Michael FitzGerald

A Comprehensive View of Parental Satisfaction With Pediatric Emergency Department Visits

STUDY OBJECTIVE We develop a comprehensive view of aspects of care associated with parental satisfaction with pediatric emergency department (ED) visits, using both quantitative and qualitative data. METHODS This was a retrospective observational study using data from an institution-wide system to measure patient satisfaction. For this study, 2,442 parents who brought their child to the ED were interviewed with telephone survey methods. The survey included closed-ended (quantitative) and open-ended (qualitative data) questions, in addition to a cognitive interview-style question. RESULTS Overall parental satisfaction was best predicted by how well physicians and nurses work together, followed by wait time and pain management. Issues concerning timeliness of care, perceived quality of medical care, and communication were raised repeatedly by parents in response to open-ended questions. A cognitive interview-style question showed that physicians and nurses sharing information with each other, parents receiving consistent and detailed explanations of their childs diagnosis and treatments, and not having to answer the same question repeatedly informed parent perceptions of physicians and nurses working well together. Staff showing courtesy and respect through compassion and caring words and behaviors and paying attention to nonmedical needs are other potential satisfiers with emergency care. CONCLUSION Using qualitative data to augment and clarify quantitative data from patient experience of care surveys is essential to obtaining a complete picture of aspects of emergency care important to parents and can help inform quality improvement work aimed at improving satisfaction with care.

Screening for asymptomatic gonorrhea and chlamydia in the pediatric emergency department

Background Because adolescents rely heavily on emergency services for health care, a pediatric emergency department (PED) visit may be their only opportunity for sexually transmitted infection (STI) screening. The primary objectives of this study were to determine the proportion of Neisseria gonorrheae (GC) and Chlamydia trachomatis (CT) infections in asymptomatic PED adolescents and patient-perceived barriers to STI screening. Methods A convenience sample of patients aged 14 to 21 years presenting to an urban PED with nongenitourinary complaints was offered screening for GC and CT. Regardless of declining or accepting screening, all were asked to complete a questionnaire designed to identify barriers to screening. Results Sixty-eight percent of those approached participated (n = 719). Those who agreed to STI screening were more likely to be nonwhite (61.4% vs. 38.6%, P = 0.001) and publically insured (63.3%) versus privately insured (29.3%) or no insurance (7.58%). Four hundred three (56%) participants provided urine samples, and of those, 40 (9.9%) were positive for an STI. Controlling for other demographics, race was a significant predictor, with the odds of testing positive for nonwhite participants 5.90 times that of white participants. Patients who refused testing were more likely to report not engaging in sexual activity (54.3% vs. 42.4%, P = 0.009) and less likely to perceive that they were at risk for STIs. Conclusions There are high proportions of GC and CT among asymptomatic adolescents visiting an academic urban PED. A universal PED STI screening program may be an important component of STI reduction initiatives, especially among adolescents who do not perceive that they are at risk and may not receive testing elsewhere.

Pediatrician Ambiguity in Understanding Palliative Sedation at the End of Life

Context: Palliative sedation is a means of relieving intractable symptoms at the end of life, however, guidelines about its use lack consistency. In addition, ethical concerns persist around the practice. There are reports of palliative sedation in the pediatric literature, which highlight various institutional perspectives. Objectives: This survey of 4786 pediatric providers sought to describe their knowledge of and current practices around pediatric palliative sedation. Methods: Our survey was administered to pediatricians who care for children at the end of life. The survey assessed agreement with a definition of palliative sedation, as well as thoughts about its alignment with aggressive symptom management. Bivariate analyses using χ2 and analysis of variance were calculated to determine the relationship between responses to closed-ended questions. Open-ended responses were thematically coded by the investigators and reviewed for agreement. Results: Nearly half (48.6%) of the respondents indicated that the stated definition of palliative sedation “completely” reflected their own views. Respondents were split when asked if they viewed any difference between palliative sedation and aggressive symptom management: Yes (46%) versus No (54%). Open-ended responses revealed specifics about the nature of variation in interpretation. Conclusions: Responses point to ambiguity surrounding the concept of palliative sedation. Pediatricians were concerned with a decreased level of consciousness as the goal of palliative sedation. Respondents were split on whether they view palliative sedation as a distinct entity or as one broad continuum of care, equivalent to aggressive symptom management. Institutional-based policies are essential to clarify acceptable practice, enable open communication, and promote further research.

Evaluation of regional hospitals' use of children in disaster drills

OBJECTIVE Describe the prevalence of pediatric casualties in disaster drills by community hospitals and determine if there is an association between the use of pediatric casualties in disaster drills and the proximity of a community hospital to a tertiary childrens hospital. DESIGN Survey, descriptive study. SETTING Tertiary childrens hospital and surrounding community hospitals. PARTICIPANTS Hospital emergency management personnel for 30 general community hospitals in the greater Cincinnati, Ohio region. INTERVENTIONS None MAIN OUTCOME MEASURE(S) The utilization of pediatric casualties in community hospital disaster drills and its relationship to the distance of those hospitals from a tertiary childrens hospital. RESULTS Sixteen hospitals reported a total of 57 disaster drills representing 1,309 casualties. The overwhelming majority (82 percent [1,077/1,309]) of simulated patients from all locations were 16 years of age or older. Those hospitals closest to the childrens hospital reported the lowest percentage of pediatric patients (10 percent [35/357]) used in their drills. The hospitals furthest from the childrens hospital reported the highest percentage of pediatric patients (32 percent [71/219]) used during disaster drills. CONCLUSIONS The majority of community hospitals do not incorporate children into their disaster drills, and the closer a community hospital is to a tertiary childrens hospital, the less likely it is to include children in its drills. Focused effort and additional resources should be directed toward preparing community hospitals to care for children in the event of a disaster.

