Mary C. Ottolini

Utility of complete blood count and blood culture screening to diagnose neonatal sepsis in the asymptomatic at risk newborn.

Background. In May 1996, the CDC recommended obtaining a complete blood count and blood culture (BC) from all asymptomatic “at risk” newborns; those ≥35 weeks gestation born to mothers with group B streptococcal vaginal colonization or those with maternal fever, premature rupture of membranes or previous infant with group B streptococcal disease; who did not receive adequate intrapartum antibiotic prophylaxis. Design/methods. During the study period (May 1996 to July 1999), a complete blood count and BC were obtained within 4 h from all asymptomatic at risk newborns of ≥35 weeks gestation. White blood cell count (WBC) and BC results and prevalence of clinical or culture-proven sepsis were obtained by chart review. We determined the sensitivity/specificity and likelihood ratios of an abnormal WBC (total >30 000 or <5000/mm3; absolute neutrophil count <1500/mm3, or a band form-polymorphonuclear cell ratio of >0.2) to distinguish between clinically septic vs. nonseptic term at risk newborns. Results. Of 20 554 deliveries 1665 were initially asymptomatic at risk newborns; 17 (1.0%) developed early onset sepsis, all within 48 h. WBC was abnormal in 7 of 17 (41%) and in 447 of 1648 (27%) who remained nonseptic. None of the 1665 term at risk newborns had a positive BC. The sensitivity and specificity of an abnormal WBC in predicting which at risk newborns would develop sepsis were 41 and 73%, respectively. The positive likelihood ratio was 1.52, whereas the negative likelihood ratio was 0.81, with an odds ratio of 1.88. Conclusions. Since the implementation of the CDC guidelines for maternal intrapartum antibiotic prophylaxis, culture-proved sepsis has become rare at our institution. Although BC did not aid in the diagnosis of sepsis among asymptomatic at risk newborns, close observation in the first 24 h remained critically important.

Parent-Pediatrician Communication about Complementary and Alternative Medicine Use for Children

Anonymous self-report surveys of a convenience sample of caregivers accompanying children to the pediatrician for acute or well visits at 4 pediatric practices in the Washington, DC area from July through November 1998 were evaluated. Three hundred seventy-eight (85%) of 443 caregivers approached participated. The 348 surveys completed by parents (92%) were analyzed. As previously reported, in this sample 21% of parents used complementary and alternative medicine (CAM) for their child. Overall, 53% of parents expressed the desire to discuss CAM with their pediatrician, increasing to 75% (p<0.001) among those who used CAM themselves and 81% (p<0.01) among those who used CAM for their child. Among parents who used CAM for their child, 36% had discussed it with their pediatrician. Factors associated with increased disclosure to the pediatrician were CAM use in children younger than 6 years (p<0.05), “bioenergetic” CAM use (p<0.02), and parent CAM non-use (p<0.05). Despite parents’ significant interest in discussion about CAM, few factors were associated with adequate parent-pediatrician communication.

Variations in Management of Common Inpatient Pediatric Illnesses: Hospitalists and Community Pediatricians

OBJECTIVE. The goal was to test the hypothesis that pediatric hospitalists use evidence-based therapies and tests more consistently in the care of inpatients and use therapies and tests of unproven benefit less often, compared with community pediatricians. METHODS. A national survey was administered to hospitalists and a random sample of community pediatricians. Hospitalists and community pediatricians reported their frequency of use of diagnostic tests and therapies, on 5-point Likert scales (ranging from never to almost always), for common inpatient pediatric illnesses. Responses were compared in univariate and multivariable logistic regression analyses controlling for gender, race, years out of residency, days spent attending per year, hospital practice type, and completion of fellowship/postgraduate training. RESULTS. Two hundred thirteen pediatric hospitalists and 352 community pediatricians responded. In multivariable regression analyses, hospitalists were significantly more likely to report often or almost always using the following evidence-based therapies for asthma: albuterol and ipratropium in the first 24 hours of hospitalization. After the first urinary tract infection, hospitalists were more likely to report obtaining the recommended renal ultrasound and voiding cystourethrogram. Hospitalists were significantly more likely than community pediatricians to report rarely or never using the following therapies of unproven benefit: levalbuterol, inhaled steroid therapy, and oral steroid therapy for bronchiolitis; stool culture and rotavirus testing for gastroenteritis; and ipratropium after 24 hours of hospitalization for asthma. CONCLUSION. Overall, in comparison with community pediatricians, hospitalists reported greater adherence to evidence-based therapies and tests in the care of hospitalized patients and less use of therapies and tests of unproven benefit.

