1
|
Festekjian A, Hall JE, Zipkin R, Schiff J, Pham PK, Mesropyan L, Araradian C, Nager AL, Chang TP. A checklist intervention for pediatric emergency department transfer of care sign-outs. Am J Emerg Med 2024; 77:215-219. [PMID: 38216365 DOI: 10.1016/j.ajem.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 01/01/2024] [Accepted: 01/01/2024] [Indexed: 01/14/2024] Open
Affiliation(s)
- Ara Festekjian
- Department of Pediatrics, Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd, Mailstop 113, Los Angeles, CA 90027, United States of America; Keck School of Medicine, University of Southern California, Los Angeles, CA, United States of America.
| | - Jeanine E Hall
- Department of Pediatrics, Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd, Mailstop 113, Los Angeles, CA 90027, United States of America; Keck School of Medicine, University of Southern California, Los Angeles, CA, United States of America.
| | - Ronen Zipkin
- Department of Pediatrics, Division of Hospital Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd, Mailstop 94, Los Angeles, CA 90027, United States of America; Keck School of Medicine, University of Southern California, Los Angeles, CA, United States of America.
| | - Jared Schiff
- Department of Pediatrics, Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd, Mailstop 113, Los Angeles, CA 90027, United States of America; Keck School of Medicine, University of Southern California, Los Angeles, CA, United States of America.
| | - Phung K Pham
- Department of Pediatrics, Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd, Mailstop 113, Los Angeles, CA 90027, United States of America
| | - Levon Mesropyan
- University of California Los Angeles, Burbank Pediatrics, 2625 W. Alameda, Suite 300, Burbank, CA 9150, United States of America.
| | - Cynthia Araradian
- Oregon Health Sciences University*, 3181 S.W. Jackson Park Road, Portland, OR 97239, United States of America.
| | - Alan L Nager
- Department of Pediatrics, Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd, Mailstop 113, Los Angeles, CA 90027, United States of America; Keck School of Medicine, University of Southern California, Los Angeles, CA, United States of America.
| | - Todd P Chang
- Department of Pediatrics, Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd, Mailstop 113, Los Angeles, CA 90027, United States of America; Keck School of Medicine, University of Southern California, Los Angeles, CA, United States of America.
| |
Collapse
|
2
|
Heyming TW, Knudsen-Robbins C, Shelton SK, Pham PK, Brukman S, Wickens M, Valdez B, Bacon K, Thorpe J, Kwon KT, Schultz C. 9-1-1 Activations from Ambulatory Care Centers: A Sicker Pediatric Population. Prehosp Disaster Med 2023; 38:749-756. [PMID: 37877361 PMCID: PMC10694466 DOI: 10.1017/s1049023x23006544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 08/29/2023] [Accepted: 09/04/2023] [Indexed: 10/26/2023]
Abstract
BACKGROUND Pediatric patients transferred by Emergency Medical Services (EMS) from urgent care (UC) and office-based physician practices to the emergency department (ED) following activation of the 9-1-1 EMS system are an under-studied population with scarce literature regarding outcomes for these children. The objectives of this study were to describe this population, explore EMS level-of-care transport decisions, and examine ED outcomes. METHODS This was a retrospective review of patients zero to <15 years of age transported by EMS from UC and office-based physician practices to the ED of two pediatric receiving centers from January 2017 through December 2019. Variables included reason for transfer, level of transport, EMS interventions and medications, ED medications/labs/imaging ordered in the first hour, ED procedures, ED disposition, and demographics. Data were analyzed with descriptive statistics, X test, point biserial correlation, two-sample z test, Mann-Whitney U test, and 2-way ANOVA. RESULTS A total of 450 EMS transports were included in this study: 382 Advanced Life Support (ALS) runs and 68 Basic Life Support (BLS) runs. The median patient age was 2.66 years, 60.9% were male, and 60.7% had private insurance. Overall, 48.9% of patients were transported from an office-based physician practice and 25.1% were transported from UC. Almost one-half (48.7%) of ALS patients received an EMS intervention or medication, as did 4.41% of BLS patients. Respiratory distress was the most common reason for transport (46.9%). Supplemental oxygen was the most common EMS intervention and albuterol was the most administered EMS medication. There was no significant association between level of transport and ED disposition (P = .23). The in-patient admission rate for transported patients was significantly higher than the general ED admission rate (P <.001). CONCLUSION This study demonstrates that pediatric patients transferred via EMS after activation of the 9-1-1 system from UC and medical offices are more acutely ill than the general pediatric ED population and are likely sicker than the general pediatric EMS population. Paramedics appear to be making appropriate level-of-care transport decisions.
