Child Health Needs and the Pediatric Emergency Medicine Workforce: 2020-2040

Approximately 30 million ill and injured children annually visit emergency departments (EDs) in the United States. Data suggest that patients seen in pediatric EDs by board-certified pediatric emergency medicine (PEM) physicians receive higher-quality care than those cared for by non-PEM physicians. These benefits, coupled with the continued growth in PEM since its inception in the early 1990s, have impacted child health broadly. This article is part of a Pediatrics supplement focused on predicting the future pediatric subspecialty workforce supply by drawing on the American Board of Pediatrics workforce data and a microsimulation model of the future pediatric subspecialty workforce. The article discusses the utilization of acute care services in EDs, reviews the current state of the PEM subspecialty workforce, and presents projected numbers of PEM subspecialists at the national, census region, and census division on the basis of this pediatric subspecialty workforce supply model through 2040. Implications of this model on education and training, clinical practice, policy, and future workforce research are discussed. Findings suggest that, if the current growth in the field of PEM continues on the basis of the increasing number and size of fellowship programs, even with a potential reduction in percentage of clinical time and attrition of senior physicians, the PEM workforce is anticipated to increase nationally. However, the maldistribution of PEM physicians is likely to be perpetuated with the highest concentration in New England and Mid-Atlantic regions and "PEM deserts" in less populated areas.

The 2019-2020 dengue fever epidemic: genomic markers indicating severity in Dominican Republic children

We performed an observational cohort study to assess associations between genetic factors of dengue fever (DF) severity in children in the Dominican Republic. 488 participants had serologically confirmed DF. We replicated the association between IFIH1 gene (rs1990760) and severe DF (n=80/488, p=0.006) and identified novel associations needing further investigation.

Narrative Performance Level Assignments at Initial Entrustment and Graduation: Integrating EPAs and Milestones to Improve Learner Assessment

PURPOSE

To determine which narrative performance level for each general pediatrics entrustable professional activity (EPA) reflects the minimum level clinical competency committees (CCCs) felt should be associated with graduation as well as initial entrustment and compare expected narrative performance levels (ENPLs) for each EPA with actual narrative performance levels (ANPLs) assigned to residents at initial entrustment.

METHOD

A series of 5 narratives, corresponding to the 5 milestone performance levels, were developed for each of the 17 general pediatrics EPAs. In academic year (AY) 2015-2016, the CCCs at 22 Association of Pediatric Program Directors Longitudinal Educational Assessment Research Network member sites reported ENPLs for initial entrustment and at time of graduation. From AYs 2015-2016 to 2017-2018, programs reported ANPLs for initial entrustment decisions. ENPLs and ANPLs were compared using a logistic mixed effects model.

RESULTS

ENPLs for graduation and entrustment were most often level 3 (competent) followed by level 4 (proficient). For 8 EPAs, the ENPLs for graduation and entrustment were the same. For the remaining 9, some programs would entrust residents before graduation or graduate them before entrusting them. There were 4,266 supervision level reports for initial entrustment for which an ANPL was provided. ANPLs that were lower than the ENPLs were significantly more likely to be assigned to the medical home-well child (OR = 0.39; 95% CI: 0.26-0.57), transition to adult care (OR = 0.43; 95% CI: 0.19-0.95), behavioral or mental health (OR = 0.36; 95% CI: 0.18-0.71), make referrals (OR = 0.31; 95% CI: 0.17-0.55), lead a team (OR = 0.34; 95% CI: 0.22-0.52), and handovers (OR = 0.18; 95% CI: 0.09-0.36) EPAs.

CONCLUSIONS

CCCs reported lower ENPLs for graduation than for entrustment for 5 EPAs, possibly indicating curricular gaps that milestones and EPAs could help identify.

Thresholds and interpretations: How clinical competency committees identify pediatric residents with performance concerns

BACKGROUND

Clinical competency committee (CCC) identification of residents with performance concerns is critical for early intervention.

METHODS

Program directors and 94 CCC members at 14 pediatric residency programs responded to a written survey prompt asking them to describe how they identify residents with performance concerns. Data was analyzed using thematic analysis.