Assessment of the need for a cardiac morphology curriculum for paediatric cardiology fellows

BACKGROUND Expert knowledge of cardiac malformations is essential for paediatric cardiologists. Current cardiac morphology fellowship teaching format, content, and nomenclature are left up to the discretion of the individual fellowship programmes. We aimed to assess practices and barriers in morphology education, perceived effectiveness of current curricula, and preferences for a standardised fellow morphology curriculum. METHODS A web-based survey was developed de novo and administered anonymously via e-mail to all paediatric cardiology fellowship programme directors and associate directors in the United States of America; leaders were asked to forward the survey to fellows. RESULTS A total of 35 directors from 32 programmes (51%) and 66 fellows responded. Curriculum formats varied: 28 (88%) programmes utilised pathological specimens, 25 (78%) invited outside faculty, and 16 (50%) utilised external conferences. Director nomenclature preferences were split - 6 (19%) Andersonian, 8 (25%) Van Praaghian, and 18 (56%) mixed. Barriers to morphology education included time and inconsistent nomenclature. One-third of directors reported that <90% of recent fellow graduates had adequate abilities to apply segmental anatomy, identify associated cardiac lesions, or communicate complex CHD. More structured teaching, protected time, and specimens were suggestions to improve curricula. Almost 75% would likely adopt/utilise an online morphology curriculum. CONCLUSIONS Cardiac morphology training varies in content and format among fellowships. Inconsistent nomenclature exists, and inadequate morphology knowledge is perceived to contribute to communication failures, both have potential patient safety implications. There is an educational need for a common, online cardiac morphology curriculum that could allow for fellow assessment of competency and contribute to more standardised communication in the field of paediatric cardiology.

A Survey Assessment of Perceived Importance and Methods of Maintenance of Critical Procedural Skills in Pediatric Emergency Medicine.

Supplemental digital content is available in the text. Objective The aim of this study was to delineate pediatric emergency medicine provider opinions regarding the importance of, and to ascertain existing processes by which practitioners maintain, the following critical procedural skills: oral endotracheal intubation, intraosseous line placement, pharmacologic and electrical cardioversion, tube thoracostomy, and defibrillation. Methods A customized survey was administered to all members of the Listserv for the American Academy of Pediatrics Section on Emergency Medicine. Perceived importance of maintaining critical pediatric procedural skills was measured using a 5-point Likert-type scale. Secondary outcomes included presence and type of mandatory training, availability of on-site backup, and perceived barriers to maintenance of skills. Results Two hundred sixty-two members (25%) responded representing 106 different institutions, 70% of freestanding children’s hospitals that received graduate medical education payments in 2014, and 68% of pediatric emergency medicine fellowship programs. More than 90% of respondents felt it was either very or extremely important to maintain competency for 5 of the 6 critical procedures, but no more than 49% of respondents felt that clinical care alone provided opportunity to maintain skills. The proportion of respondents indicating no mandatory training for each critical procedural skill was as follows: oral endotracheal intubation (23%), intraosseous line placement (30%), pharmacologic cardioversion (32%), electrical cardioversion (32%), tube thoracostomy (40%), and defibrillation (32%). Conclusions Critical procedural skills are perceived by emergency providers who care for children as extremely important to maintain. Direct care of pediatric patients likely does not provide sufficient opportunity to maintain these skills. There are widespread deficiencies relating to mandatory maintenance of critical procedural skill training.

Pediatric bereavement services: a survey of practices at children's hospitals.

The death of a child can be an overwhelming experience for parents. Hospitals are often the first place to get information or to seek services, yet little is known about what types of bereavement services, information, or support are typically available. This study was designed to identify types of bereavement support offered to parents whose child died at a pediatric hospital, to ascertain who provides support and to see how those services are institutionally organized and funded. The investigation gathered data using an online, custom-designed survey completed by bereavement providers at 122 of the 188 pediatric hospitals invited to participate. This article summarizes the ways hospitals follow-up with families, from provision of educational materials to a menu of support services including memorial services, counseling, and community referrals.

