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PubMed2006

Pediatric pelvic fractures: a marker for injury severity.

Pelvic fractures comprise a small number of annual Level I pediatric trauma center admissions. This is a review of the University of Chicago Level I Pediatric Trauma Center experience with pediatric pelvic fractures. This is a retrospective review of the University of Chicago Level I Pediatric Trauma Center experience with pediatric pelvic fractures during the 12-year period from 1992 to 2004. From 1992 to 2004, there were 2850 pediatric trauma admissions. Thirteen patients were identified with pelvic fractures; seven were boys and six were girls. The average age was 8 years old. The mechanism of injury in all cases was motor vehicle related; 11 patients (87%) sustained pedestrian-motor vehicle crashes. According to the Torode and Zeig classification system, type III fractures occurred in eight patients (62%) and type IV fractures occurred in six patients (31%). Associated injuries occurred in eight patients (62%). Seven of these patients (88%) had associated injuries involving two or more organ systems. Of the associated injuries, additional orthopedic injuries were the most common, occurring in 62 per cent of our patients. Neurological injuries occurred in 54 per cent of patients, vascular injuries in 39 per cent, pulmonary injuries in 31 per cent, and genitourinary injuries in 15 per cent. Five patients (38%) were treated operatively; only two patients underwent operative management directly related to their pelvic fracture. The remaining three patients underwent operative management of associated injuries. The mortality rate was 0 per cent. Although pelvic fractures are an uncommon injury in pediatric trauma patients, the morbidity associated with these injuries can be profound. The majority of pelvic fractures in children are treated nonoperatively, however, more than one-half of these patients have concomitant injuries requiring operative management. When evaluating and treating pediatric pelvic fractures, a systematic multidisciplinary approach must be taken to evaluate and prioritize the pelvic fracture and the associated injuries.

Adolescent↗
PubMed1986

The subspecialty of pediatric dermatology.

Department chairmen of 127 certified pediatric and eighty-six certified dermatology residency programs were surveyed in an attempt to characterize the subspecialty of pediatric dermatology. Responses were received from 114 different institutions. The results indicate that pediatric dermatologists are located mainly in large teaching hospitals (pediatric wards with more than 100 beds or children's hospitals) and selected private practice settings. Fifty-eight percent of pediatric dermatologists are less than 40 years of age. Forty-nine percent of these individuals are board-certified in both specialties. Very few "pediatric dermatologists" see pediatric patients exclusively. Only 20% have a patient population that is composed of more than 75% children. The responses also suggest that professional opportunities in this subspecialty are limited at the present time.

Adult↗
PubMed1993

The adult patient in the pediatric emergency department.

STUDY OBJECTIVE: To establish the frequency of use of pediatric emergency departments by adult patients and the spectrum of disease with which they present. DESIGN: Prospective, descriptive study and unblinded survey. SETTING: Children's Hospital pediatric ED. TYPE OF PARTICIPANTS: Seventy-two adult patients presenting to a pediatric ED during a two-year period and 31 pediatric emergency medicine fellowship directors. INTERVENTIONS: For each patient, we recorded demographic information, chief complaint, interventions by physicians, diagnosis, condition, and disposition after initial care. Pediatric emergency medicine fellowship training program directors were surveyed by telephone regarding their experiences with adult patients and the extent of adult emergency medicine training within their programs. MAIN RESULTS: Of the 72 adult patients evaluated, one third (22) were treated for trauma and the remaining 50 for medical illness. More than 40 different diagnoses were encountered, including stroke and myocardial infarction. Twenty patients (27.8%) required hospitalization, four (5.6%) in intensive care settings. Of the 31 fellowship directors surveyed, 27 (87.1%) indicated that adult patients had been managed in their EDs during the previous year. All but one reported that their fellowship programs incorporated between one and four months of adult emergency medicine in their curricula. CONCLUSION: Adults frequently present to pediatric EDs for both minor and serious illnesses. Training in adult emergency medicine should be a part of all pediatric emergency medicine fellowship programs.

Adult↗
PubMed1998

Minimally invasive surgery: the pediatric surgery experience.

