Joel A. Fein

Assessing pediatric senior residents' training in resuscitation: Fund of knowledge, technical skills, and perception of confidence

Objective To describe pediatric housestaff knowledge, experience, confidence in pediatric resuscitations and their ability to perform important resuscitation procedures during the usual training experience. Design and participants Cohort study of PGY-3 level residents in a ACGME accredited pediatric residency training program at a large, tertiary care children’s hospital. Methods Fund of knowledge was assessed by administering the standardized test from the Pediatric Advanced Life Support (PALS) Course in addition to a supplemental short answer test requiring clinical problem-solving skills. Procedural skills were evaluated through observation of the resident performing four procedures during a skills workshop using a weighted step-wise grading sheet. Resident experience and confidence was quantified using an anonymous survey. Results Ninety-seven percent of residents participated. Residents achieved high scores on the standardized PALS test (93.2% ± 5.5), but performed less well when answering more complicated questions (60.0% ± 9.9) on the short answer test. No resident was able to successfully perform both basic and advanced airway skills, and only 11% successfully completed both vascular skills. Although residents were overall confident in their resuscitation skills, performance in the skill workshop revealed significant deficits. For example, only 18% performed ancillary airway maneuvers properly. None of the residents performed all four skills correctly. Experience in both real and mock resuscitations was infrequent. Residents reported receiving feedback on their performance less than half of the time. Over 89% of them felt that resuscitation knowledge and skill were important for their future chosen career. Conclusion Pediatric residents infrequently lead or participate in real or mock resuscitations. Although confident in performing many of the necessary resuscitation skills, few residents performed critical components of these skills correctly. Current pediatric residency training may not provide sufficient experience to develop adequate skills, fund of knowledge, or confidence needed for resuscitation.

Adverse Childhood Experiences Expanding the Concept of Adversity

INTRODUCTION Current knowledge of Adverse Childhood Experiences (ACEs) relies on data predominantly collected from white, middle- / upper-middle-class participants and focuses on experiences within the home. Using a more socioeconomically and racially diverse urban population, Conventional and Expanded (community-level) ACEs were measured to help understand whether Conventional ACEs alone can sufficiently measure adversity, particularly among various subgroups. METHODS Participants from a previous large, representative, community-based health survey in Southeast Pennsylvania who were aged ≥18 years were contacted between November 2012 and January 2013 to complete another phone survey measuring ACEs. Ordinal logistic regression models were used to test associations between Conventional and Expanded ACEs scores and demographic characteristics. Analysis was conducted in 2013 and 2014. RESULTS Of 1,784 respondents, 72.9% had at least one Conventional ACE, 63.4% at least one Expanded ACE, and 49.3% experienced both. A total of 13.9% experienced only Expanded ACEs and would have gone unrecognized if only Conventional ACEs were assessed. Certain demographic characteristics were associated with higher risk for Conventional ACEs but were not predictive of Expanded ACEs, and vice versa. Few adversities were associated with both Conventional and Expanded ACEs. CONCLUSIONS To more accurately represent the level of adversity experienced across various sociodemographic groups, these data support extending the Conventional ACEs measure.

Medication errors in a pediatric emergency department.

OBJECTIVE To initiate investigation into the medication errors that occur in a pediatric emergency department. These errors have the potential for significant morbidity and mortality, as well as costly litigation. METHODS We conducted a retrospective chart review of all medication and intravenous fluid errors identified in a pediatric emergency department through incident reports filed over a 5-year period. An attempt was made to determine who was involved with the errors and what caused the errors. The patient outcomes were noted and classified according to clinical significance using previously published criteria. RESULTS Thirty-three incident reports involving medication or intravenous fluid errors were analyzed. Most errors occurred on the evening and night shifts. Nurses were involved in 39% of reported errors; the nurse and emergency physician were jointly involved in 36%. The most common error was an incorrect dose of medication (35%) or incorrect medication given (30%). In one third of the cases, the family was not made aware of the error. In 12%, patients required additional treatment, and one was admitted to the hospital because of the error. There were no deaths. CONCLUSION Incorrect recording of patient weights leading to an incorrect medication dose and failure to note drug allergy are common causes for medication errors in the pediatric emergency department. Incorrect drugs and i.v. fluids are given because of similar names and packaging. Many of the errors in the ED seem to be preventable.