Collapse
Affiliation(s)
- Theodore W. Heyming
- Children’s Hospital of Orange County (CHOC Children’s), Orange, CaliforniaUSA
- Department of Emergency Medicine, University of California at Irvine School of Medicine, Irvine, CaliforniaUSA
| | - Chloe Knudsen-Robbins
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OhioUSA
| | - Shelby K. Shelton
- Children’s Hospital of Orange County (CHOC Children’s), Orange, CaliforniaUSA
| | - Phung K. Pham
- Children’s Hospital of Orange County (CHOC Children’s), Orange, CaliforniaUSA
| | - Shelley Brukman
- Children’s Hospital of Orange County (CHOC Children’s), Orange, CaliforniaUSA
| | - Maxwell Wickens
- Children’s Hospital of Orange County (CHOC Children’s), Orange, CaliforniaUSA
| | - Brooke Valdez
- Children’s Hospital of Orange County (CHOC Children’s), Orange, CaliforniaUSA
| | - Kellie Bacon
- Children’s Hospital of Orange County (CHOC Children’s), Orange, CaliforniaUSA
| | - Jonathan Thorpe
- Department of Pediatrics, University of California at Irvine School of Medicine, Irvine, CaliforniaUSA
| | - Kenneth T. Kwon
- CHOC Children’s at Mission Hospital, Mission Viejo, CaliforniaUSA
| | - Carl Schultz
- Orange County Health Care Agency, Santa Ana, CaliforniaUSA
| |
Collapse
|
3
|
Shieh A, Pham PK, Plouffe NA, Heyming TW. Negative Appendectomies: Evaluating Diagnostic Imaging Techniques at General versus Pediatric Emergency Departments. J Emerg Med 2023; 64:304-310. [PMID: 36868944 DOI: 10.1016/j.jemermed.2022.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 11/09/2022] [Accepted: 12/13/2022] [Indexed: 03/05/2023]
Abstract
BACKGROUND Although appendicitis is the most common pediatric surgical emergency, the path to diagnosis remains equivocal, with utilization of imaging modalities largely institution dependent. OBJECTIVES Our objective was to compare imaging practices and negative appendectomy rates between patients transferred from nonpediatric hospitals to our pediatric hospital and primary patients presenting directly to our institution. METHODS We retrospectively reviewed all laparoscopic appendectomy cases performed at our pediatric hospital in 2017 for imaging and histopathologic results. Two-sample z-test was used to examine negative appendectomy rates between transfer and primary patients. The negative appendectomy rates of patients who received different imaging modalities were analyzed using the Fisher's exact test. RESULTS Of 626 patients, 321 (51%) were transferred from nonpediatric hospitals. The negative appendectomy rate for transfer patients was 6.5% and 6.6% for primary patients (p = 0.99). Ultrasound (US) was the only imaging obtained in 31% of transfer and 82% of primary patients. The negative appendectomy rate of US performed at transfer hospitals compared with our pediatric institution was not significantly different (11% vs. 5%, p = 0.06). Computed tomography (CT) was the only imaging obtained in 34% of transfer and 5% of primary patients. Both US and CT were completed for 17% of transfer and 19% of primary patients. CONCLUSION The negative appendectomy rates of transfer and primary patients were not significantly different despite more frequent CT use at nonpediatric facilities. It may be valuable to encourage US utilization at adult facilities given the potential to safely reduce CT use in the evaluation of suspected pediatric appendicitis.
