with similar painful conditions. The lumbar puncture is a painful procedure that historically has been commonly performed without local anesthesia, especially in young infants. Objective: The aim of the study was to determine what type of pain management, if any, pediatric patients received during lumbar puncture and whether its use varied by patient age. Methods: We performed a retrospective review of patients who had cerebrospinal fluid cultures obtained via lumbar puncture during 2003 at a large urban childrens hospital. Eligible cases were reviewed for demographic data, hospital patient care area, and type of pain management used for the procedure. Results: Of the 353 children who had lumbar punctures performed, 84 (23.8%) received some form of pain management before their lumbar puncture. Sixty (17.0%) received local anesthesia, 43 (12.2%) received sedation, and 19 (5.4%) of these received both local anesthesia and sedation. Younger patients received pain management less frequently (P < 0.001): 16 (6.5%) of 246 neonates (0-2 months), 4 (14.3%) of 28 infants (3-18 months), 9 (60%) of 15 preschoolers (19-59 months), and 55 (85.9%) of 64 older children (60 months to 21 years). Among infants, patients treated in the emergency department received pain management more often than those treated in the nursery (13/103 [12.6%] vs 1/117 [0.9%]; P = 0.001). Conclusions: Despite advances in the awareness and attentiveness given to pain and pain management in the pediatric population, children are still not receiving satisfactory pain management for lumbar punctures.

Script concordance testing: Assessing residents' clinical decision-making skills for infant lumbar punctures

Purpose Residents must learn which infants require a lumbar puncture (LP), a clinical decision-making skill (CDMS) difficult to evaluate because of considerable practice variation. The authors created an assessment model of the CDMS to determine when an LP is indicated, taking practice variation into account. The objective was to detect whether script concordance testing (SCT) could measure CDMS competency among residents for performing infant LPs. Method In 2011, using a modified Delphi technique, an expert panel of 14 attending physicians constructed 15 case vignettes (each with 2 to 4 SCT questions) that represented various infant LP scenarios. The authors distributed the vignettes to residents at 10 academic pediatric centers within the International Simulation in Pediatric Innovation, Research, and Education Network. They compared SCT scores among residents of different postgraduate years (PGYs), specialties, training in adult medicine, LP experience, and practice within an endemic Lyme disease area. Results Of 730 eligible residents, 102 completed 47 SCT questions. They could earn a maximum score of 47. Median SCT scores were significantly higher in PGY-3s compared with PGY-1s (difference: 3.0; 95% confidence interval [CI] 1.0–4.9; effect size d = 0.87). Scores also increased with increasing LP experience (difference: 3.3; 95% CI 1.1–5.5) and with adult medicine training (difference: 2.9; 95% CI 0.6–5.0). Residents in Lyme-endemic areas tended to perform more LPs than those in nonendemic areas. Conclusions SCT questions may be useful as an assessment tool to determine CDMS competency among residents for performing infant LPs.

Intranasal fentanyl for initial treatment of vaso-occlusive crisis in sickle cell disease

Analgesia administration for children with vaso‐occlusive crises is often delayed in the emergency department. Intranasal fentanyl (INF) has been shown to be safe and effective in providing rapid analgesia for other painful conditions. Our objective was to determine if children with a vaso‐occlusive crisis (VOC) who received initial treatment with INF compared to placebo achieved a greater decrease in pain score after 20 min.

The Correlation of Workplace Simulation-Based Assessments With Interns' Infant Lumbar Puncture Success: A Prospective, Multicenter, Observational Study.

Introduction Little data are available to guide supervisors’ decisions regarding when trainees are prepared to safely perform their first procedure on a patient. We aimed to describe the correlation of simulation-based assessments, in the workplace, with interns’ first clinical infant lumbar puncture (ILP) success. Methods This is a prospective, observational subcomponent of a larger study of incoming interns at 33 academic medical centers (July 2010 to June 2012) assessing the impact of just-in-time training. When an intern’s patient required an ILP, a just-in-time simulation-based skills refresher was conducted with his or her supervisor. At the end of the refresher, supervisors assessed interns’ ILP skills on a simulator in the workplace before clinical performance using a four point anchored scale. The primary outcome was the correlation of supervisors’ assessment and interns’ procedural success. The number needed to assess for this instrument (1 / absolute risk reduction) was calculated. Results A total of 1600 interns were eligible to participate, and 1215 were enrolled. A total of 297 completed an assessment and a subsequent clinical ILP. Success rates for each scale rating were 29% (18/63) for novice, 39% (51/130) for beginner, 55% (46/83) for competent, and 43% (9/21) for proficient. The correlation coefficient was 0.161 (95% confidence interval, 0.057–0.265), indicating a weak correlation between supervisor rating and success. Success rate was 53% for the ratings of competent or proficient compared with 35% for the ratings of novice or beginner. Using the global rating scale for the summative assessment to determine procedural readiness could lead to 1 fewer patient experiencing a failed ILP for every 6 interns tested (6.2; 95% confidence interval, 4.0–8.5). Conclusions A simulation-based assessment of interns conducted in the workplace before their first ILP has some value in predicting clinical ILP success.

