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PubMed2002

Pediatric sedation: can it be safely performed by non-anesthesiologists?

PURPOSE OF REVIEW: The purpose of the present review is to provide the reader with a synopsis of the recent literature on sedation of children by non-anesthesiologists. RECENT FINDINGS: Health care centers are experiencing an increasing demand for sedation of pediatric patients. Whether provided by physician anesthesiologists, nurse anesthetists, or appropriately credentialed non-anesthesia clinicians, this increase is a reflection of new advances in the area of diagnostic imaging, better pharmacologic agents, and a heightened awareness of the psychologic needs of children. By definition anesthesiologists are the experts when it comes to providing sedation to patients. For pediatric patients, pediatric anesthesiologists provide the most appropriate specialization. However, because of insufficient manpower, anesthesiologists cannot adequately meet the increasing workload of providing sedation for each child in need. SUMMARY: In some circumstances the incidence of adverse events when sedation is provided by non-anesthesiologist can be high. Predicators of adverse outcome have been identified. Given strict adherence to sedation guidelines and appropriate credentialing of the sedation provider, non-anesthesiologists can safely provide sedation for children.

Journal Article↗
PubMedDate not supplied

School-based health centers. Statewide quality improvement program.

School-based health centers have been proposed as an avenue to provide health care for vulnerable youth. Colorado has 45 school-based health centers that provided 50,000 visits to 18,600 vulnerable youth in the 1998-1999 school year. Sustainability of the centers, however, depends on the ability to obtain an ongoing stream of revenue including managed care contracts, which in turn depend on the center's ability to meet the standard of care in the community. School-based health centers should meet standards of care similar to those of community health centers including certification, credentialing of providers, and a systematic evaluation of the outcomes of services. This article reports on a statewide quality improvement program that established certification standards for school-based health centers, verified the credentials of providers at the centers, and measured quality of care in centers across the state.

Accreditation↗
PubMed1995

General surgeons and the Advanced Trauma Life Support course: is it time to refocus?

OBJECTIVE: The aim of this study was to assess Advanced Trauma Life Support (ATLS) training status of general surgeons, its perceived utility, and its relation to clinical trauma practice. METHODS: A national sample of 1300 general surgeons was surveyed by mail about trauma training, ATLS status, trauma call, and confidence in clinical trauma care abilities. RESULTS: Response rate was 61%. Respondents most commonly (67%) felt they learned a great deal about trauma care in residency training; 13% responded similarly regarding ATLS. Course participation within 4 years of the survey was reported by 33% of respondents. Nearly 75% of those not taking the course cited primary reasons related to relevance (30%), redundancy (29%), and credentialing (15%). Inaccessibility, inconvenience, and cost were lesser factors. Of those expressing extreme confidence with trauma resuscitation, 40% had taken ATLS; 15% of those expressing a lesser degree of confidence had taken ATLS. CONCLUSIONS: The ATLS course represents a standard of initial trauma care education in which only one-third of surgeons report current participation. Many view ATLS as not relevant or useful, yet take trauma call. To ensure standard education and patient care, an ATLS course curriculum specifically geared to the general surgeon should be developed and made a mandatory component of residency training or a requirement for board certification and trauma call credentialing.

Clinical Competence↗
PubMed2001

Web-based medicine as a means to establish centers of surgical excellence in the developing world.

The growth of the Internet has provided a unique opportunity for rapid, global communication. Web-based medicine uses this technology to help surgeons in developing regions of the world gain direct access to recognized experts. This serves to empower local surgeons in the developing world through direct skill-transfer and encouraging academic pursuit. Web-based medicine follows the paradigm of a university without borders, therefore requiring exacting patient record keeping, monthly peer review, and continuing medical education of all its participants. All those who participate in Web-based medicine have undergone a credentialing process to guarantee that they possess adequate credentials. Patient confidentiality is strictly maintained. Web-based medicine also provides a follow-up strategy for medical volunteer groups who provide overseas services. Interplast, Inc., has administered a Web-based medicine site at http://www.wiredmd.com since July of 1999. A total of 767 cleft malformation cases performed locally by participating host surgeons in the developing world have been reviewed through the site. Additionally, 16 consultations have been posted and discussed by participating surgeons worldwide. Financing remains the major impediment to the globalization of this technology.

Cleft Lip↗
PubMed2005

Physician assistants as physician extenders in the pediatric intensive care unit setting-A 5-year experience.