Pediatric Hospitalists: Report of a Leadership Conference

OBJECTIVES. To summarize a meeting of academic pediatric hospitalists and to describe the current state of the field. METHODS. The Ambulatory Pediatric Association sponsored a meeting for academic pediatric hospitalists in November 2003. The purpose of the meeting was to discuss and to define roles of academic pediatric hospitalists, including their roles as clinicians, educators, and researchers, and to discuss organizational issues and unique hospitalist issues within general academic pediatrics. Workshops were held in the areas of organization and administration, academic life, research, and education. A literature review was also conducted in the areas discussed. RESULTS. More than 130 physicians attended. Thirteen workshops were held, and all information was summarized in large-group sessions for all attendees. CONCLUSIONS. Pediatric hospital medicine is a rapidly growing field, with an estimated 800 to 1000 pediatric hospitalists currently practicing. Initial work has defined the clinical environment and has begun to stake out a unique knowledge and skill set. The Pediatric Hospitalists in Academic Settings conference demonstrated the audience for additional development and the resources to move forward.

Pediatric Hospital Medicine Core Competencies: Development and methodology

BACKGROUND Pediatric hospital medicine is the most rapidly growing site-based pediatric specialty. There are over 2500 unique members in the three core societies in which pediatric hospitalists are members: the American Academy of Pediatrics (AAP), the Academic Pediatric Association (APA) and the Society of Hospital Medicine (SHM). Pediatric hospitalists are fulfilling both clinical and system improvement roles within varied hospital systems. Defined expectations and competencies for pediatric hospitalists are needed. METHODS In 2005, SHMs Pediatric Core Curriculum Task Force initiated the project and formed the editorial board. Over the subsequent four years, multiple pediatric hospitalists belonging to the AAP, APA, or SHM contributed to the content of and guided the development of the project. Editors and collaborators created a framework for identifying appropriate competency content areas. Content experts from both within and outside of pediatric hospital medicine participated as contributors. A number of selected national organizations and societies provided valuable feedback on chapters. The final product was validated by formal review from the AAP, APA, and SHM. RESULTS The Pediatric Hospital Medicine Core Competencies were created. They include 54 chapters divided into four sections: Common Clinical Diagnoses and Conditions, Core Skills, Specialized Clinical Services, and Healthcare Systems: Supporting and Advancing Child Health. Each chapter can be used independently of the others. Chapters follow the knowledge, skills, and attitudes educational curriculum format, and have an additional section on systems organization and improvement to reflect the pediatric hospitalists responsibility to advance systems of care. CONCLUSION These competencies provide a foundation for the creation of pediatric hospital medicine curricula and serve to standardize and improve inpatient training practices.

Development and Evaluation of a CD-ROM Computer Program to Teach Residents Telephone Management