BACKGROUND: Minimally invasive surgery (MIS) has become an important aspect of general surgery. The degree to which pediatric surgeons have incorporated MIS into their practice is not known. STUDY DESIGN: An MIS survey was sent to all members of the American Pediatric Surgical Association. Respondents were separated into two groups: nonperformers and performers of MIS. Performers were asked how they were trained in MIS and the total number and types of minimally invasive procedures they have performed. RESULTS: Eighty-two percent of surveyed pediatric surgeons perform MIS. Eighty-seven percent received some or all of their training in a postgraduate course. Two percent received their only training during their general surgery residency. Forty-seven percent of performers reported 50 or fewer total procedures. A wide variety of procedures were reported, but laparoscopic cholecystectomy (95%) was the procedure most frequently reported. Thoracoscopic procedures (71%) were also reported at high rates. CONCLUSIONS: Most pediatric surgeons in our survey perform MIS. The high rate of laparoscopic cholecystectomies reported suggests that the initial MIS experience of pediatric surgeons in our survey is similar to adult general surgeons. The frequency, however, of thoracic cases reported indicates that MIS techniques are being applied to all areas of pediatric surgery. The total minimally invasive procedure experience of our respondents also suggests that pediatric surgeons are early in their learning curve.

Adult↗
PubMed2003

The market for pediatric surgeons: an updated survey of recent graduates.

PURPOSE: The aim of this study was to identify the demand for pediatric surgeons as perceived by recent graduates of North American pediatric surgery training programs. METHODS: A survey was mailed to every pediatric surgeon who completed a certified training program in North America between 1998 and 2000; 81% of 83 responded. Data from the previous survey of 1992 through 1997 graduates provided longitudinal comparisons. The data were analyzed using univariate and bivariate statistical analysis. RESULTS: The number of graduates was 28, 31, and 24 for 1998, 1999, and 2000, respectively, down from 35 graduates in 1997. All found positions in pediatric surgery, and first-year incomes continue to rise. Fewer graduates (54%) desired an academic position coupled with research compared with previous survey respondents (64%), and 69% were able to find such a position. A practice at a university children's hospital remained the most desired by over 80%, but only 38% obtained positions in this type of practice. However, 55% were able to find a position in a children's hospital (university or community), which had declined gradually to a low of 32% in 1997. The 1998 to 2000 graduates perceive a much stronger demand for pediatric surgeons compared with previous survey respondents (46% v 14%), and greater than 50% felt that too few pediatric surgeons were being trained. CONCLUSIONS: The market demand for pediatric surgeons remains strong as measured by employment and income. The perception of the market by the 1998 through 2000 graduates is positive, which contrasts with the 1992 through 1997 graduates. However, there continues to be significant market changes including a proliferation of positions at community Children's hospitals.

Adult↗
PubMed1992

Can the need for a physician as part of the pediatric transport team be predicted? A prospective study.

OBJECTIVES: To evaluate the quality of objective information obtained during telephone requests for the transport of pediatric patients. To evaluate the ability of subjective judgment, the Pediatric Risk of Mortality (PRISM) score, and the presence of tachycardia for age to predict the need for a physician on as a member of the pediatric transport team. DESIGN: Prospective data collection. SETTING: The pediatric transport program of a children's hospital. PATIENTS: All 129 infants and children transported over a 4-month period. MEASUREMENTS AND MAIN RESULTS: We defined an objective measure of the need for a physician's presence during the transport of a pediatric patient, based on either the necessity for procedural or medical interventions during the time of transport or on direct admission to the pediatric ICU after transport. At the time of initial telephone contact, a physician's subjective opinion of the need for physician presence was recorded, a PRISM score was derived, and the presence of tachycardia (adjusted for age) was determined. Subsequently, the vital signs recorded on the record of this request were compared with those vital signs charted at the referring hospital at the time of the initial telephone request. A total of 96% of vital signs obtained during the initial telephone contact were consistent with those percentages in the referring hospital medical records. Fifty (39%) of 129 transported patients required procedural or medical interventions or pediatric ICU admission. Subjective judgments predicted physician need with a high sensitivity (0.98), but with a low specificity (0.18). PRISM score predicted 62 (48%) of 129 transports to be "physician-required" (sensitivity = 0.72; specificity = 0.67). There was no statistical association between tachycardia for age and the objective need for a physician's presence. CONCLUSIONS: Objective information obtained during request for transfer was reliable. At the time of request for transfer, subjective judgment, PRISM score, and the presence of tachycardia did not predict the need for a physician presence during transport.