OBJECTIVE: To describe the scope of practice and complementary role of physician assistants as physician extenders in the pediatric intensive care unit. DESIGN: Descriptive report of a 5-yr experience using a physician assistant-resident staffing model in comparison to the traditional resident-only coverage. SETTING: Six-bed pediatric intensive care unit at a tertiary care center subject to longstanding New York Hospital Code 405 restrictions on resident work hours. INTERVENTIONS: Orientation, training, credentialing, and evaluation of physician assistants. MEASUREMENTS AND MAIN RESULTS: New Accreditation Council for Graduate Medical Education regulations based on the longstanding New York Hospital Code 405 limit the number of resident hours worked per week. Our hospital employs physician assistants as physician extenders in the pediatric intensive care unit to enable regulatory compliance. Physician assistants were oriented for a period of 6 months to 1 yr to develop skill competencies, observe and learn pediatric intensive care unit practices and procedures, and complete credentialing to perform traditionally physician, nursing, and respiratory therapist functions. Physician assistants were then assigned to an independent but supervised patient care role similar to that of a resident physician. The impact of the physician assistant program was assessed by the attending physicians, and resident opinions were surveyed. CONCLUSIONS: Physician assistants play a complementary role as physician extenders in the pediatric intensive care unit, enabling compliance with New York state and Accreditation Council for Graduate Medical Education resident work hour regulations. Physician assistants perform similar tasks and activities as the pediatric intensive care unit residents and integrate well with them in enhancing bedside patient care. Over time, physician assistants provide additional direction to the residents by virtue of their familiarity with unit-specific policies and procedures and repetitive pediatric intensive care unit practice patterns. As multifunctional members of the health care team, they support nursing and respiratory therapy functions and improve the day-to-day functioning of the unit. The physician assistant serves as a key member of the pediatric intensive care unit transport team. Limitations observed include high job turnover rates among the physician assistants and confusion between their role as shift workers or professional employees.

Accreditation↗
PubMed2005

Constructed criteria: redefining merit to justify discrimination.

This article presents an account of job discrimination according to which people redefine merit in a manner congenial to the idiosyncratic credentials of individual applicants from desired groups. In three studies, participants assigned male and female applicants to gender-stereotypical jobs. However, they did not view male and female applicants as having different strengths and weaknesses. Instead, they redefined the criteria for success at the job as requiring the specific credentials that a candidate of the desired gender happened to have. Commitment to hiring criteria prior to disclosure of the applicant's gender eliminated discrimination, suggesting that bias in the construction of hiring criteria plays a causal role in discrimination.

Adult↗
PubMed2006

Registered nurses as responsible clinicians under the New Zealand Mental Health (Compulsory Assessment and Treatment) Act 1992.

The objectives of this research were to determine how many registered nurses are working as 'responsible clinicians', under what phases of the legislation they are functioning, and to describe the enabling processes and barriers to nurses undertaking this statutory role. An anonymous descriptive survey was distributed to the 11 nurses who were currently responsible clinicians as well as five senior nurses selected from each of the 21 District Health Boards and the Auckland Regional Forensic Psychiatry Services (n = 121). The response rate was 88.4% (n = 107). The survey questioned respondents on statutory roles currently undertaken. Respondents were asked whether the responsible clinician role was a legitimate one for nurses and whether they were motivated to attain it. They were also asked which competencies of the role they believed they met, their perceptions of credentialing processes and the educational requirements needed to achieve the role. A descriptive statistical analysis was undertaken and open-ended questions were analysed using content analysis. Of the approximately 395 responsible clinicians nationally, 11 (2.8%) are nurses. Most nurses viewed the role as legitimate. However, many were unaware of competencies for the role and credentialing processes, and were somewhat ambivalent about achieving the role due to current workload, role conflict and lack of remuneration. Competency deficits were highlighted. There are grounds to encourage nurses as responsible clinicians given the intent of the legislation. This will require the promulgation of appropriate mental health policy, and a concerted effort by major stakeholders in mental health service delivery.

Adult↗
PubMed2005

Pediatric sedation in North American children's hospitals: a survey of anesthesia providers.

BACKGROUND: Information about the existence and organization of pediatric sedation services in North America is not available. We conducted a survey to collect this information from anesthesiologists at pediatric institutions and to identify factors perceived as limiting the development of sedation services. METHOD: We electronically mailed a confidential survey about pediatric sedation practice to an attending anesthesiologist involved in pediatric sedation at 116 children's hospitals in the United States and Canada. We identified the institutions using Internet resources. Electronic mailing addresses were obtained from departmental websites, society membership directories and departmental administrators. Our follow-up for nonresponders was by a second e-mail and a telephone call. RESULTS: A total of 54 completed questionnaires were received, a response rate of 47%. Forty-nine (91%) were received from US hospitals, and the remainder from Canadian. Fifty percent of hospitals had a formal pediatric sedation service. Fifty-four percent utilized a 'mobile' provider model. Hospital credentialing for nonanesthesiologist providers varied between 66 and 76% for 'deep' and 'conscious' sedation, respectively. A nurse-physician provider combination was the most common, utilized in 59% of hospitals. Anesthesiologists were the sole sedation providers in 26% of institutions. Propofol was used regularly by nonanesthesiologists for sedation of nonintubated (42%) and intubated (63%) patients. Eighty-seven percent of institutions reported barriers to development of pediatric sedation services. The most common barrier was a shortage of providers, particularly anesthesiologists. CONCLUSIONS: Propofol use by nonanesthesiologists is common. Addressing the shortage of providers, and allocating resources for credentialing providers will encourage further development of pediatric sedation practice.