Development and Field Pretest of the Feedback Quality Index: A Tool for Assessing Feedback Frequency and Quality in a Clinical Setting

Objectives: This paper describes the systematic development, design, and field pretest of the Feedback Quality Index (FQI) - a brief survey for assessing feedback regularity and quality in a clinical setting. Medical educators need this type of tool so they can identify specific problems related to feedback provision and evaluate the impact of efforts de- signed to address those problems. The purposes of this study are to provide evidence for the feasibility and validity of the tool and to provide guidance and suggestions regarding its use. Methods: Decisions regarding the design and implementation of the FQI were guided by a systematic approach to survey development to ensure that common sources of non-sampling error were identified and addressed. A field pretest imple- mentation was conducted to gather evidence regarding the feasibility of the tool and the validity of the data. Feasibility was assessed based on the effort needed to administer, complete, and analyze the FQI while evidence for validity was based on an analysis of question quality. Results: Field pretest results indicated that the FQI can be feasibly administered, completed, and analyzed. An analysis of question quality revealed that most questions were understood correctly by respondents and the level of detail they pro- vide in describing the feedback received provides evidence for the accuracy of their recollections. Conclusions: The current version of the FQI is a useful tool that programs could use to assess feedback frequency and quality, identify specific problems, and evaluate efforts to address those problems. Additional studies need to be con- ducted to further assess and improve the validity of the FQI. Such efforts will not only improve the accuracy of the FQI but could also enhance our conceptual understanding of what constitutes effective feedback in the clinical setting.

Performance of International Medical Graduates in Pediatric Residency: A Study of Peer and Faculty Perceptions

BACKGROUND International medical graduates (IMGs) constitute approximately 25% of the US pediatric workforce. Their recruitment into US residency training raises concerns regarding their competence, although this has not been formally studied. Cincinnati Childrens Hospital has systematically recruited IMGs over the past 16 years. This study evaluates perceptions of IMG performance by faculty and US graduate (USG) peers. METHODS We surveyed IMG, USG, and faculty groups, including current and former trainees, assessing perceived IMG performance compared with that of USGs in terms of clinical knowledge/skills, resource utilization, communication, public health knowledge and efficiency, and overall impact on the program. RESULTS Overall perceived performance was within 1 standard deviation of expected USG performance. IMGs outperformed USGs in clinical knowledge/skills and resource utilization but underperformed in communication, public health knowledge, and efficiency. Significant differences were noted in communication with patients and public health knowledge; IMGs ranked their performance significantly lower than USGs/faculty ranked their performance. Overall impact was perceived positively, including an increased interest in global health in among USGs. CONCLUSIONS Carefully recruited IMGs are perceived to perform nearly equal to their USG peers, and their presence is perceived as positive to a major pediatric residency program. Specific domains for educational interventions are identified for programs wishing to expand IMG recruitment.

Response to Commentary: “How badly do we need instruction in paediatric cardiac anatomy?”

WE THANK DR ANDERSON FOR HIS INTEREST and thoughtful commentary on our article entitled “Assessment of the need for a cardiac morphology curriculum for paediatric cardiology fellows”. We appreciate his insights into the execution of the curriculum on which we are embarking on the basis of this published needs assessment. We also hope that this endeavour will have implications beyond the United States’ training programmes, although for simplicity’s sake our original needs assessment focussed on fellowship education within the United States training programmes. Overall, we agree that this effort will require collaboration and assistance from those with interest and expertise in education and cardiac morphology, and we welcome anyone interested to get in touch with the authors directly. We specifically address some points brought forth by Dr Anderson in his commentary. As our study demonstrates, the need for a common language is imperative to communication between providers. The work by the International Nomenclature Committee for Pediatric and Congenital Heart Disease serves as a basis for a common language and will certainly provide a scaffold for our curriculum. Dr Anderson goes on to describe that there are more similarities than previously understood between the two commonly used nomenclature systems – “Andersonian” and “Van Praaghian”. These similarities and differences are brought together nicely by Dr Ezon et al in their recent atlas.We agree that the last decade has brought some consensus between the two systems. Important differences, however, continue to exist – for example, the simple classification of double-outlet right ventricle is not consistent between the two systems. Some hearts classified as Tetralogy of Fallot, secondary to mitral-to-aortic valve fibrous continuity, with the aorta assigned to the left ventricle under the Van Praagh system are called double-outlet right ventricle by the Anderson classification system secondary to the degree of aortic override (>50% over the right ventricle, despite the aortic/mitral relationship). Therefore, understanding the major features and classification schemes that govern both systems is imperative to understanding the meaning of their language. Given the widespread use of both systems, especially within the United States of America, the only way to fully prepare fellows to be successful communicators within the current paediatric cardiology community is to familiarise them with both major classification systems – in essence, making them bilingual. Although it is our hope that the International Classification of Disease (ICD-11) classifications will serve as a common language moving forward, this change will take time and considerable effort in spreading this language, the details of which are still being debated within the nomenclature committee. Therefore, although ideally our proposed curriculum would present one unified way of speaking, we think the reality of current practice necessitates our learners understanding both major systems, using the ICD-11 terminology as a guide. Consistent with the principles of adult learning theory and appealing to the learning styles of our Correspondence to: L. S. Rogers, Division of Pediatric Cardiology, Children’s Memorial Herman Hospital, UT Health, 6410 Fannin Street, Suite 425, Houston, TX 77030, United States of America. Tel: +1 713 500 5737; Fax: +1 713 500 5751; E-mail: lindsay.s.rogers@uth.tmc.edu Cardiology in the Young 2017; Page 1 of 2