Gunjan Tiyyagura

Pediatric Anaphylaxis Management in the Prehospital Setting

Abstract Purpose. Anaphylaxis is a life-threatening systemic allergic reaction that occurs after contact with an allergy-causing substance. Timely administration of intramuscular epinephrine is the treatment of choice for controlling symptoms and decreasing fatalities. Our purpose was to investigate the prehospital management of anaphylaxis among patients receiving care in an urban tertiary care pediatric emergency department (PED). Methods. We performed a retrospective chart review from May 2008 to January 2010 of patients 18 years or younger who received care in the PED for anaphylaxis. Data were extracted by one investigator and included demographic information, patient symptoms, past medical history, medications administered (including route and provider), and final disposition. Results. We reviewed 218 cases of anaphylaxis in 202 children. Mean age of patients was 7.4 years; 56% of patients were male. A total of 214 (98%) manifested symptoms in the skin/mucosal system, 68% had respiratory symptoms, 44% had gastrointestinal symptoms, and 2% had hypotension. Sixty-seven percent had a previous history of allergic reaction and 38% had a history of asthma. Seventy-six percent of the patients presented with anaphylaxis to food products, 8% to medications, 1% to stings, and 16% to unknown allergens. Reactions occurred at home or with family members 87% of the time, and at school 12% of the time. Only 36% of the patients who met criteria for anaphylaxis had epinephrine administered by emergency medical services (EMS). Among 26 patients with anaphylactic reactions at school, 69% received epinephrine by the school nurse. Of the 117 patients with known allergies who were with their parents at the time of anaphylactic reaction, 41% received epinephrine. Thirteen patients were seen by a physician prior to coming to the PED; all received epinephrine at the physicians office. In total, epinephrine was given to 41% (89) of the 218 cases prior to coming to the PED. Conclusions. Our evaluation revealed low rates of epinephrine administration by EMS providers and parents/patients. Education about anaphylaxis is imperative to encourage earlier administration of epinephrine.

Latino Caregiver Experiences With Asthma Health Communication

In this article, we analyze qualitative data from a purposeful sample of limited English proficiency (LEP) asthma health caregivers. We used ethnically concordant, semistructured, in-depth Spanish-language interviews and a follow-up focus group to explore issues related to communication during pediatric asthma encounters in medical settings. Inductive coding of Spanish transcripts by a bilingual research team was performed until thematic saturation was reached. Several key findings emerged. LEP caregivers encountered significant asthma burdens related to emotional stress, observed physical changes, and communication barriers. Language-discordant communication and the use of ad hoc interpreters were common. This finding is complex, and was influenced by perceptions of interpreter availability, delays in care, feelings of mistrust toward others, and individual emotional responses. Language-concordant education and suitable action plans were valued and desired. We discuss a revealing depiction of the LEP caregiver experience with asthma health communication and recommend areas for further inquiry.

Barriers and facilitators to recognition and reporting of child abuse by prehospital providers

Abstract Background: Prehospital care providers are in a unique position to provide initial unadulterated information about the scene where a child is abusively injured or neglected. However, they receive minimal training with respect to detection of Child Abuse and Neglect (CAN) and make few reports of suspected CAN to child protective services. Aims: To explore barriers and facilitators to the recognition and reporting of CAN by prehospital care providers. Design/Methods: Twenty-eight prehospital care providers participated in a simulated case of infant abusive head trauma prior to participating in one-on-one semi-structured qualitative debriefs. Researchers independently coded transcripts from the debriefing and then collectively refined codes and created themes. Data collection and analysis continued past the point of thematic saturation. Results: Providers described 3 key tasks when caring for a patient thought to be maltreated: (1) Medically managing the patient, which included assessment of the patients airway, breathing, and circulation and management of the chief complaint, followed by evaluation for CAN; (2) Evaluating the scene and family interactions for signs suggestive of CAN, which included gathering information on the presence of elicit substances and observing how the child behaves in the presence of caregivers; and (3) Creating a safety plan, which included, calling police for support, avoiding confrontation with the caregivers and sharing suspicion of CAN with hospital providers and child protective services. Reported barriers to recognizing CAN included discomfort with pediatric patients; uncertainty related to CAN (accepting parental story about alternative diagnosis and difficulty distinguishing between accidental and intentional injuries); a focus on the chief complaint; and limited opportunity for evaluation. Barriers to reporting included fear of being wrong; fear of caregiver reactions; and working in a fast-paced setting. In contrast, facilitators to reporting included understanding of the mandated reporter role; sharing thought processes with peers; and supervisor support. Conclusions: Prehospital care providers have a unique vantage point in detecting CAN, but limited resources and knowledge related to this topic. Focused education on recognition of signs of physical abuse; increased training on scene safety; real-time decision support; and increased follow-up related to cases of CAN may improve their detection of CAN.