Child↗
PubMed1998

Cost of extracorporeal life support in pediatric patients with acute respiratory failure.

OBJECTIVES: To determine the impact of extracorporeal life support (ECLS) on mortality in pediatric patients with acute hypoxemic respiratory failure (AHRF) at our institution; and to calculate the hospital charges associated with the use of ECLS. DESIGN: Retrospective review of medical records and hospital charges. SETTING: Pediatric intensive care unit (ICU) of a university-affiliated children's hospital. PATIENTS: Twenty patients admitted to the pediatric ICU between 1991 and 1995 for AHRF who received ECLS as a part of their hospital course. INTERVENTIONS: Predicted mortality was calculated using the Pediatric Respiratory Failure score and was compared with survival at the time of hospital discharge. Hospital charges were used as a proxy for resource utilization. Cost-per-life-year-saved calculations were performed based on a normal life expectancy for survivors. MEASUREMENTS AND MAIN RESULTS: Twenty patients were identified. The median age was 4.83 yrs. The median duration of ECLS was 9 days, with 19.5 days in the pediatric ICU and 23.5 days for the entire hospital length of stay. The observed mortality rate for these patients was 20%. Median predicted mortality rate based on the Pediatric Respiratory Failure score calculation was 83%. The hospital charges incurred by these patients was a median of $199,096. Based on a normal life expectancy for survivors, this results in a cost of $4,190/life-year. CONCLUSIONS: ECLS for the pediatric patient with AHRF is done at a considerable cost. However, ECLS affects survival favorably, and compares favorably when considering cost/life-year calculations. The data presented in this study may serve as a benchmark for comparison with newer therapies (i.e., liquid ventilation, nitric oxide). These data also provide a framework for cost-based analyses at other ECLS institutions.

Adolescent↗
PubMedDate not supplied

Does pediatric orthopedic subspecialization affect hospital utilization and charges?

In the current climate of health care reform, there is a perception that overspecialization is responsible for increased medical costs. Few studies support the premise that high-quality surgical subspecialization improves the cost effectiveness of care. The purpose of this study was to compare hospital utilization and charges between a pediatric hospital staffed by pediatric orthopedic subspecialists and a community hospital system for the care of closed femur fractures and slipped capital femoral epiphysis (SCFE) in a pediatric population. We reviewed hospital charges and length-of-stay (LOS) data for all children treated for closed femoral shaft fractures and SCFE between 1992 and 1994 within the Intermountain Health Care System (IHC). Within the IHC, there are 23 community hospitals and one children's hospital (PCMC). Patients were matched for age and injury severity. Four of six orthopedic surgeons at PCMC are pediatric orthopedists, but none of the community orthopedists has subspecialty training in pediatric orthopedics. For closed femoral shaft fractures (n = 334), the average hospital charges were less (PCMC, $4,943/Other IHC, $9,031), and length of stay was shorter (PCMC, 2.81 days/Other IHC, 8.91 days) when the child was treated at the children's hospital by pediatric orthopedic subspecialists. For SCFE (n = 63), the average hospital charges were less (PCMC, $2,824/Other IHC, $3,544) and the length of stay was shorter (PCMC, 1.13 days/Other IHC, 1.64 days) at the children's hospital. These data suggest that hospital utilization and charges were significantly decreased if the care was provided by pediatric orthopedic subspecialists in a children's hospital.

Adolescent↗
PubMed1995

Preferences of parents for pediatric emergency physicians' attire.