Objective. Under managed care, telephone management is crucial to pediatric practice, but an effective method is needed to teach residents telephone skills. Our objective was to design an interactive CD-ROM program to teach residents an organized, consistent approach to telephone complaints and to determine whether use of the program was associated with better subsequent telephone management than reading the same information. Setting. The general pediatric ambulatory center of a tertiary care childrens hospital. Participants.  A total of 24 PL-2 and PL-3 pediatric residents. Design. A randomized, prospective, controlled comparison was conducted of resident management of two telephone calls: a 5-year-old with cough and trouble breathing, and a 7-year-old with fever. Thirteen residents were randomized to the computer group and 11 to the reading control group. Intervention. Scripts, scoring, and feedback for 10 CD-ROM-simulated calls were developed from texts and pediatrician survey using a modified Delphi technique. Volunteers acted out the callers role in scenario scripts and were recorded onto a CD-ROM. The computer simulated calls by recognizing questions typed in a free-form format and answering with a voice response. Feedback was provided for omissions in history-taking and errors in assessment, triage, and home management. The computer group worked through the CD-ROM calls while the control group had equal time to read the same information. Evaluation Measures. A trained, standardized patient acted as the mother in pretest calls placed at the beginning of the month and posttest calls at the end. Calls were recorded and scored in a blinded manner using scoring templates and on interpersonal skills using the Patient Perception Questionnaire. Results. Pretest scores for the two calls were similar in the computer versus the control group (cough, 70.33% ± 8.36 vs 68.46% ± 6.73; fever, 75.64% ± 9.82 vs 73.59% ± 9.06). Posttest scores were significantly higher in the computer group than in the control group on both calls (cough, 79.08% ± 8.17 vs 69 ± 13.3; fever: 83.33% ± 9.96 vs 70.35% ± 9.66). Interpersonal skills also were similar pretest (19 ± 3.4 vs 20 ± 2.7). There was modest improvement in both groups without a statistically significant difference in posttest scores (24.2 ± 2.9 vs 22.5 ± 3.1). Conclusions. Use of this CD-ROM telephone management program was associated with better postintervention telephone management. The program augments faculty instruction by teaching a consistent, general approach to telephone management.

The Referral and Consultation Entrustable Professional Activity: Defining the Components in Order to Develop a Curriculum for Pediatric Residents

From the Department of Pediatrics, George Washington University, Children’s National Health System, Office of Medical Education, Washington, DC (Dr Hamburger, Dr Agrawal, Dr Boogaard, Dr Weisz, and Dr Ottolini); Departments of Pediatrics (Dr Lane and Dr Hanson), and Family Medicine (Dr Hanson), University of Colorado School of Medicine, Children’s Hospital Colorado, Aurora, Colo The authors declare that they have no conflict of interest. Address correspondence to Ellen K. Hamburger, MD, Department of Pediatrics, George Washington University, Children’s National Medical System, Office of Medical Education, 111 Michigan Ave NW, Washington, DC 20037 (e-mail: ehamburg@childrensnational.org).

Families as Partners in Hospital Error and Adverse Event Surveillance

Importance Medical errors and adverse events (AEs) are common among hospitalized children. While clinician reports are the foundation of operational hospital safety surveillance and a key component of multifaceted research surveillance, patient and family reports are not routinely gathered. We hypothesized that a novel family-reporting mechanism would improve incident detection. Objective To compare error and AE rates (1) gathered systematically with vs without family reporting, (2) reported by families vs clinicians, and (3) reported by families vs hospital incident reports. Design, Setting, and Participants We conducted a prospective cohort study including the parents/caregivers of 989 hospitalized patients 17 years and younger (total 3902 patient-days) and their clinicians from December 2014 to July 2015 in 4 US pediatric centers. Clinician abstractors identified potential errors and AEs by reviewing medical records, hospital incident reports, and clinician reports as well as weekly and discharge Family Safety Interviews (FSIs). Two physicians reviewed and independently categorized all incidents, rating severity and preventability (agreement, 68%-90%; &kgr;, 0.50-0.68). Discordant categorizations were reconciled. Rates were generated using Poisson regression estimated via generalized estimating equations to account for repeated measures on the same patient. Main Outcomes and Measures Error and AE rates. Results Overall, 746 parents/caregivers consented for the study. Of these, 717 completed FSIs. Their median (interquartile range) age was 32.5 (26-40) years; 380 (53.0%) were nonwhite, 566 (78.9%) were female, 603 (84.1%) were English speaking, and 380 (53.0%) had attended college. Of 717 parents/caregivers completing FSIs, 185 (25.8%) reported a total of 255 incidents, which were classified as 132 safety concerns (51.8%), 102 nonsafety-related quality concerns (40.0%), and 21 other concerns (8.2%). These included 22 preventable AEs (8.6%), 17 nonharmful medical errors (6.7%), and 11 nonpreventable AEs (4.3%) on the study unit. In total, 179 errors and 113 AEs were identified from all sources. Family reports included 8 otherwise unidentified AEs, including 7 preventable AEs. Error rates with family reporting (45.9 per 1000 patient-days) were 1.2-fold (95% CI, 1.1-1.2) higher than rates without family reporting (39.7 per 1000 patient-days). Adverse event rates with family reporting (28.7 per 1000 patient-days) were 1.1-fold (95% CI, 1.0-1.2; P = .006) higher than rates without (26.1 per 1000 patient-days). Families and clinicians reported similar rates of errors (10.0 vs 12.8 per 1000 patient-days; relative rate, 0.8; 95% CI, .5-1.2) and AEs (8.5 vs 6.2 per 1000 patient-days; relative rate, 1.4; 95% CI, 0.8-2.2). Family-reported error rates were 5.0-fold (95% CI, 1.9-13.0) higher and AE rates 2.9-fold (95% CI, 1.2-6.7) higher than hospital incident report rates. Conclusions and Relevance Families provide unique information about hospital safety and should be included in hospital safety surveillance in order to facilitate better design and assessment of interventions to improve safety.