RESULTS

Six themes emerged from analysis and were grouped into two domains. The first domain included four themes, each describing a path through which residents could meet or exceed a concern threshold:1) written comments from rotation assessments are foundational in identifying residents with performance concerns, 2) concerning performance extremes stand out, 3) isolated data points may accumulate to raise concern, and 4) developmental trajectory matters. The second domain focused on how CCC members and program directors interpret data to make decisions about residents with concerns and contained 2 themes: 1) using norm- and/or criterion-referenced interpretation, and 2) assessing the quality of the data that is reviewed.

CONCLUSIONS

Identifying residents with performance concerns is important for their education and the care they provide. This study delineates strategies used by CCC members across several programs for identifying these residents, which may be helpful for other CCCs to consider in their efforts.

Putting the pediatrics milestones into practice: a consensus roadmap and resource analysis

The Accreditation Council for Graduate Medical Education has partnered with member boards of the American Board of Medical Specialties to initiate the next steps in advancing competency-based assessment in residency programs. This initiative, known as the Milestone Project, is a paradigm shift from traditional assessment efforts and requires all pediatrics residency programs to report individual resident progression along a series of 4 to 5 developmental levels of performance, or milestones, for individual competencies every 6 months beginning in June 2014. The effort required to successfully make this shift is tremendous given the number of training programs, training institutions, and trainees. However, it holds great promise for achieving training outcomes that align with patient needs; developing a valid, reliable, and meaningful way to track residents' development; and providing trainees with a roadmap for learning. Recognizing the resources needed to implement this new system, the authors, all residency program leaders, provide their consensus view of the components necessary for implementing and sustaining this effort, including resource estimates for completing this work. The authors have identified 4 domains: (1) Program Review and Development of Stakeholders and Participants, (2) Assessment Methods and Validation, (3) Data and Assessment System Development, and (4) Summative Assessment and Feedback. This work can serve as a starting point and framework for collaboration with program, department, and institutional leaders to identify and garner necessary resources and plan for local and national efforts that will ensure successful transition to milestones-based assessment.

Decreasing Adverse Events through Night Talks: An Interdisciplinary, Hospital-Based Quality Improvement Project

BACKGROUND

The majority of medical adverse events are secondary to errors in communication. The Joint Commission (known until 2007 as the Joint Commission on the Accreditation of Healthcare Organizations) reports that 70% of sentinel events are the result of communication failures. Review of nonperioperative adverse events at Cincinnati Children's Hospital Medical Center in 2007 found similar statistics: 57% were related to failure to recognize abnormal vital signs and to communicate or address parents' or nurses' concerns.

OBJECTIVE

To increase by 80% the number of days between near misses in pediatric neurosurgical patients because of failure to address abnormal vital signs or parents' or nurses' concerns during the night shift.

MATERIALS AND METHODS

Baseline data on near misses from the previous night were collected with the use of a written questionnaire completed the next morning by the interns, patient-care facilitators or charge nurse, and attending physicians. Laminated cards with three standardized questions were created to guide a late-evening review of patients' status by residents, attending physicians, and nurses: the Night Talks discussion. After initiation of Night Talks, data were collected for issues addressed by Night Talks as well as for preventable adverse events.

MAIN OUTCOME MEASURE

Number of days between near misses.

RESULTS

During a two-month period before the introduction of Night Talks, there was an average of 3.8 days between near misses on neurosurgery patients. After the initiation of Night Talks, days between near misses due to the failure to address abnormal vital signs or parents' or nurses' concerns increased to 201 days, a 5360% change.

CONCLUSION

Instituting standardized Night Talks substantially reduced near misses in neurosurgical patients at our institution at night.

Microburst Teaching and Learning

Amidst changes in the health care field with requirements for increased efficiency and limited time for teaching, there is a need for a teaching-learning model which maximizes the learning process and is exciting, fun, and motivating for both teacher and learner. Microburst Teaching and Learning is one strategy for combining various teaching styles and methods in 'bursts' with different learning styles to enhance the learning process.The model accommodates adult learning theory, adult attention span, learner motivation, the variety of learning styles found in learners, and the need for efficiency. Preliminary reactions to the Microburst Model indicate its appeal and motivating nature as a useful teaching-learning model.The next steps are to more critically evaluate the efficacy of the model for a broader range of clinical preceptors and to examine the variety of specific teaching strategies to determine which methods work best in specific settings. Because there are many potential teaching methods and teaching styles from which medical teachers can choose, a companion article outlining these specific methods and styles is currently in preparation.Weanticipate the article's publication within the next year.