While several studies have evaluated patient/parent's preference for physicians' attire in pediatric clinics, pediatric wards, and in adult emergency settings, none has been done in a pediatric emergency department (PED). Furthermore, factors that may influence these preferences such as severity of illness, time of visit, and type of emergency department (ED) visit (surgical vs medical) have not been considered. This study was designed to evaluate parents' attitudes toward pediatric emergency department physicians' professional appearance. By way of a survey, the parents/guardians of 360 patients presenting to Children's Hospital Medical Center PED in Cincinnati, Ohio, were presented with eight photographs of physician pairs (male/female) dressed in different levels of attire ranging from a formal style (white laboratory coat, dress shoes, and tie) to surgical scrubs with tennis shoes. They were asked to choose the pair of practitioners they liked the most and the least, and to indicate whether their perception of competence was affected by physician attire. Preferences were analyzed by gender, age, responsible person, insurance group, type of visit, severity of illness, and time of visit. The results showed that, when asked which physicians they would prefer the most to evaluate their child in the PED, the majority of subjects chose photographs of physicians dressed most formally (158/360 [chi 2, P < 0.0001]). When asked which physician they preferred the least, 229 subjects chose the photograph of doctors wearing no white laboratory coat, no tie, and tennis shoes (chi 2, P < 0.0001). Neither severity of illness, time of visit, insurance group, age, race, or gender of the guardian or parent had a significant statistical effect on the most preferred or disliked attire. However, subjects visiting the ED between 7 AM and 11 PM clearly preferred the formal attire when compared with the 11 PM to 7 AM shift (chi 2, P = 0.016). A significant difference was noted between the preference of surgical scrubs by the parents of patients with surgical emergencies (42/90 [58%]) vs medical patients (30/270 [23%]) (chi 2, P < 0.0001). Combining parents' selections, 75% preferred photographs of physicians wearing white laboratory coats, while 84% chose photographs of doctors who wore tennis shoes as the least liked physicians. Seventy-two percent of parents felt the physicians they preferred the most were not necessarily more capable than the other choices. Sixty-nine percent of subjects felt that it did not matter what their pediatric emergency physician was wearing. Formal attire was associated with "professional appearance" in 64% of the responses. Our study demonstrated that: 1) pediatric emergency physician's attire does not matter to most parents. However, when asked to choose, clear preferences for likes and dislikes become evident. 2) Parents/guardians prefer pediatric emergency physicians who wear formal attire, including white laboratory coat, and do not like casual dress with tennis shoes. 3) Severity of illness, insurance type, and age, race, and gender of guardians do not affect preferences. 4) Parents of patients with surgical emergencies are more likely to prefer doctors wearing surgical scrubs. 5) Parents visiting the ED during night shift (11 PM to 7 AM) showed less interest in formal attire. Our findings may assist in parent/physician interaction in a PED setting.

Adult↗
PubMed1999

Variability in physician opinion on limiting pediatric life support.

OBJECTIVE: We conducted this study to investigate how physicians in a pediatric intensive care unit (ICU) currently make decisions to withdraw and withhold life support. Consultation with the patient's primary caregiver often precedes decisions about withdrawal and limitation of life support in chronically ill patients. In these scenarios, the patient's primary caregiver was the pediatric oncologist. To evaluate the influence of subspecialty training, we compared the attitudes of the pediatric intensivists and the oncologists using scenarios describing critically ill oncology patients. DESIGN: Cross-sectional survey. Each physician was randomly assigned 4 of 8 potential case scenarios. SETTING: A total of 29 American pediatric ICUs. PARTICIPANTS: Pediatric intensive care and oncology attendings and fellows. INTERVENTION: Systematic manipulation of patient characteristics in two hypothetical case scenarios describing 6-year-old female oncology patients presenting to the ICU after the institution of mechanical ventilator support for acute respiratory failure. Cases 1 through 4 described a patient who, before admission, had a 99% projected 1-year probability of survival from her underlying cancer and suffered from severe neurologic disabilities. Cases 5 through 8 described a patient who was neurologically normal before admission and had a <1% chance of surviving longer than 1 year because of her underlying cancer. Each physician was randomly assigned 2 cases from cases 1 through 4 and 2 cases from cases 5 through 8. Within each of these case scenarios, parental preferences (withdraw or advance support or look for guidance from the caregivers) and probability of survival (5% vs 40%) were manipulated. Before distribution, the survey instrument was pilot-tested and underwent a rigorous assessment for clinical sensibility. PRIMARY OUTCOME MEASURES: Physicians ratings of the importance of 10 factors considered in the decision to withdraw life support, and their decisions about the appropriate level of care to provide. Respondents were offered five management options representing five levels of care: 1) discontinue inotropes and mechanical ventilation but continue comfort measures; 2) discontinue inotropes and other maintenance therapy but continue mechanical ventilation and comfort measures; 3) continue with current management but add no new therapeutic intervention; 4) continue with current management, add additional inotropes, change antibiotics and the like as needed, but do not start dialysis; and 5) continue with full aggressive management and plan for dialysis if necessary. Respondents also were asked whether they would obtain an ethics consultation. RESULTS: A total of 270 physicians responded to our survey (165 of 198 potentially eligible pediatric intensivists and 105 of 178 pediatric oncologists for response rates of 83% and 59%, respectively). The respondents considered the probability of ICU survival and the wishes of the parents regarding the aggressiveness of care most important in the decision to limit life-support interventions. No clinically important differences were found when the responses of oncologists were compared with those of intensivists. In six of eight possible scenarios, the same level of intensity of care was chosen by less than half of all respondents. In three scenarios, >/=10% of respondents chose full aggressive management as the most appropriate level of care, whereas another >/=10% chose comfort measures only when viewing the same scenario. The most significant respondent factors affecting choices were professional status (attending vs fellow) and the self-rated importance of functional neurologic status. The majority of respondents (83%) believed that the intensive care and the oncology staff were usually in agreement at their institution about the level of intervention to recommend to the parents. (ABSTRACT TRUNCATED)