Pediatric hospitalists and medical education.

Pediatric hospital medicine (PHM) is moving toward becoming an American Board of Pediatrics (ABP) subspecialty, roughly a decade after its formal inception in 2003. Education has played a central role as the field has evolved. Hospitalists are needed to educate trainees, medical students, residents, fellows, and nurse practitioner and physician assistant students in inpatient pediatric practice. Continuous professional development is needed for hospitalists currently in practice to augment clinical skills, such as providing sedation and placing peripherally inserted central catheter lines, and nonclinical skills in areas such as quality improvement methodology, hospital administration, and health service research. To address the educational needs of the current and future state of PHM, additional training is now needed beyond residency training. Fellowship training will be essential to continue to advance the field of PHM as well as to petition the ABP for specialty accreditation. Training in using adult educational theory, curriculum, and assessment design are critical for pediatric hospitalists choosing to advance their careers as clinician-educators. Several venues are available for gaining advanced knowledge and skill as an educator. PHM clinician-educators are advancing the field of pediatric education as well as their own academic careers by virtue of the scholarly approach they have taken to designing and implementing curricula for unique PHM teaching situations. PHM educators are changing the educational paradigm to address challenges to traditional education strategies posed by duty hour restrictions and the increasing drive to shorten the duration of the hospitalization. By embracing learning with technology, such as simulation and e-learning with mobile devices, PHM educators can address these challenges as well as respond to learning preferences of millennial learners. The future for PHM education is bright.

Virtual Reality for Pediatric Sedation: A Randomized Controlled Trial Using Simulation.

Introduction: Team training for procedural sedation for pediatric residents has traditionally consisted of didactic presentations and simulated scenarios using high-fidelity mannequins. We assessed the effectiveness of a virtual reality module in teaching preparation for and management of sedation for procedures. Methods: After developing a virtual reality environment in Second Life® (Linden Lab, San Francisco, CA) where providers perform and recover patients from procedural sedation, we conducted a randomized controlled trial to assess the effectiveness of the virtual reality module versus a traditional web-based educational module. A 20 question pre- and post-test was administered to assess knowledge change. All subjects participated in a simulated pediatric procedural sedation scenario that was video recorded for review and assessed using a 32-point checklist. A brief survey elicited feedback on the virtual reality module and the simulation scenario. Results: The median score on the assessment checklist was 75% for the intervention group and 70% for the control group (P = 0.32). For the knowledge tests, there was no statistically significant difference between the groups (P = 0.14). Users had excellent reviews of the virtual reality module and reported that the module added to their education. Conclusions: Pediatric residents performed similarly in simulation and on a knowledge test after a virtual reality module compared with a traditional web-based module on procedural sedation. Although users enjoyed the virtual reality experience, these results question the value virtual reality adds in improving the performance of trainees. Further inquiry is needed into how virtual reality provides true value in simulation-based education.