Pediatrics

Planetary Pediatrics Publication date: July 2019 Source: Academic Pediatrics, Volume 19, Issue 5 Author(s): Jeffrey Goldhagen

Reviewer Acknowledgment Publication date: July 2019 Source: Academic Pediatrics, Volume 19, Issue 5 Author(s):

Implementation of Recommendations for Long-Acting Contraception Among Women Aged 13 to 18 Years in Primary Care Publication date: July 2019 Source: Academic Pediatrics, Volume 19, Issue 5 Author(s): Sharisse M. Arnold Rehring, Liza M. Reifler, Jennifer H. Seidel, Karen A. Glenn, John F. Steiner Abstract Objective Clinical specialty societies recommend long-acting reversible contraceptives (LARCs) as first-line contraception for adolescent women. We evaluated whether a combined educational and process improvement intervention enhanced LARC placement in primary care within an integrated health care system. Methods The intervention included journal clubs, live continuing education, point-of-care guidelines, and new patient materials. We conducted a retrospective cohort study across 3 time periods: baseline (January 2013−September 2015), early implementation (October 2015–March 2016), and full implementation (April 2016–June 2017). The primary outcome was the proportion of LARCs placed by primary care clinicians among women aged 13 to 18 years compared with gynecology clinicians. Results Kaiser Foundation Health Plan of Colorado cared for approximately 20,000 women aged 13 to 18 years in each calendar quarter between 2013 and 2017. Overall, LARC placement increased from 7.0 per 1000 members per quarter at baseline to 13.0 per 1000 during the full intervention. Primary care clinicians placed 6.2% of all LARCs in 2013, increasing to 32.1% by 2017 (P < .001), including 45.5% of contraceptive implants. Clinicians who attended educational sessions were more likely to adopt LARCs than those who did not (17.9% vs 6.4% respectively, P = .009). Neither overall LARC placement rates (relative risk, 1.9; 95% confidence interval, 0.7−5.6) nor contraceptive implant rates (relative risk, 3.0; 95% confidence interval, 0.9−9.8) increased significantly in clinicians who attended educational activities. Conclusions This multimodal intervention was associated with increased LARC placement for adolescent women in primary care. The combination of education and process improvement is a promising strategy to promote clinician behavior change.

Impacts of a Pediatric Extracorporeal Cardiopulmonary Resuscitation (ECPR) Simulation Training Program Publication date: July 2019 Source: Academic Pediatrics, Volume 19, Issue 5 Author(s): Taylor Sawyer, Christopher Burke, D. Michael McMullan, Titus Chan, Hector Valdivia, Larissa Yalon, Joan Roberts Abstract Objective To examine the impacts of a large-scale simulation-based extracorporeal cardiopulmonary resuscitation (ECPR) training program in an academic children's hospital. Methods The study followed a quasi-experimental, mixed-method, time series design. Two-hour high-fidelity ECPR simulations were held monthly in the pediatric, cardiac, and neonatal intensive care units. Intensive care unit–specific cases were used in each unit. The learning objectives for all cases were the same. Each simulation included an average of 11 health care professionals, including nurses, physicians, respiratory therapist, and perfusionists. Impacts of training were examined using Kirkpatrick's 4-level model: reactions, learning, behaviors, and results. Participant surveys, semistructured interviews, facilitator observations, applied cognitive task analysis, and hospital code data were used to examine the impacts of training. Results From February 2014 to October 2016, a total of 332 health care professionals participated in 29 ECPR simulations. Participants enjoyed the simulations and reported learning gains. Applied cognitive task analysis revealed 2 specific behaviors, coordination of compressions with surgical cannulation and performing sterile compressions, that were targeted for further training. The rate of adherence to the ECPR activation protocol improved from 83% (48/58) before simulations started to 95% (92/97) after simulations (P = .02). ECPR activation time decreased from 7 minutes (interquartile range, 4–9 minutes) before simulations started to 2 minutes (interquartile range, 1–4 minutes) after simulations (P < .01). Conclusions Large-scale simulation-based ECPR training was associated with positive reactions, learning gains, behavioral change, improved adherence to the ECPR activation protocols, and faster activation times. Other children's hospital that perform ECPR should consider simulation-based training.

