Phung K. Pham

Pediatric emergency medicine asynchronous e-learning: A multicenter randomized controlled solomon four-group study

OBJECTIVES Asynchronous e-learning allows for targeted teaching, particularly advantageous when bedside and didactic education is insufficient. An asynchronous e-learning curriculum has not been studied across multiple centers in the context of a clinical rotation. We hypothesize that an asynchronous e-learning curriculum during the pediatric emergency medicine (EM) rotation improves medical knowledge among residents and students across multiple participating centers. METHODS Trainees on pediatric EM rotations at four large pediatric centers from 2012 to 2013 were randomized in a Solomon four-group design. The experimental arms received an asynchronous e-learning curriculum consisting of nine Web-based, interactive, peer-reviewed Flash/HTML5 modules. Postrotation testing and in-training examination (ITE) scores quantified improvements in knowledge. A 2 × 2 analysis of covariance (ANCOVA) tested interaction and main effects, and Pearsons correlation tested associations between module usage, scores, and ITE scores. RESULTS A total of 256 of 458 participants completed all study elements; 104 had access to asynchronous e-learning modules, and 152 were controls who used the current education standards. No pretest sensitization was found (p = 0.75). Use of asynchronous e-learning modules was associated with an improvement in posttest scores (p < 0.001), from a mean score of 18.45 (95% confidence interval [CI] = 17.92 to 18.98) to 21.30 (95% CI = 20.69 to 21.91), a large effect (partial η(2) = 0.19). Posttest scores correlated with ITE scores (r(2) = 0.14, p < 0.001) among pediatric residents. CONCLUSIONS Asynchronous e-learning is an effective educational tool to improve knowledge in a clinical rotation. Web-based asynchronous e-learning is a promising modality to standardize education among multiple institutions with common curricula, particularly in clinical rotations where scheduling difficulties, seasonality, and variable experiences limit in-hospital learning.

Pediatric Advance Directives: Parents’ Knowledge, Experience, and Preferences

OBJECTIVES: To explore parents’ and caregivers’ experience, knowledge, and preferences regarding advance directives (ADs) for children who have chronic illness. METHODS: We conducted a prospective, cross-sectional survey of parents and caregivers of children who have chronic illness. During ambulatory medical visits, participants were asked about previous AD experience and knowledge, future preferences regarding AD discussions, their child’s past and current health status, and family demographics. RESULTS: Among 307 participants surveyed, previous AD experience was low, with 117 (38.1%) having heard of an AD, 54 (17.6%) having discussed one, and 77 (25.1%) having known someone who had an AD. Furthermore, 27 (8.8%) participants had an AD or living will of their own, and 8 (2.6%) reported that their chronically ill child had an AD. Previous AD knowledge was significantly more likely among parents and caregivers who had a college degree than those who did not have a high school diploma, yet significantly less likely among primarily Spanish-speaking parents and caregivers than those primarily English-speaking. Interest in creating an AD for the child was reported by 151 (49.2%) participants, and was significantly more likely among families who had more frequent emergency department visits over the previous year. CONCLUSIONS: The limited AD experience and knowledge of parents and caregivers of children who have chronic illness and their interest in creating an AD suggest an unmet need among families of children who have chronic illness, and an opportunity to enhance communication between families and medical teams regarding ADs and end-of-life care.

Traditional nurse triage vs physician telepresence in a pediatric ED

OBJECTIVES The objective of the study is to compare traditional nurse triage (TNT) in a pediatric emergency department (PED) with physician telepresence (PTP). METHODS This is a prospective 2 × 2 crossover study with random assignment using a sample of walk-in patients seeking care in a PED at a large, tertiary care childrens hospital, from May 2012 to January 2013. Outcomes of triage times, documentation errors, triage scores, and survey responses were compared between TNT and PTP. Comparison between PTP to actual treating PED physicians regarding the accuracy of ordering blood and urine tests, throat cultures, and radiologic imaging was also studied. RESULTS Paired samples t tests showed a statistically significant difference in triage time between TNT and PTP (P = .03) but no significant difference in documentation errors (P = .10). Triage scores of TNT were 71% accurate, compared with PTP, which were 95% accurate. Both parents and children had favorable scores regarding PTP, and most indicated that they would prefer PTP again at their next PED visit. Physician telepresence diagnostic ordering was comparable with the actual PED physician ordering, showing no statistical differences. CONCLUSIONS Using PTP technology to remotely perform triage is a feasible alternative to traditional nurse triage, with no clinically significant differences in time, triage scores, errors, and patient and parent satisfaction.

