Martin Pusic

CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury

Background: There is controversy about which children with minor head injury need to undergo computed tomography (CT). We aimed to develop a highly sensitive clinical decision rule for the use of CT in children with minor head injury. Methods: For this multicentre cohort study, we enrolled consecutive children with blunt head trauma presenting with a score of 13–15 on the Glasgow Coma Scale and loss of consciousness, amnesia, disorientation, persistent vomiting or irritability. For each child, staff in the emergency department completed a standardized assessment form before any CT. The main outcomes were need for neurologic intervention and presence of brain injury as determined by CT. We developed a decision rule by using recursive partitioning to combine variables that were both reliable and strongly associated with the outcome measures and thus to find the best combinations of predictor variables that were highly sensitive for detecting the outcome measures with maximal specificity. Results: Among the 3866 patients enrolled (mean age 9.2 years), 95 (2.5%) had a score of 13 on the Glasgow Coma Scale, 282 (7.3%) had a score of 14, and 3489 (90.2%) had a score of 15. CT revealed that 159 (4.1%) had a brain injury, and 24 (0.6%) underwent neurologic intervention. We derived a decision rule for CT of the head consisting of four high-risk factors (failure to reach score of 15 on the Glasgow coma scale within two hours, suspicion of open skull fracture, worsening headache and irritability) and three additional medium-risk factors (large, boggy hematoma of the scalp; signs of basal skull fracture; dangerous mechanism of injury). The high-risk factors were 100.0% sensitive (95% CI 86.2%–100.0%) for predicting the need for neurologic intervention and would require that 30.2% of patients undergo CT. The medium-risk factors resulted in 98.1% sensitivity (95% CI 94.6%–99.4%) for the prediction of brain injury by CT and would require that 52.0% of patients undergo CT. Interpretation: The decision rule developed in this study identifies children at two levels of risk. Once the decision rule has been prospectively validated, it has the potential to standardize and improve the use of CT for children with minor head injury.

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.

Pediatric Intravenous Insertion in the Emergency Department: Bevel Up or Bevel Down?

Objective: Intravenous catheters are usually inserted with the bevel facing up. Bevel down may be superior in small and/or dehydrated children. We seek to determine whether there is a difference in the success rate of intravenous insertion using these 2 methods. Methods: We recruited children requiring an intravenous catheter in the emergency department where there was time to obtain consent. Patients were randomized to have the first attempt bevel up or bevel down. If the first attempt was unsuccessful, the alternate technique was used on second attempt. Attempts beyond 2 were not tracked. Results: We recruited 428 patients. Data are available from 396 (201 bevel-up and 195 bevel-down techniques). At least 63 different nurses participated. The nurses participated in the study a median number of 2 times (maximum, 36). Four nurses used the bevel-down technique more than 10 times. The success rate on first attempt was 75.6% (95% confidence interval [CI], 69.8-81.4) for bevel up and 60% (95% CI, 53.2-66.8) for bevel down. The success rate on second attempt was 56.8% (95% CI, 45.3-68.2) for bevel up and 42.9% (95% CI, 30.3-55.5) for bevel down. In the subgroup of infants weighing less than 5 kg, there was no difference between the 2 techniques on the first attempt, with bevel up having a success of 33% (95% CI, 8.4-57.6) and bevel down 30% (95% CI, 4.1-55.9). Conclusions: The bevel-up technique performed superior to bevel-down technique in this study. The bevel-down technique might be useful in small infants.

Using signal detection theory to model changes in serial learning of radiological image interpretation

Signal detection theory (SDT) parameters can describe a learner’s ability to discriminate (d′) normal from abnormal and the learner’s criterion (λ) to under or overcall abnormalities. To examine the serial changes in SDT parameters with serial exposure to radiological cases. 46 participants were recruited for this study: 20 medical students (MED), 6 residents (RES), 12 fellows (FEL), 5 staff pediatric emergency physicians (PEM), and 3 staff radiologists (RAD). Each participant was presented with 234 randomly assigned ankle radiographs using a web-based application. Participants were given a clinical scenario and considered 3 views of the ankle. They classified each case as normal or abnormal. For abnormal cases, they specified the location of the abnormality. Immediate feedback included highlighting on the images and the official radiologist’s report. The low experience group (MED, RES, FEL) showed steady improvement in discrimination ability with each case, while the high experience group (PEM, RAD) had higher and stable discrimination ability throughout the exercise. There was also a difference in the way the high and low experience groups balanced sensitivity and specificity (λ) with the low experience group tending to make more errors calling positive radiographs negative. This tendency was progressively less evident with each increase in expertise level. SDT metrics provide valuable insight on changes associated with learning radiograph interpretation, and may be used to design more effective instructional strategies for a given learner group.

Are pediatric interns prepared to perform infant lumbar punctures? A multi-institutional descriptive study.