Child↗
PubMed2003

Scope of practice issues in the delivery of pediatric health care.

In recent years, there has been an increase in the number of nonphysician pediatric clinicians and an expansion in their respective scopes of practice. This raises critical public policy and child health advocacy concerns. The American Academy of Pediatrics (AAP) believes that optimal pediatric health care depends on a team-based approach with coordination by a physician leader, preferably a pediatrician. The pediatrician is uniquely suited to manage, coordinate, and supervise the entire spectrum of pediatric care, from diagnosis through all stages of treatment, in all practice settings. The AAP recognizes the valuable contributions of nonphysician clinicians, including nurse practitioners and physician assistants, in delivering optimal pediatric care. The AAP also believes that nonphysician clinicians who provide health care services in underserved areas should be supported by consulting pediatricians and other physicians using technologies including telemedicine. Pediatricians should serve as advocates for optimal pediatric care in state legislatures, public policy forums, and the media and should pursue opportunities to resolve scope of practice conflicts outside state legislatures. The AAP affirms that as nonphysician clinicians seek to expand their scopes of practice as providers of pediatric care, standards of education, training, examination, regulation, and patient care are needed to ensure patient safety and quality health care for all infants, children, adolescents, and young adults.

Delivery of Health Care↗
PubMed2006

Comparing perceptions of training for medicine-pediatrics and categorically trained physicians.

OBJECTIVE: The objective of this study was to compare the perceptions of clinical preparedness among graduates of categorical pediatric and internal medicine residency programs versus medicine-pediatric training programs and whether these varied for recent or older graduates. METHODS: A mail survey study was conducted in the fall of 2004 of a random sample of 245 and 246 internal medicine physicians who applied for or took a general certifying examination between 1980 and 1997 (older graduates) and between 1998 and 2003 (recent graduates), respectively, and a random sample of 248 and 247 pediatricians who applied for or took a general certifying examination between 1980 and 1997 (older graduates) and between 1998 and 2003 (recent graduates). Analyses compared results from a recent, similar survey of medicine-pediatric physicians. RESULTS: Response rate for pediatricians was 78% and for internal medicine physicians was 64%. Categorically trained pediatricians were more likely than medicine-pediatrics-trained physicians to report that they were very well prepared to care for infants (65% vs 50%) but less likely well trained to care for adolescents (17% vs 45%). Categorically trained internal medicine residents were less likely to feel very well prepared to care for both adults and elders than their medicine-pediatrics-trained counterparts. CONCLUSIONS: Categorically trained pediatricians and internal medicine physicians believed that they were no better prepared to care for their patients than medicine-pediatrics-trained physicians. Regardless of their beliefs of their preparedness, medicine-pediatrics physicians in practice spend a significant majority of their time in the care of adults rather than children. Our findings indicate that this is not because of their perception of a lack of training or preparation in the care of children relative to categorically trained pediatricians. Other factors, including but not limited to patient demographic changes, reimbursement for care, and the job market, potentially play a significant role.