Anesthesia↗
PubMed1999

Elite formation under occupation: the internal stratification of palestinian elites in the West Bank and Gaza Strip.

This paper examines the internal stratification of Palestinian elites in the West Bank and Gaza Strip under Israeli occupation. Our general aim is to clarify the extent to which social and political subordination to outside rule influences the development of indigenous elites in stateless societies. In contrast to nation-state societies, such elites may be horizontally stratified into a wider range of institutional settings, and vertically stratified by anti-occupation activism alongside the attainment of occupational prestige. In addition, context-specific determinants of their stratification patterns, such as refugee status, regionality, and country in which educational credentials were acquired, should be considered. A secondary content analysis of interviews conducted by the Palestinian Panorama centre with 249 elite members reveals, that the vertical stratification of Palestinian elites along occupational attainment and anti-occupation activism constitutes two quite independent status dimensions. A multinomial logit regression shows that, horizontally, elite groups are embedded in four distinct types of institutional activity, further demonstrating the multi-faceted formation of Palestinian elites. Contextual resources, such as refugee versus non-refugee status, regionality, and the acquiring of Western credentials, have differential effects on the vertical and horizontal stratification of Palestinian elites. The implications of these findings for further research on elite formation in the post-Oslo Palestinian society and in other stateless societies are discussed in conclusion.

Adult↗
PubMed2005

Turf wars: what can modern medicine learn from medieval guilds?

Medieval guilds for a time grew wealthy under a system of work rules that granted them a virtual trade monopoly, but such protection was worthless in the face of innovations in communications and commerce. Many medical specialists have grown wealthy under a guild system based on board certification. Unfortunately, creation of a vascular medicine board is unlikely to resolve the ongoing turf wars between cardiologists, radiologists, and vascular surgeons. Moreover, if medical specialists (who are facing innovations in the form of the Internet and telemedicine) wish to avoid the fate of the medieval guilds, a more flexible system based on individual competency is needed. While credentialing based on individual competence is good for specialists, it creates increased liability for hospitals because specialist credentialing will become more discretionary and less ministerial.

Attitude of Health Personnel↗
PubMed1980

Providers and receivers in the private psychiatric Medicaid system.

The authors investigated the credentials of foreign medical graduate (FMG) and U.S. medical graduate (USMG) psychiatrists providing a substantial amount of Medicaid care and compared them with those of a group of other psychiatric practitioners in New York City. USMGs were more likely to be Board certified, but FMGs were as likely to have APA membership, psychoanalytic training, medical school and hopsital affiliation, and fellowships. The credentials of the Medicaid psychiatrists and the group of New York psychiatrists were similar. Hispanic FMG psychiatrists provided a major service for the Spanish-speaking community, but the poor black population underused Medicaid services. Diagnosis did not appear to be influenced by racial bias.

Black or African American↗
PubMed2006

The challenge of changing roles and improving surgical care now: Crew Resource Management approach.

Many surgeons are also pilots; the two activities demand similar skill sets. Surgeons have developed an interest in aviation models for managing risk and reducing adverse events, such as Crew Resource Management training. This article provides seven suggestions from aviators that might be adopted by surgeons in an effort to improve surgical care and mitigate patient harm. Each suggestion is offered based on the value added to aviation, with an acknowledgment that the suggestion may be more or less applicable in surgery. The suggestions for dealing with the changing roles for surgeons are: Crew Resource Management-type training to improve teamwork should be required for hospital credentialing, surgeons should brief the operating room team before an operation, surgeons should write standards specific to their organization, surgeons should recognize fatigue and age as factors in performance, surgeons should have "check-rides" as a part of the credentialing process, surgeons should abandon the mortality and morbidity conference in favor of a data collection system that effectively examines adverse events for root causes of error, and all members of the surgical team should be subject to mandatory, random drug testing.

General Surgery↗
PubMed1989

Translating a health professional certification test to another language. A pilot analysis.

There has been increased pressure in recent years for examinations used for occupational and professional credentialing to be offered in several languages. When credentialing programs are international in scope, rather than national, examination translation may be a necessity, and a validation of the translation will be required. Yet, few candidates may sit for the translated version, jeopardizing the power and generalizability of statistical analysis. How should a board proceed in meeting its linguistic responsibility when faced with a small n? This article describes such a situation, and the linguistic and psychometric procedures that were developed and applied on a pilot translation by the International Board of Lactation Consultant Examiners (IBLCE).