Technical Report—Pediatric and Adolescent Mental Health Emergencies in the Emergency Medical Services System

Emergency department (ED) health care professionals often care for patients with previously diagnosed psychiatric illnesses who are ill, injured, or having a behavioral crisis. In addition, ED personnel encounter children with psychiatric illnesses who may not present to the ED with overt mental health symptoms. Staff education and training regarding identification and management of pediatric mental health illness can help EDs overcome the perceived limitations of the setting that influence timely and comprehensive evaluation. In addition, ED physicians can inform and advocate for policy changes at local, state, and national levels that are needed to ensure comprehensive care of children with mental health illnesses. This report addresses the roles that the ED and ED health care professionals play in emergency mental health care of children and adolescents in the United States, which includes the stabilization and management of patients in mental health crisis, the discovery of mental illnesses and suicidal ideation in ED patients, and approaches to advocating for improved recognition and treatment of mental illnesses in children. The report also addresses special issues related to mental illness in the ED, such as minority populations, children with special health care needs, and childrens mental health during and after disasters and trauma.

Before and after the trauma bay: the prevention of violent injury among youth.

Despite a decline in the incidence of homicide in recent years, the United States retains the highest youth homicide rate among the 26 wealthiest nations. Homicide is the second leading cause of death overall and the leading cause of death for male blacks aged 15 to 24 years. High rates of health care recidivism for violent injury, along with increasing research that demonstrates the effectiveness of violence prevention strategies in other arenas, dictate that physicians recognize violence as a complex preventable health problem and implement violence prevention activities into current practice rather than relegating violence prevention to the criminal justice arena. The emergency department (ED) and trauma center settings in many ways are uniquely positioned for this role. Exposure to firearm violence doubles the probability that a youth will commit violence within 2 years, and research shows that retaliatory injury risk among violent youth victims is 88 times higher than among those who were never exposed to violence. This article reviews the potential role of the ED in the prevention of youth violence, as well as the growing number of ED- and hospital-based violence prevention programs already in place.

Cytokine elevations in infants with bacterial and aseptic meningitis.

We sought to determine whether the detection of cytokines, produced during the inflammatory response, would aid in the diagnosis of meningitis in young infants. We measured cerebrospinal fluid (CSF) and plasma levels of interleukin-6 (IL-6) and tumor necrosis factor (TNF) in 62 infants less than 6 months of age whose condition was evaluated for meningitis. Twenty infants had culture-proved meningitis, 22 had aseptic meningitis, and 20 control infants had no evidence of meningitis. The CSF IL-6 levels were elevated in all 20 infants with bacterial meningitis and in 9 of 22 infants with aseptic meningitis but were undetectable in all control subjects. Furthermore, CSF IL-6 levels were 10 times greater in infants with bacterial versus aseptic meningitis (p < 0.001). Levels of TNF in CSF were detected in 12 of 20 infants with bacterial meningitis and were undetectable in infants with aseptic meningitis and in control infants (p < 0.02). Plasma IL-6 and TNF levels were unreliable for the detection of meningitis in this patient population. We conclude that the presence of IL-6 in the CSF reliably identifies infants with meningitis and that the presence of CSF TNF is a highly specific indicator of bacterial meningeal inflammation.

Management of pediatric trauma

Injury is the number 1 killer of children in the United States. In 2004, injury accounted for 59.5% of all deaths in children younger than 18 years. The financial burden to society of children who survive childhood injury with disability continues to be enormous. The entire process of managing childhood injury is complex and varies by region. Only the comprehensive cooperation of a broadly diverse group of people will have a significant effect on improving the care and outcome of injured children. This statement has been endorsed by the American Association of Critical-Care Nurses, American College of Emergency Physicians, American College of Surgeons, American Pediatric Surgical Association, National Association of Childrens Hospitals and Related Institutions, National Association of State EMS Officials, and Society of Critical Care Medicine.