Justifications for Discrepancies Between Competency Committee and Program Director Recommended Resident Supervisory Roles Publication date: July 2019 Source: Academic Pediatrics, Volume 19, Issue 5 Author(s): Daniel J. Schumacher, Sue Poynter, Natalie Burman, Sean P. Elliott, Michelle Barnes, Caren Gellin, Javier Gonzalez del Rey, Daniel Sklansky, Lynn Thoreson, Beth King, Alan Schwartz, the APPD LEARN CCC Study Group Abstract Objective To explore justifications for differences between summative entrustment decisions made about pediatric residents by individuals who are charged with the review of residents (clinical competency committee, or CCC, members) and those who ultimately make final summative decisions about resident performance (program directors, or PDs). Methods Individual CCC member and PD supervisory role categorizations were made in the 2015 to 2016 academic year at 14 pediatric residency programs, placing residents into 1 of 5 progressive supervisory roles. When PD recommendations differed from CCC members, a free-text justification was requested. Free-text responses were analyzed using manifest content analysis. Results In total, 801 supervisory role categorizations were made by both CCC members and PDs, with the same recommendations made in 685 cases. In the 116 instances of discrepancy, PDs assigned a lower level of supervisory responsibility (n = 73) more often than a greater one (n = 43). When moving residents to a greater supervisory role category, PDs had more justifications anchored in resident performance than experience. When moving residents to a lower supervisory role categorization, PDs conversely noted experience more than performance. Conclusions PDs provide more justifications anchored in resident performance when moving residents to a greater supervisory role category compared with CCC members. However, when moving residents to a lower supervisory role categorization, they note experience more than performance. These patterns may or may not be entirely consistent with a competency-based approach and should be explored further.

The Challenges of Multisource Feedback: Feasibility and Acceptability of Gathering Patient Feedback for Pediatric Residents Publication date: July 2019 Source: Academic Pediatrics, Volume 19, Issue 5 Author(s): David Mahoney, Alyssa Bogetz, Amanda Hirsch, Katherine Killmond, Elisa Phillips, Vasudha Bhavaraju, Alisa McQueen, Nicola Orlov, Rebecca Blankenburg, Caroline E. Rassbach Abstract Objective The Accreditation Council for Graduate Medical Education calls for residency programs to incorporate multisource feedback, which may include patient feedback, into resident competency assessments. Program directors face numerous challenges in gathering this feedback. This study assesses the feasibility and acceptability of patient feedback collection in the inpatient and outpatient setting at 3 institutions. Methods Patient feedback was collected using a modified version of the Communication Assessment Tool (CAT). Trained research assistants administered the CAT to eligible patients and families in pediatric ward, intensive care, and outpatient settings from July to October 2015. Completion rates and reasons for non-completion were recorded. Patient satisfaction with the CAT was assessed on a 5-point Likert scale. Results The CAT was completed by 860/1413 (61%) patients. Completion rates in the pediatric ward and intensive care settings were 45% and 38%, respectively, compared to 91% in the outpatient setting. In inpatient settings, survey non-completion was typically due to participant unavailability; this was rarely a reason in the outpatient setting. A total of 93.4% of patients were satisfied or very satisfied with using the CAT. It was found that 6.36 hours of research assistant time would be required to gather a valid quantity of patient feedback for a single resident in the outpatient setting, compared to 10.14 hours in the inpatient setting. Conclusions Although collecting feedback using our standardized protocol is acceptable to patients, obtaining sufficient feedback requires overcoming several barriers and a sizable time commitment. Feedback collection in the outpatient setting may be higher yield than in the inpatient setting due to greater patient/family availability. Future work should focus on innovative methods to gather patient feedback in the inpatient setting to provide program directors with a holistic view of their residents' communication skills.

Medical Student Participation in Patient- and Family-Centered Rounding: A National Survey of Pediatric Clerkships Publication date: July 2019 Source: Academic Pediatrics, Volume 19, Issue 5 Author(s): Margaret J. Trost, Nicholas M. Potisek, L. Barry Seltz, Melanie Rudnick, Mary Rose Mamey, Michele Long, Patricia D. Quigley Abstract Objective Pediatrics rotations may be medical students' only experience with patient- and family-centered rounding (PFCR). It is unclear how students participate in or are prepared for PFCR. We surveyed national pediatrics clerkships to determine the prevalence of PFCR and the proportion providing orientation in order to inform a needs assessment for PFCR orientation. Methods A 5-item peer-reviewed survey was distributed to the Council on Medical Student Education in Pediatrics (COMSEP) membership as part of a larger survey in 2017. Institutional differences among programs performing PFCR were compared using chi-square and t-tests. Responses to 1 open-ended question were coded and grouped into broad categories using content analysis. Results The full COMSEP survey received answers from 190 participants representing 103 medical schools. Our questions received 174 responses representing 94 schools (98 training sites) and had an 85% (83/98) prevalence of student PFCR participation. Although most (n = 108; 85%) reported that their students received PFCR orientation, half (n = 62; 49%) considered orientation "informal," and only 2 reported using published curricula. After didactics, the most common orientation materials were handouts (n = 33; 26%), videos (n = 13; 10%), and role play (n = 7; 6%). Orientation was most commonly initiated at the start of clerkship (n = 62; 49%) by clerkship administration (n = 38; 30%), but 20% (n = 26) reported resident-led orientation. Qualitative responses (n = 98) were coded and organized into 4 themes; the greatest perceived challenges for medical students on PFCR were communication and anxiety. Conclusions Although most students participate in and receive orientation to PFCR, there is wide variability in the content, timing, and administration of orientation. A nationally disseminated, evidence-based orientation curriculum may reduce educational variability and better prepare students for PFCR.