Adult↗
PubMed1997

Response to battered mothers in the pediatric emergency department: a call for an interdisciplinary approach to family violence.

BACKGROUND: Child abuse and wife abuse are linked. Studies indicate 30% to 59% of mothers of children reported for child abuse also are battered. In homes where domestic violence occurs, the children are at increased risk of physical abuse or neglect. Children who witness battering of their mothers are at risk for psychosocial sequelae including developmental delays and posttraumatic stress disorder. OBJECTIVE: To determine pediatric emergency medicine fellows' level of preparedness to respond to battered mothers, and to assess obstacles and attitudinal barriers to their effective response. STUDY DESIGN: Self-reported written survey. METHODS: A 30-item anonymous questionnaire was mailed to 162 pediatric emergency medicine fellows in the United States and Canada in 1995. A response rate of 77.2% (n = 125) was achieved. RESULTS: Before fellowship, 97.6% of respondents had training (including formal courses, conferences, and direct patient contact) on child abuse/neglect although only 29.6% received similar instruction on woman battering. There was a marked disparity between patient contact experience for child abuse/neglect and woman battering throughout training. Before fellowship, 89/122 (73%) reported direct involvement in at least 10 cases of child abuse/neglect. Seventy-one (57.3%) of 124 fellows had not handled any cases of woman battering before fellowship; 106/124 (85.5%) had been directly involved in fewer than 10 cases. During fellowship 81 (67.5%) of 120 respondents had been involved in at least 10 cases of child abuse/neglect and 46/120 (38.3%) had handled at least 20 cases. In contrast, 72 (73.5%) of the 98 responding fellows had not handled any cases of woman battering during fellowship. Furthermore, 86/100 fellows reported no formal training on woman battering in their fellowship curricula. Only 5/118 (4.2%) reported having protocols in place for responding to battered women in the pediatric emergency department. Items most frequently selected from a list of potential obstacles to responding to battered women included: lack of a protocol (82/113), lack of formal training in the field (103/118), and lack of experience with woman battering cases (100/117). The majority, 75/118 (63.6%), believed that responding to battered mothers did not belong in the preview of pediatrics. Potential attitudinal barriers confirmed with the greatest frequency included: frustration that nothing could be done and lack of time to respond appropriately to battered mothers in the pediatric emergency department. CONCLUSIONS: Battered mothers are rarely identified in the pediatric emergency department even though the physicians report handling a significant number of child abuse/neglect cases. Education on domestic violence, including the implications of woman battering for childrens' health, should be incorporated in the training curricula of pediatric emergency department physicians to raise awareness of the need to explore for the presence of concurrent abuse in both children and their mothers. Identifying battered women through their children will impact greatly on the welfare of both mother and child.

Adult↗
PubMed2004

The Pediatric Alliance for Coordinated Care: evaluation of a medical home model.