Research ArticleAdverse Childhood Experiences: Expanding the Concept of Adversity

INTRODUCTION Current knowledge of Adverse Childhood Experiences (ACEs) relies on data predominantly collected from white, middle- / upper-middle-class participants and focuses on experiences within the home. Using a more socioeconomically and racially diverse urban population, Conventional and Expanded (community-level) ACEs were measured to help understand whether Conventional ACEs alone can sufficiently measure adversity, particularly among various subgroups. METHODS Participants from a previous large, representative, community-based health survey in Southeast Pennsylvania who were aged ≥18 years were contacted between November 2012 and January 2013 to complete another phone survey measuring ACEs. Ordinal logistic regression models were used to test associations between Conventional and Expanded ACEs scores and demographic characteristics. Analysis was conducted in 2013 and 2014. RESULTS Of 1,784 respondents, 72.9% had at least one Conventional ACE, 63.4% at least one Expanded ACE, and 49.3% experienced both. A total of 13.9% experienced only Expanded ACEs and would have gone unrecognized if only Conventional ACEs were assessed. Certain demographic characteristics were associated with higher risk for Conventional ACEs but were not predictive of Expanded ACEs, and vice versa. Few adversities were associated with both Conventional and Expanded ACEs. CONCLUSIONS To more accurately represent the level of adversity experienced across various sociodemographic groups, these data support extending the Conventional ACEs measure.

Feasibility and Effects of a Web-Based Adolescent Psychiatric Assessment Administered by Clinical Staff in the Pediatric Emergency Department

OBJECTIVES To determine the adoption rate of the Web-based Behavioral Health Screening-Emergency Department (BHS-ED) system during routine clinical practice in a pediatric ED, and to assess this systems effect on identification and assessment of psychiatric problems. DESIGN Descriptive design to evaluate the feasibility of a clinical innovation. SETTING The ED of an urban tertiary care childrens hospital. PARTICIPANTS Adolescents from 14 to 18 years of age, without acute or critical injuries or illness, presenting with nonpsychiatric symptoms. INTERVENTION The ED clinical staff initiated the use of the BHS-ED system, which identifies and assesses adolescents for depression, suicidal ideation, posttraumatic stress, substance use, and exposure to violence. Treating clinicians reviewed results and followed routine care practices thereafter. MAIN OUTCOME MEASURES Adoption rate of the BHS-ED system by nursing staff, identification rates of occult psychiatric problems, and social worker or psychiatrist assessment. Data were collected for 19 months before implementation of the BHS-ED system and for 9 months during implementation. RESULTS Of 3979 eligible patients, 1327 (33.4%) were asked by clinical staff to get screened using the BHS-ED; of these 1327 patients, 857 (64.6%) completed the screening and 470 (35.4%) refused. During implementation, identification of adolescents with psychiatric problems increased significantly (4.2% vs 2.5%; odds ratio [OR], 1.70; 95% confidence interval [CI], 1.38-2.10), as did ED assessments by a social worker or psychiatrist (2.5% vs 1.7%; OR, 1.47; 95% CI, 1.13-1.90). Of the 857 patients who were screened with the BHS-ED, 90 (10.5%) were identified as having psychiatric problems (OR, 4.58; 95% CI, 3.53-5.94), and 71 (8.3%) were assessed (OR, 5.12; 95% CI, 3.80-6.88). CONCLUSIONS In a busy pediatric ED, computerized, self-administered adolescent behavioral health screening can be incorporated into routine clinical practice. This can lead to small but significant increases in the identification of unrecognized psychiatric problems.

Development, Validation, and Utility of Internet-Based, Behavioral Health Screen for Adolescents

OBJECTIVES: The goals were to develop and to validate the Internet-based, Behavioral Health Screen (BHS) for adolescents and young adults in primary care. METHODS: Items assessing risk behaviors and psychiatric symptoms were built into a Internet-based platform with broad functionality. Practicality and acceptability were examined with 24 patients. For psychometric validation, 415 adolescents completed the BHS and well-established rating scales. Participants recruited from primary care waiting rooms were 12 to 21 years of age (mean: 15.8 years); 66.5% were female and 77.5% black. RESULTS: The BHS screens in 13 domains by using 54 required items and 39 follow-up items. The administration time was 8 to 15 minutes (mean: 12.4 minutes). The scales are unidimensional, are internally consistent (Cronbachs α = 0.75–0.87), and discriminate among adolescents with a range of diagnostic syndromes. Sensitivity and specificity were high, with overall accuracy ranging from 78% to 85%. Patients with scores above scale cutoff values for depression, suicide risk, anxiety, and posttraumatic stress disorder symptoms were ≥4 times more likely to endorse other risk behaviors or stressors. CONCLUSIONS: The BHS addresses practical and clinical barriers to behavioral health screening in primary care. It is a brief but comprehensive, self-report, biopsychosocial assessment. The psychiatric scales are valid and predictive of risk behaviors, which facilitates exclusion of false-positive results, as well as assessment and triage.