An overdose of extended-release guanfacine

Extended-release guanfacine is a centrally acting α2-adrenergic agonist that was recently approved for treatment of attention-deficit/hyperactivity disorder. The following is a case discussion of a 12-year-old boy with attention-deficit/hyperactivity disorder and Tourette syndrome, who presented 18 hours after ingestion of 3 times his usual dose of extended-release guanfacine. On presentation, he was lethargic, bradycardic, and hypertensive with an otherwise nonfocal neurological examination. He remained hypertensive until administration of an intravenous antihypertensive agent (nicardipine) 24 hours after ingestion. After cessation of the calcium-channel blocker, he continued to have intermittent episodes of symptomatic hypotension for the next 2½ days. This extremely protracted course of hypertension followed by prolonged symptomatic hypotension is rare with ingestions of centrally acting α2-adrenergic agonists. As this drug is increasingly prescribed for treatment of a disease with increasing prevalence, it is imperative that emergency physicians become familiar with the varying presentations of its toxicity.

The heart of the matter: an atypical presentation of Takayasu arteritis in the Pediatric Emergency Department.

Takayasu arteritis (TA) is a rare chronic large-vessel vasculitis of unknown etiology. Although commonly thought of as an adult disease, initial manifestations frequently appear during adolescence. This is a case discussion of an 11-year-old boy with a recent history of fever who presented with shortness of breath, sore throat, chest pain, hypertension, and a new murmur. He had a markedly elevated antistreptolysin O titer, had a prolonged PR interval, and was initially evaluated with acute rheumatic fever. After admission, he had persistent hypertension, proteinuria, and hemoptysis, which prompted a magnetic resonance angiography that revealed aortic enhancement and thickening, and he was evaluated with TA. To our knowledge, this is the first case report in the pediatric literature of TA presenting with heart block. This case highlights the recondite nature of the systemic vasculitides and emphasizes the importance of keeping a broad differential diagnosis when seeing patients who present with common complaints.

Screening residents for infant lumbar puncture readiness with just-in-time simulation-based assessments

Background Determining when to entrust trainees to perform procedures is fundamental to patient safety and competency development. Objective To determine whether simulation-based readiness assessments of first year residents immediately prior to their first supervised infant lumbar punctures (LPs) are associated with success. Methods This prospective cohort study enrolled paediatric and other first year residents who perform LPs at 35 academic hospitals from 2012 to 2014. Within a standardised LP curriculum, a validated 4-point readiness assessment of first year residents was required immediately prior to their first supervised LP. A score ≥3 was required for residents to perform the LP. The proportion of successful LPs (<1000 red blood cells on first attempt) was determined. Process measures included success on any attempt, number of attempts, analgesia usage and use of the early stylet removal technique. Results We analysed 726 LPs reported from 1722 residents (42%). Of the 432 who underwent readiness assessments, 174 (40%, 95% CI 36% to 45%) successfully performed their first LP. Those who were not assessed succeeded in 103/294 (35%, 95% CI 30% to 41%) LPs. Assessed participants reported more frequent direct attending supervision of the LP (diff 16%; 95% CI 8% to 22%), greater use of topical analgesia (diff 6%; 95% CI 1% to 12%) and greater use of the early stylet removal technique (diff 11%; 95% CI 4% to 19%) but no difference in number of attempts or overall procedural success. Conclusions Simulation-based readiness assessments performed in a point-of-care fashion were associated with several desirable behaviours but were not associated with greater clinical success with LP.