OBJECTIVES: The American Academy of Pediatrics recommends a medical home for children with special health care needs (CSHCN). In the Pediatric Alliance for Coordinated Care (PACC), 6 pediatric practices introduced interventions to operationalize the medical home for CSHCN. The intervention consisted of a designated pediatric nurse practitioner acting as case manager, a local parent consultant for each practice, the development of an individualized health plan for each patient, and continuing medical education for health care professionals. The objectives of this study were 1) to characterize CSHCN in the PACC, 2) to assess parental satisfaction with the PACC intervention, 3) to assess the impact on hospitalizations and emergency department episodes, and 4) to assess the impact on parental workdays lost and children's school days lost for CSHCN before and during the PACC intervention. METHODS: A total of 150 CSHCN in 6 pediatric practices in the Boston, Massachusetts, area were studied. Participants were recruited by their pediatricians on the basis of medical/developmental complexity. Physicians completed enrollment information about each child's diagnosis and severity of condition. Families completed surveys at baseline and follow-up (at 2 years), assessing their experience with health care for their children. RESULTS: A total of 60% of the children had >5 conditions, 41% were dependent on medical technology, and 47% were rated by their physician as having a "severe" condition. A total of 117 (78%) families provided data after the intervention. The PACC made care delivery easier, including having the same nurse to talk to (68%), getting letters of medical necessity (67%), getting resources (60%), getting telephone calls returned (61%), getting early medical care when the child is sick (61%), communicating with the child's doctor (61%), getting referrals to specialists (61%), getting prescriptions filled (56%), getting appointments (61%), setting goals for the child (52%), understanding the child's medical condition (56%), and relationship with the child's doctor (58%). Families of children who were rated "severe" were most likely to find these aspects of care "much easier" with the help of the pediatric nurse practitioner. Satisfaction with primary care delivery was high at baseline and remained high throughout the study. There was a statistically significant decrease in parents missing >20 days of work (26% at baseline; 14.1% after PACC) and in hospitalizations (58% at baseline; 43.2% after PACC). The approximate cost per child per year of the intervention was 400 dollars. CONCLUSIONS: The PACC medical home intervention increases parent satisfaction with pediatric primary care. Those whose needs are most severe seem to benefit most from the intervention. There are some indications of improved health as well as decreased burden of disease with the intervention in place. The PACC model allows a practice to meet many of the goals of serving as a medical home with a relatively small financial investment.

Adolescent↗
PubMed2002

Effect of a pediatric hospitalist system on housestaff education and experience.

OBJECTIVE: To determine the effect of a pediatric hospitalist system on housestaff education and experience. SETTING: Free-standing academic children's hospital. Hospitalists were introduced in June 24, 1998, to supervise teaching and care on the general pediatric wards. METHODS: On 2 surveys, housestaff rated their skills, knowledge, and experiences on the wards (experiences survey), and the quality of teaching and supervision by attending physicians (attending survey). Responses before and after the introduction of the hospitalist system were compared using Wilcoxon nonparametric tests. RESULTS: Seventy-six (70%) of the 109 interns and 54 (62%) of the 87 senior residents responded to the experiences survey. Following introduction of the hospitalist system, the interns' mean overall rating of the general pediatrics wards rose from 4.1 to 4.7 on a 5-point Likert scale (P =.01). Their ratings of comparison rotations did not change significantly. Interns' satisfaction with the educational experience (3.2 to 3.5 of a 4-point Likert scale, P<.05), supervision, and quality of life on the pediatrics wards also improved significantly, as did their self-assessments of skills and knowledge related to general pediatrics training. Senior residents' ratings were generally unchanged. Three hundred seventy-one (63%) of the 593 attending physicians' surveys were completed. Compared with nonhospitalist attendings, hospitalists were rated more effective role models (4.7 vs 4.5 points, P<.05) and teachers (4.7 vs 4.4 points, P<.01). They were rated more knowledgeable (4.8 vs 4.5 of 5, P<.001) and accessible (4.7 vs 4.5 points, P<.05), involved housestaff more in the learning process (4.7 vs 4.4 points, P<.05), and gave better feedback (4.5 vs 4.2 points, P<.01). Hospitalists' bedside teaching, however, was rated lower (3.7 vs 4.2 points, P<.001). CONCLUSIONS: Overall, hospitalists were rated significantly higher as educators than were traditional attending physicians. Introduction of a hospitalist system was associated with improved intern experience and quality of life on general pediatrics wards, and with improved self-reported skills and knowledge in general pediatrics.

Educational Measurement↗
PubMed2005

Interexaminer reliability in physical examination of pediatric patients with abdominal pain.