Characterization of Microstructural Injury: A Novel Approach in Infant Abusive Head Trauma—Initial Experience

Abusive head trauma (AHT) is the leading cause of morbidity and mortality among abused children, yet the neuroanatomical underpinnings of AHT outcome is incompletely understood. The aim of this study was to characterize white matter (WM) abnormalities in infants with AHT using diffusion tensor imaging (DTI) and determine which microstructural abnormalities are associated with poor outcome. Retrospective DTI data from 17 infants (>3 months) with a diagnosis of AHT and a comparison cohort of 34 term infants of similar post-conceptual age (PCA) were compared using a voxel-based DTI analysis of cerebral WM. AHT cases were dichotomously classified into mild/moderate versus severe outcome. Clinical variables and conventional imaging findings were also analyzed in relation to outcome. Outcomes were classified in accordance with the Pediatric Cerebral Performance Category Score (PCPCS). Reduced axial diffusivity (AD) was shown in widespread WM regions in the AHT infants compared with controls as well as in the AHT severe outcome group compared with the AHT mild/moderate outcome group. Reduced mean diffusivity (MD) was also associated with severe outcome. Radial diffusivity (RD), conventional magnetic resonance findings, brain metric measurements, and clinical/laboratory variables (with the exception of Glascow Coma Scale) did not differ among AHT outcome groups. Findings support the unique role of DTI techniques, beyond conventional imaging, in the evaluation of microstructural WM injury of AHT. Reduced AD (likely reflecting axonal damage) and MD were associated with poor clinical outcome. DTI abnormalities may uniquely reflect AHT patterns of axonal injury that are not characterized by conventional imaging, which may have both therapeutic and prognostic implications.

REDUCING ANXIETY IN THE PEDIATRIC EMERGENCY DEPARTMENT: A COMPARATIVE TRIAL

BACKGROUND Anxiety among patients in a pediatric emergency department (PED) can be significant, but often goes unaddressed. OBJECTIVE Our aim was to determine whether exposure to Child Life (CL) or hospital clowning (HC) can reduce anxiety in children presenting to a PED. METHODS Patients were randomized to CL, HC, or control and assessed upon entry to examination room (T1), before physician arrival (T2), and during physician examination (T3), using the modified Yale Preoperative Anxiety Scale (m-YPAS). CL and HC interventions occurred for 5 to 10 min before physician entry. Effects were analyzed using mixed analysis of variance. RESULTS m-YPAS scores ranged from 23 to 59, with a higher score indicating increased anxiety. Mixed analysis of variance on the study sample (n = 113) showed a significant interaction between groups (CL, HC, control) and time (p = 0.02). Additional analyses indicated effect of group only at T2 (CL: mean = 23.8; 95% confidence interval [CI] 23.2-24.5; HC: mean 25.2; 95% CI 24.2-26.2; control: mean = 26.1; 95% CI 24.2-27.9; p = .02). Subanalysis of patients with T1 m-YPAS score ≥ 28 (n = 56) showed a significant interaction between group and time (p = 0.01). Additional analysis showed effect of group only at T2 (CL: mean 24.4; 95% CI 23.3-25.6; HC: mean 27.0; 95% CI 25.2-28.7; control: mean 29.2; 95% CI 25.6-32.7; p = 0.003). CONCLUSIONS CL services can reduce state anxiety for patients presenting to a PED with heightened anxiety at baseline. This reduction occurred immediately after CL intervention, but was not observed in patients exposed to HC or during physician examination.

March of the Living, a Holocaust Educational Tour: Effect on Adolescent Jewish Identity

March of the Living (MOTL) is a worldwide two-week trip for high school seniors to learn about the Holocaust by traveling to sites of concentration/death camps and Jewish historical sites in Poland and Israel. The mission statement of MOTL International states that participants will be able to “bolster their Jewish identity by acquainting them with the rich Jewish heritage in pre-war Eastern Europe.” However, this claim has never been studied quantitatively. Therefore, 152 adolescents who participated in MOTL voluntarily completed an initial background questionnaire, a Jewish Identity Survey and a Global Domains Survey pre-MOTL, end-Poland and end-Israel. Results suggest that Jewish identity did not substantially increase overall or from one time period to the next.