Allied Health Personnel↗
PubMed2002

State certification for school nurses.

State-specific credentialing of school nurses is generally equivalent to state teacher certification and is regulated by state departments of education. This certification establishes statewide employment standards for school nurses, as opposed to competency-based professional certification. Although more than half of all states currently have some type of credentialing for school nurses, it takes many different forms. The advantages of certification are pronounced but are surpassed by the barriers to its establishment. Considerations in establishing certification are presented along with analysis of the various forms of certification that exist in states that have school nurse certification.

Adult↗
PubMed1985

Definition of clinical pharmacy as a specialty in clinical practice. Committee on Clinical Pharmacy as a Specialty. American Pharmacy Association.

Specialty credentialing has been discussed extensively and debated within pharmacy for more than ten years. Within the profession, there now appears to be a consensus on the need for and appropriateness of acknowledging professional practice areas as unique, defined entities. However, there remain substantive differences on how the definition of specialty practice should be constructed. One approach is to identify practice areas by functional activity (e.g., nuclear pharmacy, drug information) and/or therapeutic focus (e.g., psychopharmacy, clinical pharmacokinetics). A second approach is to define clinical pharmacy as a specialty practice that would, at least initially, coalesce clinical practitioners with the common denominator of an active role in the therapeutic decision-making process. The following document was developed by the Committee on Clinical Pharmacy as a Specialty (CCPS). The CCPS is independent of any formal organizational affiliations. It will serve as the preface to a petition that will be submitted to the Board of Pharmaceutical Specialties requesting recognition of clinical pharmacy as a specialty. The intention of the committee is to resolve the question of specialty status for clinical pharmacy through the Board of Pharmaceutical Specialties' review process. It is then hoped that pharmacy can move forward on the important issue of specialty credentialing.

Certification↗
PubMed2005

Simulation-based education for cardiac, thoracic, and vascular anesthesiology.

Simulation has been used for medical teaching and testing for at least four decades in some form, such as that used for cardiopulmonary resuscitation training; however, new technology applied to medical and procedural training has recently led to a marked increase in the use of simulation-based instruction. Educational theory has further supported simulation for medical education and procedural training. Simulation-based testing to demonstrate competence with new procedures is already required by the US Food and Drug Administration for one angiographically-placed device, and it is likely that simulation-based credentialing for procedures will be increasingly prevalent. Anesthesiologists, like other physicians, may be credentialed or certified based on their performance in a simulated environment in the future. This review describes some of the current simulation-based education techniques related to cardiovascular and thoracic anesthesiology. Additional discussion covers some of the applicable educational theory and the expected future uses of simulation modalities in healthcare education, testing, and practice.

Anesthesia↗
PubMed2006

Independent evaluations of IMRT through the use of an anthropomorphic phantom.

Intensity-modulated radiation therapy (IMRT) has gained rapid and wide-spread acceptance in the radiation oncology community for its ability to create dose distributions that conform to the convoluted shapes of many tumors. It is a complicated treatment technique, for which quality assurance procedures are correspondingly complicated and labor intensive. Several of the cooperative cancer study groups that conduct clinical trials under the auspices of the National Cancer Institute have required participating institutions to seek credentialing before enrolling patients in trials involving IMRT. The Radiological Physics Center has conducted such credentialing programs through the use of anthropomorphic phantoms that evaluate the planning and delivery of IMRT. The experience obtained through the irradiation of the phantoms by a number of institutions demonstrates that institutions vary significantly in their ability to deliver doses and dose distributions that agree with their own treatment plans.

Humans↗
PubMed2002

National survey of pharmacist certified diabetes educators.

We sought to determine the demographics of pharmacists who were certified diabetes educators (CDEs) and information about their training, professional affiliations, and types of diabetes education services that they provide. We also queried these pharmacists about clinical activities, reimbursement, impact of certification, and intent to pursue CDE recertification. A list of pharmacists who were CDEs as of August 31, 2000, was obtained from the National Certification Board for Diabetes Educators. We then sent a six-page anonymous survey to 415 pharmacist CDEs; 233 surveys (56.1%) were returned. Of these respondents, 140 are women and 93 are men, with a mean age of 41.5 years. Most reside in Southern or Western states. Average time since pharmacist licensure was 17 years, and average time as a CDE was 5 years. Most had completed postgraduate training, including residencies and/or fellowships; 52.8% had faculty appointments; 46.7% stated they were billing for their services; and 45.9% were obtaining reimbursement. Most pharmacists (84.4%) stated that they intended to pursue CDE recertification. Providing details about pharmacist CDEs and their clinical activities may motivate other pharmacists to pursue this credential. Pharmacists are often the most accessible of all health care providers, and earning the CDE credential may be an important contribution to diabetes care and education.

Accreditation↗