OBJECTIVE: To test the interexaminer reliability of abdominal examinations performed by pediatric emergency medicine physicians and surgeons in an emergency department. METHODS: A prospective cross-sectional study in which 3 different types of physicians (pediatric emergency department residents, pediatric emergency department attending physicians, and pediatric surgeons in training) independently examined a convenience sample of children (aged 3-19 years) with initial complaint of abdominal pain. The interexaminer reliability of 6 components of the abdominal examination (the presence or absence of abdominal distension, abdominal tenderness to percussion, abdominal tenderness to palpation, abdominal guarding, rebound tenderness, and bowel sounds) and the clinical diagnosis of peritonitis was tested. RESULTS: Sixty-eight patients were examined by pediatric emergency department residents and pediatric emergency department attending physicians. All 3 physician types examined 46 of these 68 patients. When comparing residents and attending physicians, the components of the abdominal examination showed less than moderate chance-adjusted agreement (kappa range, -0.04 to 0.38). When comparing attending physicians and surgeons, the presence of rebound tenderness showed moderate agreement (kappa = 0.54). The rest of the components demonstrated less than moderate chance-adjusted agreement (kappa range, -0.04 to 0.34). CONCLUSIONS: The components of the abdominal examination are poorly reliable between physician types. Only the "rebound tenderness" component of the abdominal examination shows moderate agreement between the pediatric emergency department attending physicians and the surgeon. No component of the abdominal examination appears to be consistently reliable. Interexaminer agreement must be considered when developing management strategies for acute abdomen. Interventions to improve reliability should be developed.

Abdominal Pain↗
PubMed1992

Home visits by pediatric residents. A valuable educational tool.

OBJECTIVE: To establish how many pediatric residency programs offer home visits, to assess the feasibility of making home visits as part of pediatric training, and to determine whether residents perceive home visits as worthwhile learning experiences. DESIGN: A questionnaire was mailed to all medical school pediatric departments in the United States and Puerto Rico to determine the prevalence of home visits during residency training. To study the feasibility of residents making home visits, a pilot program was instituted. PARTICIPANTS: Fourteen pediatric residents participated in the study. Each resident visited a house, trailer, apartment, or shelter for the homeless that was within a 20-minute radius from the medical center. To determine the educational value of home visits, each resident wrote a one-page report immediately on his or her return to the hospital. After about 6 months, all participating residents completed a questionnaire retrospectively evaluating their home visits. SELECTION PROCEDURES: Interns who were neither on-call nor postcall the day of the visits were invited to participate. Patients were selected because they were homebound (eg, ventilator-dependent), had missed follow-up appointments, or had transportation difficulties. RESULTS: Thirteen percent of the pediatric residency programs surveyed currently include home visits. In all 14 of the pilot visits, the home was located without difficulty and the patient was at home. In each case, the family welcomed the visit. All the pediatric residents believed that the home visit was a worthwhile learning experience. CONCLUSIONS: Although very few programs (13%) currently offer home visits as part of pediatric residency training, such visits are feasible within a large urban area. Residents are enthusiastic about seeing how and where their patients live, and consider home visits a worthwhile learning experience.

House Calls↗
PubMed1994

Use of the electrocardiogram in a pediatric emergency department.

OBJECTIVE: To ascertain the quality of electrocardiogram (ECG) use in a pediatric emergency department (PED). RESEARCH DESIGN: Patient series. SETTING: Pediatric emergency department in a university-based hospital. PARTICIPANTS: Seventy patients, aged 2 months to 22 years. MEASUREMENTS: All ECGs obtained in the PED were received by the Division of Pediatric Cardiology during the 15-month study period. The charts of all patients were then reviewed to determine the (1) indications for obtaining an ECG; (2) accuracy of documentation; (3) impact of ECG results on the treatment of patients; and (4) concordance between PED and pediatric cardiologists in ECG interpretation. RESULTS: Chest pain was the most commonly documented indication, accounting for 54% of the ECGs obtained. Other indications were suspected arrhythmias (11%), seizure and syncope (11%), drug exposure (8%), and miscellaneous (16%). Twelve charts (17%) lacked documentation of ECG results. Ten ECGs (14%) were performed improperly. Twenty three (32%) were interpreted differently by the pediatric cardiologists; 14 ECGs (20%) had potential clinical relevance. Thirty-seven (52%) ECGs were useful in patient care; this was significantly associated with the presence of a PED attending (P = .03 by Fisher's Exact Test). CONCLUSION: We recommend education of pediatric residents in ECG interpretation and subsequent review by a pediatric cardiologist of each ECG performed in the PED.

Arrhythmias, Cardiac↗