Parent activation in the pediatric emergency department: Theory vs. reality

OBJECTIVE To measure parent activation and test for its associations with sociodemographics, clinical factors, and short-term outcomes. METHODS By convenience sampling, 246 parents of children treated in an emergency department (ED) of a childrens hospital completed the Parent-Patient Activation Measure (P-PAM) and answered sociodemographic questions. Clinical information was abstracted from medical records. Phone calls to parents and primary care physician offices were conducted within one-month post-ED visit for information about short-term outcomes. RESULTS We discovered higher than expected activation among our sample (mean = 73), higher activation scores by Spanish language and child chronic illness status, and associations between activation scores and ED visit and discharge instruction comprehension and filling prescriptions (short-term outcomes). However, the theory of parent activation did not adequately fit the data. CONCLUSION Before the P-PAM in pediatric clinical care becomes widespread, further research is necessary to better understand parent activation and its associations with pediatric outcomes. PRACTICE IMPLICATIONS Although the PAM has shown promise in accurately measuring patient activation across various populations and disease processes, the same is not yet true of the P-PAM. To date, pediatric studies using the P-PAM have called its psychometric properties into question. Further research is needed to understand and measure parent activation.

Caregiver Expectations and Satisfaction of Urgent Care in a Pediatric Emergency Department.

Health care delivery expectations that may affect patient and caregiver satisfaction are not clearly understood. This study examined caregiver expectations and satisfaction with urgent care in a pediatric emergency department. Of 201 caregivers surveyed, we found that caregivers have specific expectations regarding clinical care of their child in terms of radiographic imaging, blood testing, antibiotics, pain management, and subspecialty consultation. Caregivers were generally less dissatisfied with the actual care provided than the urgent care physicians expected.

Mental health screening among adolescents and young adults in the emergency department

Objective To determine if a new, non-validated mental health screener can detect the prevalence of alcohol/drug abuse, traumatic exposure, and behavioral symptoms in adolescents and young adults seeking care in a pediatric emergency department (ED) for medical complaints. Methods An 11-item mental health screener (Emergency Department Distress Response Screener [ED-DRS] investigator developed) was created. Patients 12 years or older seen for medical complaints were assessed by physicians using the ED-DRS. Data were analyzed using the Kuder-Richardson Formula 20, &khgr;2 test, Mann-Whitney U test, and Spearman correlation. Results Among 992 ED patients, mean age was 15.11 ± 2.10 years (46.2% boys; 53.8% girls). Approximately 77.9% were Hispanic/Latino. Symptomatic patients (S) answered “yes” to at least 1 ED-DRS item; asymptomatic patients answered “no” to all items. The S patients comprised 47.5% of the sample; asymptomatic patients comprised 52.5%. Among S patients, alcohol/drug abuse frequency was 14%. The traumatic exposure frequencies included: 33.5% physically or emotionally traumatized, 29.3% bullied, 21.2% physically abused, 8.1% touched inappropriately and 7.0% exposed to domestic violence. Behavioral symptom frequencies included: 33.8% depressed mood, 30.4% anxiety, 23.8% high energy behavior, 6.6% hallucinations, and 6.2% suicidal/homicidal ideation. Conclusions Although patients present to the ED with medical complaints, they may be at risk for concomitant mental health problems potentially discoverable using the ED-DRS.

The Effect of Language on the Discharge Process in a Pediatric Emergency Department

Health disparities linked to language have been clearly described in the literature. However, little is known about potential disparities in care related to language in the Pediatric Emergency Department (PED). This was a cross-sectional observational study using convenience sampling of English and Spanish PED discharges before and after electronic medical record (EMR) implementation. There were minimal differences between English and Spanish-speaking families in interactional elements and basic dialogue during discharge. Yet Spanish-speaking families had longer wait times to discharge once the decision to discharge was made. Interestingly, implementation of EMR added efficiency in terms of seeing a physician after arrival and equalizing the discharge instruction process between both groups. Contrary to literature on language-related health disparities, our study revealed minimal differences between English and Spanish-speaking families specifically in the PED discharge process.