Karen Marcdante

Pediatric interhospital transport: Diagnostic discordance and hospital mortality*

Objectives: Determine the rate of discordance between the reason for transport (determined by referring institution) and the final diagnosis (determined by accepting institution), identify factors associated with diagnostic discordance, and determine whether diagnostic discordance is associated with mortality and morbidity. Design: Cross-sectional analysis of prospectively collected transport data using an existing multicenter database. Setting: Interfacility transport of neonatal and pediatric patients referred to five tertiary centers during years 1998–2000. Patients: Patients were 4,905 neonatal and pediatric patients undergoing interhospital transport ultimately assigned to a general or intensive level of care based on initial triage information. Interventions: None. Measurements and Main Results: Discordant events were categorized by diagnosis, referring hospital location, and physician type. Discordance between primary reason for transport and discharge diagnosis category occurred in 474 (11.5%) transport events (95% confidence interval 10.5–12.5). Significant predictors of diagnostic discordance included diagnoses of gastrointestinal, metabolic, multi-trauma with head injury, multi-trauma without head injury, renal, and toxicology. Acute care, referring physician, and emergency department subpopulations demonstrated similar discordance rates. One hundred ten (2.7%) patients experienced at least one unplanned event (unintended extubation, intubation requiring more than attempts, loss of intravenous access, malpositioned endotracheal tube, medication error, pneumothorax). Of the 474 patients given discordant diagnoses, 16 (3.4%) experienced at least one unplanned event compared with 94 of 3,645 (2.6%) of patients given concordant diagnoses. Hospital mortality for all transport events was 6% (95% confidence interval 5.3–6.7). Of the total discordant population, 37 of 474 died compared with 207 of 3,645 of those with concordant diagnoses (7.8% vs. 5.7%, p = .065). When adjusted for severity, age, and diagnosis, the increased mortality was not statistically significant. Conclusions: Discordance between primary reason for transport and diagnosis category is common in the pediatric interhospital transport population. Although discordance does not appear to lead to increased mortality, further study is needed to determine the impact of diagnostic discordance on other patient outcomes.

Critical incidents as a technique for teaching professionalism.

Background: The issue of professional behavior in medicine has been extensively discussed in the medical literature and clarity regarding what constitutes professional behavior, and strategies for assessing professionalism have begun to emerge. Aim: To address the information gap on effective strategies for teaching professionalism. Methods: The critical incident technique (CIT) established by Flanagan has proven to be a useful way to structure teaching and/or evaluation of professionalism. Results: By analyzing ‘real-life’ occurrences of unprofessional behavior with learners, the CIT yields common terminology and definitions of professionalism that can be explored within a structured framework for discussion. Conclusions: CIT is a versatile strategy as it can be utilized with varied audiences (e.g., students, faculty), in a wide array of settings (e.g., workshops, grand rounds). Examples of CIT use associated with teaching professionalism are reviewed and key features associated with its success are identified.

Stability of dopamine and epinephrine solutions up to 84 hours.

Objectives The current practice of preparing fresh dopamine and epinephrine solutions every 24 hrs may lead to hemodynamic instability caused by the interruption of infusions with each change. We determined the stability of these catecholamines over an 84-hr period and whether stability was enhanced by dextrose-containing solutions. Setting Tertiary care teaching hospital. Design The stability of dopamine and epinephrine, each at three commonly used concentrations, was studied in three vehicles (10 gm/dl dextrose in water [D10W], 5 gm/dl dextrose in water [D5W], and 0.9% NaCl in water [NS]). To mimic clinical conditions, solutions were placed on syringe pumps infusing continuously into a closed system at ambient temperature for 84 hrs. Measurements Concentrations of dopamine in mg/ml and epinephrine in &mgr;g/ml were measured by high-performance liquid chromatography at 0, 24, 36, 48, 72, and 84 hrs. Results Dopamine and epinephrine concentrations did not change over the 84-hr period regardless of the vehicles in which the drugs were prepared. Conclusions Clinically relevant concentrations of dopamine and epinephrine remain stable in dextrose- and saline-containing solutions for ≥84 hrs. These data suggest that solutions of these catecholamines may safely be used in clinical practice beyond the currently recommended 24 hrs.

Clinical clerkship students' perceptions of (un)safe transitions for every patient.

Purpose As calls for training and accreditation standards around improved patient care transitions have recently increased, more publications describing medical student education programs on care transitions have appeared. However, descriptions of students’ experience with care transitions and the sender/receiver communication that supports or inhibits them are limited. To fill this gap, the authors developed this project to understand students’ experiences with and perceptions of care transitions. Method At the start of a patient safety intersession at the Medical College of Wisconsin (2010), 193 third-year medical students anonymously wrote descriptions of critical incidents related to care transitions they had witnessed that evoked a strong emotional reaction. Descriptions included the emotion evoked, clinical context, and types of information exchanged. The authors analyzed the incident descriptions using a constant comparative qualitative methodology. Results Analysis revealed that 111 of the 121 medical students (92%) who disclosed emotional responses had strong negative reactions to unsuccessful transitions, experiencing frustration, irritation, fear, and anger. All of these negative emotions were associated with lack of or poor communication between the sender and receiver: ambiguous roles and responsibilities, insufficient detailing of the patient’s medical course, inadequate identification of the people involved in the transition, incomplete delineation of what the patient needed, and unclear reasons for the transition. Conclusions Third-year medical students’ descriptions of care-transition incidents reveal high rates of strong negative emotions and of communication gaps that may adversely affect patient care. Results support curricular innovations that align students’ needs and experiences with safe patient care transitions.

Defining leadership competencies for pediatric critical care fellows: Results of a national needs assessment

Abstract Introduction: Physicians in training, including those in Pediatric Critical Care Medicine, must develop clinical leadership skills in preparation to lead multidisciplinary teams during their careers. This study seeks to identify multidisciplinary perceptions of leadership skills important for Pediatric Critical Care Medicine fellows to attain prior to fellowship completion. Methods: We performed a multi-institutional survey of Pediatric Critical Care Medicine attendings, fellows, and nurses. Subjects were asked to rate importance of 59 leadership skills, behaviors, and attitudes for Pediatric Critical Care practitioners and to identify whether these skills should be achieved before completing fellowship. Skills with the highest ratings by respondents were deemed essential. Results: Five hundred and eighteen subjects completed the survey. Of 59 items, only one item (“displays honesty and integrity”) was considered essential by all respondents. When analyzed by discipline, nurses identified 21 behaviors essential, fellows 3, and attendings 1 (p < 0.05). Nurses differed (p < 0.05) from attendings in their opinion of importance in 64% (38/59) of skills. Conclusions: Despite significant variability among Pediatric Critical Care attendings, fellows, and nurses in identifying which clinical leadership competencies are important for graduating Pediatric Critical Care fellows, they place the highest importance on skills in self-management and self-awareness. Leadership skills identified as most important may guide the development of interventions to improve trainee education and interprofessional care.

167: IDENTIFYING ESSENTIAL LEADERSHIP SKILLS IN PEDIATRIC CRITICAL CARE MEDICINE

Introduction: Leadership is vitally important to the delivery of high quality health care and is especially important in the critical care environment. Intensivists must develop leadership skills during training, but a validated methodology for teaching and assessment of leadership does not exist. M