Facilitating Tough Conversations: Using an Innovative Simulation-Primed Qualitative Inquiry in Pediatric Research

Deep exploration of a complex health care issue in pediatrics might be hindered by the sensitive or infrequent nature of a particular topic in pediatrics. Health care simulation builds on constructivist theories to guide individuals through an experiential cycle of action, self-reflection, and open discussion, but has traditionally been applied to the educational domain in health sciences. Leveraging the emotional activation of a simulated experience, investigators can prime participants to engage in open dialogue for the purposes of qualitative research. The framework of simulation-primed qualitative inquiry consists of 3 main iterative steps. First, researchers determine applicability by consideration of the need for an exploratory approach and potential to enrich data through simulation priming of participants. Next, careful attention is needed to design the simulation, with consideration of medium, technology, theoretical frameworks, and quality to create simulated reality relevant to the research question. Finally, data collection planning consists of a qualitative approach and method selection, with particular attention paid to psychological safety of subjects participating in the simulation. A literature review revealed 37 articles that used this newly described method across a variety of clinical and educational research topics and used a spectrum of simulation modalities and qualitative methods. Although some potential limitations and pitfalls might exist with regard to resources, fidelity, and psychological safety under the auspices of educational research, simulation-primed qualitative inquiry can be a powerful technique to explore difficult topics when subjects might experience vulnerability or hesitation.

The association of nonaccidental trauma with historical factors, examination findings, and diagnostic testing during the initial trauma evaluation

Nonaccidental trauma (NAT) or child abuse is the deliberate or intentionally inflicted injury of a child and is a form of child maltreatment.1 One in four children experience some form of maltreatment in their lifetime.2 Annually, nearly one million children are victims of maltreatment in the UnitedEarly identification of non-accidental trauma (NAT) is a critical component of pediatric trauma care. Literature searches were conducted related to the association of NAT with seven key areas: history, exam findings (burns, oral trauma, bruising) and imaging (fractures, abdominal and brain injuries). When available, odds ratios (OR) with 95% confidence intervals (CI) for associations with NAT are presented. Systematic reviews have been published in six of the seven key areas and are described. The operational definition of NAT was widely variable across studies, prohibiting meta-analysis. Select highly associated findings included bruising in a pre-mobile child, clustering of bruises (OR 4.0, CI 2.5-6.4), petechiae (OR 9.3, CI 2.9-30.2), chemical burns 24.6 (4.94-135); contact burns 5.2 (1.6-22.9); scald burns 17.4 (6.4-72), burns to hand 1.8 (1.3-2.6), feet 6.3 (4.6-8.6), buttocks 3.1 (2.2-4.5), and perineum 2.5 (1.7-3.7), subdural hematoma (OR 8.2, 6.1-11), hypoxic ischemic injury (OR 4.2, CI 0.6-2.7), and retinal hemorrhages (OR 14.7, CI 6.4 to 33.6) among others. Of note, hollow viscus injuries, particularly duodenal injuries in children < 4 years were indicative of NAT. While there is substantial research on factors associated with NAT, future work is needed to standardize the definition of NAT for investigation and practice, such that evidence-based guidelines can be created to inform trauma providers when a comprehensive NAT evaluation is indicated.

A web-based educational video to improve asthma knowledge for limited English proficiency Latino caregivers

ABSTRACT Objectives: To evaluate limited English proficiency (LEP) Latino caregiver asthma knowledge after exposure to an educational video designed for this target group. Methods: A cross-sectional, interventional study was performed. We aimed to evaluate the post-test impact on asthma knowledge from baseline after exposure to a patient-centered, evidence-based, and professionally produced Spanish asthma educational video. Participants included LEP Latino caregivers of children 2–12 years old with persistent asthma. Enrollment was performed during ED encounters or scheduled through a local community organization. Asthma knowledge was measured with a validated Spanish parental asthma knowledge questionnaire. Differences in mean scores were calculated with a paired t-test. Results: Twenty caregivers were enrolled. Participants included mothers (100%) from Puerto Rico (75%), with a high-school diploma or higher (85%), with no written asthma action plan (65%), whose childs asthma diagnosis was present for at least 3 years (80%). Mean baseline asthma knowledge scores improved 8 points from 58.4 to 66.4 after watching the educational video (95% CI 5.3–10.7; t(19) = 6.21, p < 0.01). Knowledge improvements were similar across the ED and community groups. Knowledge gains were observed in the areas of ED utilization, medication usage, and activity limitations. Conclusions: The developed educational video improved caregiver asthma knowledge for a Latino population facing communication barriers to quality asthma care. Dissemination of this educational resource to LEP caregivers has the potential to improve pediatric asthma care in the United States.