Nonsteroidal anti-inflammatory drug and salicylate poisoning

1. Ellie E. Rakovchik, MD* 2. Daniel M. Fein, MD* 1. *Albert Einstein College of Medicine/Children’s Hospital at Montefiore, Bronx, NY. 1. Guidance Document: Management Priorities in Salicylate Toxicity . American College of Medical Toxicity. J. Med Toxicol. 2015;11(1):149-152 [OpenUrl][1][CrossRef][2][PubMed][3] 2. 1. Bronstein AC, 2. Spyker DA, 3. Cantilena LR Jr, 4. Rumack BH, 5. Dart RC 2011 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 29th Annual Report. Bronstein AC, Spyker DA, Cantilena LR Jr, Rumack BH, Dart RC. Clin Toxicol (Phila). 2012;50(10):911-1164 [OpenUrl][4][CrossRef][5][PubMed][6] 3. 1. Belson MG, 2. Watson WA 1. Flomenbaum N, 2. Goldfrank L, 3. Hoffman R, 4. et al. Nonsteroidal Antiinflammatory Drugs . Belson MG, Watson WA. In: Flomenbaum N, Goldfrank L, Hoffman R, et al., eds. Goldfrank’s Toxicologic Emergencies. New York, NY: McGraw-Hill; 2006:573-578 4. 1. Flomenbaum NE 1. Flomenbaum N, 2. Goldfrank L, 3. Hoffman R, 4. et al. Salicylates. Flomenbaum NE. In: Flomenbaum N, Goldfrank L, Hoffman R, et al., eds. Goldfrank’s Toxicologic Emergencies. New York, NY: McGraw-Hill; 2006:550-564 5. 1. O’Malley GF Emergency Department Management of the Salicylate-poisoned Patient. O’Malley GF. Emerg Med Clin N Am. 2007;25(2):333-346 [OpenUrl][7][CrossRef][8][PubMed][9] Nonsteroidal-anti-inflammatory-drugs (NSAIDs) and salicylates are commonly found in over-the-counter (OTC) analgesics that are available for purchase in large quantities at relatively little cost in the United States. Consequently, they are ubiquitous in households, often in quantities that, if ingested, can cause toxicity. Analgesics (including NSAIDs, salicylates, and acetaminophen) are the most common substance class involved in all human ingestions and the second most common in children younger than 6 years of age, after cosmetics. NSAIDs function by reversibly inhibiting the enzyme cyclooxygenase (COX), thereby preventing the formation of prostaglandins, prostacyclins, and thromboxane A2 from arachidonic acid. This ultimately results in antipyretic, analgesic, and anti-inflammatory effects. There are two isoforms of COX: COX-1, which is present in all tissues, and COX-2, which is produced locally during the inflammatory response. Common OTC NSAID formulations of ibuprofen and naproxen inhibit COX-1 more than COX-2, while newer prescription NSAIDs such as celecoxib have a greater affinity for COX-2. Most NSAID ingestions in the United States involve ibuprofen. Symptoms of NSAID overdose manifest within 4 to 6 hours of ingestion. Most NSAID ingestions are asymptomatic or are associated with only minimal gastrointestinal (GI) symptoms, such as nausea, emesis, abdominal pain, and GI bleeding. Hepatic injury resulting in increased liver enzymes and liver failure can occur. Neurologic symptoms that frequently occur in the setting of NSAID ingestion are … [1]: {openurl}?query=rft.jtitle%253DJ.%2BMed%2BToxicol%26rft.volume%253D11%26rft.spage%253D149%26rft_id%253Dinfo%253Adoi%252F10.1007%252Fs13181-013-0362-3%26rft_id%253Dinfo%253Apmid%252F25715929%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/external-ref?access_num=10.1007/s13181-013-0362-3&link_type=DOI [3]: /lookup/external-ref?access_num=25715929&link_type=MED&atom=%2Fpedsinreview%2F37%2F1%2F48.atom [4]: {openurl}?query=rft.jtitle%253DClin%2BToxicol%2B%2528Phila%2529%26rft.volume%253D50%26rft.spage%253D911%26rft_id%253Dinfo%253Adoi%252F10.3109%252F15563650.2012.746424%26rft_id%253Dinfo%253Apmid%252F23272763%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [5]: /lookup/external-ref?access_num=10.3109/15563650.2012.746424&link_type=DOI [6]: /lookup/external-ref?access_num=23272763&link_type=MED&atom=%2Fpedsinreview%2F37%2F1%2F48.atom [7]: {openurl}?query=rft.jtitle%253DEmergency%2Bmedicine%2Bclinics%2Bof%2BNorth%2BAmerica%26rft.stitle%253DEmerg%2BMed%2BClin%2BNorth%2BAm%26rft.aulast%253DO%2527malley%26rft.auinit1%253DG.%2BF.%26rft.volume%253D25%26rft.issue%253D2%26rft.spage%253D333%26rft.epage%253D346%26rft.atitle%253DEmergency%2Bdepartment%2Bmanagement%2Bof%2Bthe%2Bsalicylate-poisoned%2Bpatient.%26rft_id%253Dinfo%253Adoi%252F10.1016%252Fj.emc.2007.02.012%26rft_id%253Dinfo%253Apmid%252F17482023%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [8]: /lookup/external-ref?access_num=10.1016/j.emc.2007.02.012&link_type=DOI [9]: /lookup/external-ref?access_num=17482023&link_type=MED&atom=%2Fpedsinreview%2F37%2F1%2F48.atom