Background There are few data describing pediatric interns’ experiences, knowledge, attitudes, and skills related to common procedures. This information would help guide supervisors’ decisions about interns’ preparedness and training needs. Objectives This study aimed to describe pediatric interns’ medical school experiences, knowledge, attitudes, and skills with regard to infant lumbar punctures (LPs) and to describe the impact of these factors on interns’ infant LP skills. Methods This prospective cross-sectional descriptive study was conducted at 21 academic medical centers participating during 2010. Participants answered 8 knowledge questions, 3 attitude questions, and 6 experience questions online. Skills were assessed on an infant LP simulator using a 15-item subcomponent checklist and a 4-point global assessment. Results Eligible interns numbered 493, with 422 (86%) completing surveys and 362 (73%) completing skills assessments. The majority 287/422 (68%) had never performed an infant LP; however, 306 (73%) had observed an infant LP during school. The mean (SD) knowledge score was 63% (±21%). The mean (SD) subcomponent skills checklist score was 73% (±21%). On the global skills assessment, 225 (62%) interns were rated as beginner, and 137 (38%) were rated as competent, proficient, or expert. Independent predictors of an above-beginner simulator performance included infant LP experience on a patient (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.4–3.5), a knowledge score greater than 65% (OR, 2.4; 95% CI, 1.5–3.7), or self-reported confidence (OR, 3.5; 95% CI, 1.9–6.4). Conclusions At the start of residency, the majority of pediatric interns have little experience, poor knowledge, and low confidence and are not prepared to perform infant LPs.

A pediatrics-based instrument for assessing resident education in evidence-based practice.

OBJECTIVE The principles of evidence-based practice (EBP) are a mandated component of the pediatric residency curriculum; however, a pediatrics-based assessment tool validated with pediatric residents does not exist. METHODS We designed an assessment instrument composed of items in 4 categories: 1) demographics; 2) comfort level; 3) self-reported practice of EBP; and 4) EBP knowledge. This last section required participants to identify best evidence and most appropriate study design by using pediatric-based scenarios, develop searchable questions, and use existing published research to address diagnostic and treatment issues. Four groups completed the instrument: preclinical medical students (MS-2), incoming pediatric interns (PGY-1), incoming second- and third-year pediatric residents (PGY2-3), and expert tutors (expert). We determined internal consistency, interrater reliability, content validity, item difficulty, and construct validity. RESULTS Fifty-six subjects completed tests (MS-2, n = 13; PGY-1, n = 13; PGY2-3, n = 22; expert, n = 8). Internal reliability was good, with Cronbachs alpha = .80. Interrater reliability was high (kappa = 0.94). Items were free of floor or ceiling effects. Comfort level and self-reported practice of EBP increased with expertise level and prior EBP experience (P < .01). Scores on the knowledge section (out of 50 +/- SD) rose with training level (MS-2: 14.8 +/- 5.7; PGY-1: 22.2 +/- 3.4; PGY2-3: 31.7 +/- 6.1; experts: 43 +/- 4.0; P < .01). Scores also correlated with prior EBP education. CONCLUSIONS We have developed a reliable and valid instrument to assess knowledge and skill in EBP taught to pediatric residents. This instrument can aid pediatric educators in monitoring the impact of the EBP curriculum.

Evaluating cost awareness education in US pediatric emergency medicine fellowships.

Objectives The Accreditation Council for Graduate Medical Education mandates pediatric emergency medicine (PEM) fellowships to incorporate medical care cost teaching into the curriculum; however, there are no studies evaluating cost awareness of PEM fellows. Our objectives were to evaluate cost education during fellowship and assess fellows’ knowledge and attitudes regarding costs. Methods We conducted an anonymous electronic survey of US PEM fellows in April-June 2009. Results We received 161 (63%) of 253 responses. Respondents represented all 3 years of training and all regions of the United States. Asked if the Accreditation Council for Graduate Medical Education requires cost education, 35% responded no, and 44% were uncertain. More than 80% of fellows reported no formal cost education. More than 65% believed physicians should receive cost education during fellowship, and 75% felt the current amount of education is insufficient. Pediatric emergency medicine fellows showed low accuracy and considerable variability when estimating costs of tests and medications. Median fellows’ estimate for a complete blood count was

A Big Data and Learning Analytics Approach to Process-Level Feedback in Cognitive Simulations.

50 (interquartile range,

Conducting multicenter research in healthcare simulation: Lessons learned from the INSPIRE network

55), where actual cost is

Scalp Hematoma Characteristics Associated With Intracranial Injury in Pediatric Minor Head Injury.

32. Only 23% were within 25% of the true cost. Similarly, the proportions of fellows estimating within 25% of actual cost were small for electrolytes (10%), blood culture (12%), and erythrocyte sedimentation rate (22%). The same held true for the following medications: trimethoprim-sulfamethoxazole (28%), Cefdinir (31%), and cefixime (10%). Ability to predict costs did not improve with year of training. Conclusions Pediatric emergency medicine fellows report little formal teaching on cost issues, and their ability to estimate costs is poor. However, they are receptive to more education on this important issue.