Temperature-Adjusted Respiratory Rate for the Prediction of Childhood Pneumonia Publication date: July 2019 Source: Academic Pediatrics, Volume 19, Issue 5 Author(s): Richard G. Bachur, Kenneth A. Michelson, Mark I. Neuman, Michael C. Monuteaux Abstract Objectives As both fever and pneumonia can be associated with tachypnea, we investigated the relationship between body temperature and respiratory rate (RR) in young children and whether temperature-adjusted RR enhances the prediction of pneumonia. Methods In this retrospective cross-sectional analysis of 91,429 children < 5 years of age presenting to an urban pediatric emergency department, the relationship between triage RR and temperature was analyzed using regression analysis. We assessed the predictive value of temperature-adjusted RR for the diagnosis of pneumonia; diagnostic performance was evaluated for continuous RR as well as World Health Organization (WHO) age-based RR thresholds. Results The mean RR increased 2.6 breaths/minute for each 1°C increase in temperature. Interpatient variability was comparatively large; at any temperature, the interquartile range (75th percentile minus 25th percentile) varied from 4 to 16 breaths/minute. For predicting pneumonia, temperature- and age-adjusted RR was superior to age-adjusted RR: area under the curve (AUC) = 0.76 (95% confidence interval [CI], 0.75–0.78) versus AUC = 0.73 (95% CI, 0.72–0.75), respectively. Using WHO RR criteria, temperature-adjusted RR improved diagnostic discrimination, as the AUC increased from 0.58 (95% CI, 0.57–0.59) to 0.72 (95% CI, 0.70–0.73). Conclusions The effects of temperature on respiratory rate are modest, with a mean increase of 2.6 breaths/minute for each 1°C rise in temperature. Despite considerable interpatient variability in respiratory rates by temperature, temperature adjustment improves the diagnostic value of respiratory rate for pneumonia.

Differences in Febrile and Respiratory Illnesses in Minority Children: The Sociodemographic Context of Restrictive Parenting Publication date: July 2019 Source: Academic Pediatrics, Volume 19, Issue 5 Author(s): Danielle S. Roubinov, Nicole R. Bush, Nancy E. Adler, W. Thomas Boyce Abstract Objective To examine the moderating role of restrictive parenting on the relation of socioeconomic status (SES) to febrile illnesses (FIs) and upper respiratory illnesses (URIs) among ethnic minority and non-minority children. Methods Children from diverse ethnic backgrounds (Caucasian, African American, Asian, Latino, other, or multiethnic) were followed across the course of the kindergarten year. Parents reported on SES and parenting. A nurse completed 13 physical exams per child over the year to assess FIs and URIs. Results During the school year, 28% of children (n = 199, 56% ethnic minority) exhibited one or more FIs (range, 0–6) and 90% exhibited one or more URIs (range, 0–10). No main or moderating effects of SES or restrictive parenting on FIs or URIs were found among Caucasian children; however, among ethnic minority children, the relation of SES to FIs was conditional upon restrictive parenting (β = .66; P = .02), as the fewest FIs were found for lower SES minority children whose parents reported more restrictive practices. Additionally, among minority children, more restrictive parenting was marginally associated with fewer URIs (β = –.21; P = .05). Conclusions Unexpectedly, among minority children the fewest illnesses occurred among lower SES children whose parents endorsed more restrictive parenting. This may be due to unique appraisals of this rearing style among minority children in lower SES environments and its potential to influence immune functioning. Results suggest variability in the effects of parenting on offspring health and support context-specific evaluations of parenting in efforts to ameliorate early health disparities.

Concordance of Child and Parent Reports of Children's Screen Media Use Publication date: July 2019 Source: Academic Pediatrics, Volume 19, Issue 5 Author(s): Charles T. Wood, Asheley Cockrell Skinner, Jane D. Brown, Callie L. Brown, Janna B. Howard, Michael J. Steiner, Andrew J. Perrin, Cary Levine, Sophie N. Ravanbakht, Eliana M. Perrin Abstract Objective Little is known about the concordance of parent and child reports of children's media consumption, even though parents are often asked to report for their children in clinical care settings. Our objective was to understand how parent and child reports of children's media consumption differ in an era of changing screen media consumption via personal devices. Methods As part of a larger study about the reception of health-related cues from children's media, children ages 9 to 11 years (N = 114) and their parents independently completed identical questionnaires about specific media use and health behaviors. To examine concordance between child and parent reports of children's screen media use, we calculated the mean number of minutes per day and proportions reported by the child and parent and assessed concordance with t-tests and chi-square tests. Results On a typical day, children reported nearly an hour each of video and app game use, computer use, and television exposure. Overall, child and parent reports were similar, usually within 10 minutes of each other; however, among 3 measures of TV use, parents consistently reported less TV exposure than children. There was significant discordance in the percentages of parents and children reporting the presence of a TV in the child's room. Conclusions Parent and child reports of children's media use were generally concordant; however, there were important disagreements, such as TV use in the child's room and during meals. We discuss possible causes of discrepancies and implications.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com