Board 398 - Research Abstract Working through Barriers to Simulation-Based Just-In-Time Training and Competency Assessments for Infant Lumbar Punctures (Submission #282)

Introduction/Background Competency-based education (CBE) is a new paradigm for residency training. The International Network for Simulation-Based Pediatric Innovation, Research and Education (INSPIRE) designed and implemented a simulation-based training and assessment program to teach infant lumbar punctures (LPs). This educational model consisted of individualized mastery training during intern orientation and pre-performance just-in-time training (JITT) and competency assessments (CAs) to determine procedural readiness. We aimed to explore barriers and strategies for successful program implementation across several centers in the network. Methods We conducted a qualitative study of semi-structured interviews and focus groups (1/2013-7/2013) of site directors participating in the INSPIRE LP project using convenience sampling. Using a validated theoretical framework,1,2 we developed an interview guide. Questions were iteratively revised during the interview process for comprehensive understanding. Interviews were audio-recorded and transcribed verbatim. We inductively analyzed the transcripts using grounded theory and applied serial immersion and crystallization cycles to identify and verify emergent themes and subthemes until thematic saturation was achieved. Results Thematic saturation was attained after interviewing 19 (54%) site directors in 12 one-on-one and 3 group sessions. Collectively, directors identified >75 barriers, voicing four main barriers as most significant: vision and buy-in, education vs. patient care, teaching paradigms and communication. In many institutions, competing visions between site directors and residency directors prevented programmatic buy-in. Some site directors found that with already limited opportunities to perform LPs, residency directors refused to deny interns clinical LPs even after failed CAs. Many believed the ACGME’s mandate for CBE was a powerful motivator and provided guidance to residency directors regarding the LP CA model. Successful site directors strategized to align their project vision with the residency directors’ goals to secure buy-in and resources. Many site directors described the conflict between education and patient care while facilitating LPs in clinical arenas. Some faculty viewed the JITT and CAs as cumbersome and difficult to coordinate with interns. In busy units, supervisors and interns focused on clinical responsibilities were more likely to forget JITTs and CAs. Directors were likely to overcome workflow roadblocks in their own units; however, unfamiliarity of key players and workflow in other units usually became an insurmountable challenge. Strategies to overcome these clinical barriers included collaborating with champions from other units, delegating JITTs and CAs to educationally-minded fellows or chief residents to offset the attending workload and empowering interns to advocate for their education. Several directors discussed faculty resistance to shift their approach of teaching procedures from an apprentice to a simulation-based competency model. The difficulty of failing interns during CAs, coupled with concerns of interns losing clinical opportunities after failing, either led supervisors to pass interns after multiple attempts or prevented support of the educational paradigm. Several directors used INSPIRE data showing increased LP success rates in competent trainees and helped supervisors understand how the simulation model for education can promote quality improvement. Communicating with large groups of supervisors and interns created logistical barriers to disseminate program-related information and reminders. While email communication was common, most directors found the emergence of email fatigue. When email communication failed, personal contact with supervisors was an effective strategy to reinforce accountability and change educational culture. Overall, the ability to overcome barriers was influenced by institutional culture, the level of relational coordination between different stakeholders, and site directors’ ingenuity to identify and diversify strategies. Conclusion Understanding institution-specific barriers of implementing CBE provides a platform for developing effective entrepreneurial strategies in clinical education. The collective experiences of INSPIRE site directors highlighted unique challenges of medical education initiatives and may be instructive to clinician-educators in the continuous development and implementation of this LP or other CBE programs. References 1. Burke W and Litwin GH. A causal model of organizational performance and change. Journal of management 1992;18(3):523-45. 2. McRoy I and Gibbs P. An institution in change: a private institution in transition. The International Journal of Educational Management 2003;17:147. Disclosures RBaby Foundation rababy foundation my smart health care.