Megan McCabe

Pediatric Residents' Clinical and Educational Experiences With End-of-Life Care

OBJECTIVE. The objective of this study was to document the frequency of pediatric resident experiences with end-of-life care for children and the educational context for these experiences, as well as to determine whether residents deem their preparatory training adequate. METHODS. An Internet-based survey was distributed to all categorical pediatric residents at the Johns Hopkins Childrens Center. Survey items asked residents to (1) quantify their experiences with specific responsibilities associated with the death of a pediatric patient, (2) identify their educational experiences, and (3) respond to Likert scale statements of, “I feel adequately trained to… .” The responsibilities were discussion of withdrawal/limitation of life-sustaining therapy, symptom management, declaration of death, discussion of autopsy, completion of a death certificate, seeking self-support, and follow-up with families. RESULTS. Forty (50%) of 80 residents completed the survey. Residents had been present for a mean (± SD) of 4.7 (± 3.0) patient deaths. More than 50% of residents had participated in discussions of withdrawal/limitation of life-sustaining therapy, symptom management, completing a death certificate, and seeking personal support; however, <50% of residents had been taught how to hold discussions of withdrawal/limitation of life-sustaining therapy, declare death, discuss autopsy, complete a death certificate, and have follow-up with families. Residents did not feel adequately trained in any of these areas. CONCLUSION. Pediatric residents have limited experience with pediatric end-of-life care and highly varied educational experiences and do not feel adequately trained to fulfill the responsibilities associated with providing end-of-life care for children. Overall, this perception does not improve with increased level of training. This study identifies several target areas for curricular intervention that may ultimately improve the end-of-life experience for our pediatric patients and their families and the young physicians who care for them.

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.

Effectiveness of Centers for Disease Control and Prevention Recommendations for Outcomes of Acute Otitis Media

OBJECTIVES. To determine whether we could increase adherence to the Centers for Disease Control and Prevention (CDC) recommendations with well-accepted approaches to improving quality of care and adherence to the CDC recommendations resulted in improved outcomes for acute otitis media (AOM). METHODS. A cluster randomization study was conducted in 12 pediatric practices (6 intervention and 6 control sites). The main outcome measures were adherence to the CDC recommendations (modified to include 2 additional antimicrobial agents) and a subsequent antibiotic prescription for AOM within 30 days after diagnosis. RESULTS. Of 3152 patients referred to research assistants, 2584 (82%) were eligible. Of those eligible, 1368 (99%) of 1382 at the intervention sites and 1138 (99%) of 1146 at the control sites consented to participate. Rates of adherence to the CDC recommendations were not significantly higher at the intervention sites than at the control sites, for initial enrollment episodes (78.2% vs 70.6%) or second episodes (62.6% vs 59.9%). After controlling for clustering according to site and covariates, children who were not treated in adherence to the CDC recommendations for both episodes had 1.60 times the odds of a subsequent prescription within 12 days, compared with those treated in adherence at both episodes. CONCLUSIONS. Despite using evidence-based approaches that are known to influence physician behavior, we were unable to increase adherence to the CDC recommendations for treatment of AOM. However, we did establish that prescription of antimicrobial therapy consistent with the CDC recommendations for a second episode of AOM was associated with improved outcomes, measured as the need for subsequent antibiotic prescription. Because of the selection of resistant otopathogens, adherence to the CDC recommendations is likely more important in subsequent episodes of AOM than in the initial episode.

The AAP resilience in the face of grief and loss curriculum

A career in pediatrics can bring great joy and satisfaction. It can also be challenging and lead some providers to manifest burnout and depression. A curriculum designed to help pediatric health providers acquire resilience and adaptive skills may be a key element in transforming times of anxiety and grief into rewarding professional experiences. The need for this curriculum was identified by the American Academy of Pediatrics Section on Medical Students, Residents and Fellowship Trainees. A working group of educators developed this curriculum to address the professional attitudes, knowledge, and skills essential to thrive despite the many stressors inevitable in clinical care. Fourteen modules incorporating adult learning theory were developed. The first 2 sections of the curriculum address the knowledge and skills to approach disclosure of life-altering diagnoses, and the second 2 sections focus on the provider’s responses to difficult patient care experiences and their needs to develop strategies to maintain their own well-being. This curriculum addresses the intellectual and emotional characteristics patient care medical professionals need to provide high-quality, compassionate care while also addressing active and intentional ways to maintain personal wellness and resilience.

End-of-life care in the pediatric ICU

Purpose of review Pediatric ICUs frequently provide end-of-life (EOL) care to children. Our understanding of how EOL care is delivered to children and what constitutes effective care for dying children and their families in the ICU setting continues to evolve. This review identifies recent work describing events related to the death of a child in the ICU as well as interventional efforts to improve family and provider support. Recent findings Pediatric ICUs (PICUs) often provide EOL care to children who die in the developed world. Areas of active investigation include identifying effective communication techniques, meeting the needs of patients and parents, and providing support to care providers. Summary PICU practitioners are developing flexible and novel approaches to pediatric EOL care in the ICU setting.

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.

403: PEDIATRIC RESIDENTS’ COMFORT MANAGING CRITICALLY ILL CHILDREN PRIOR TO THEIR FIRST PICU ROTATIONS

Learning Objectives: Workplace assessments of trainee clinical skills are critical to the development and certification of competent physicians. Entrustable Professional Activities (EPAs) operationalize decisions about the level of supervision required for trainees to perform specific activities. EPAs may provide a framework for developing assessment tools of fellow performance. Methods: Using the Pediatric Critical Care Medicine (PCCM) EPA “Acute management of the critically ill patient,” a novel assessment tool was developed and implemented. Faculty created a list of discrete clinical activities (termed sub-EPAs) which were further divided based on acuity or task components into observable behaviors (termed OPAs). The tool included trainee/ supervisor identifying information, rotation, sub-EPA, OPA, and entrustment level. Free-text justification for entrustment level was required. Acceptability and validity evidence were sought using Messick’s framework. Results: Over one-year, faculty were 75% compliant with twice weekly completion of the tool. Of the sub-EPAs, 95% were assessed at least once. Sub-EPA assessment reflected the frequency of admit diagnosis in the unit. Mean entrustment level across all sub-EPAs and across the same OPA increased by year of fellowship from “requires direct supervision” (1st yr) to “requires no supervision” (3rd yr). In 171 justifications qualitatively analyzed, faculty most often identified “task” and “trainee” factors as the reason for assigned entrustment level, consistent with previous literature describing factors influencing trust. Conclusions: Strong validity evidence was found following one year evidenced by: 1) sub-EPA assessment rates (internal structure validity), 2) consistency of sub-EPA assessment with frequency of admit diagnosis (content validity), 3) rise in mean entrustment level by year of training (consequences validity), and 4) consistency of reasons for entrustment level choice with previous literature (response process and relation to other variables validity). Based on this evidence and the rigorous development process, this tool could be broadly applied in PCCM.

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