Collapse
Affiliation(s)
- Andrew Shieh
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan; Department of Pediatrics, University of California at Irvine, Irvine, California
| | - Phung K Pham
- Children's Hospital Los Angeles, Los Angeles, California; Claremont Graduate University, Claremont, California
| | | | | |
Collapse
|
4
|
Cushing AM, Liberman DB, Pham PK, Michelson KA, Festekjian A, Chang TP, Chaudhari PP. Mental Health Revisits at US Pediatric Emergency Departments. JAMA Pediatr 2023; 177:168-176. [PMID: 36574251 PMCID: PMC9856860 DOI: 10.1001/jamapediatrics.2022.4885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 10/11/2022] [Indexed: 12/29/2022]
Abstract
Importance Pediatric emergency department (ED) visits for mental health crises are increasing. Patients who frequently use the ED are of particular concern, as pediatric mental health ED visits are commonly repeat visits. Better understanding of trends and factors associated with mental health ED revisits is needed for optimal resource allocation and targeting of prevention efforts. Objective To describe trends in pediatric mental health ED visits and revisits and to determine factors associated with revisits. Design, Setting, and Participants In this cohort study, data were obtained from 38 US children's hospital EDs in the Pediatric Health Information System between October 1, 2015, and February 29, 2020. The cohort included patients aged 3 to 17 years with a mental health ED visit. Exposures Characteristics of patients, encounters, hospitals, and communities. Main Outcomes and Measures The primary outcome was a mental health ED revisit within 6 months of the index visit. Trends were assessed using cosinor analysis and factors associated with time to revisit using mixed-effects Cox proportional hazards regression. Results There were 308 264 mental health ED visits from 217 865 unique patients, and 13.2% of patients had a mental health revisit within 6 months. Mental health visits increased by 8.0% annually (95% CI, 4.5%-11.4%), whereas all other ED visits increased by 1.5% annually (95% CI, 0.1%-2.9%). Factors associated with mental health ED revisits included psychiatric comorbidities, chemical restraint use, public insurance, higher area measures of child opportunity, and presence of an inpatient psychiatric unit at the presenting hospital. Patients with psychotic disorders (hazard ratio [HR], 1.42; 95% CI, 1.29-1.57), disruptive or impulse control disorders (HR, 1.36; 95% CI, 1.30-1.42), and neurodevelopmental disorders (HR, 1.22; 95% CI, 1.14-1.30) were more likely to revisit. Patients with substance use disorders (HR, 0.60; 95% CI, 0.55-0.66) were less likely to revisit. Conclusions and Relevance Markers of disease severity and health care access were associated with mental health revisits. Directing hospital and community interventions toward identified high-risk patients is needed to help mitigate recurrent mental health ED use and improve mental health care delivery.
Collapse
Affiliation(s)
- Anna M. Cushing
- Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Los Angeles, California
| | - Danica B. Liberman
- Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Los Angeles, California
- Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles
- Department of Population and Public Health Sciences, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Phung K. Pham
- Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Los Angeles, California
| | - Kenneth A. Michelson
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Ara Festekjian
- Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Los Angeles, California
- Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Todd P. Chang
- Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Los Angeles, California
- Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Pradip P. Chaudhari
- Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Los Angeles, California
- Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles
| |
Collapse
|
5
|
Jiffry AJ, Cho CS, Schmidt AR, Pham PK, Nager AL. A Mixed Methods Needs Assessment for a Debriefing Intervention Following Critical Cases. Acad Pediatr 2023; 23:85-92. [PMID: 35605897 DOI: 10.1016/j.acap.2022.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 05/02/2022] [Accepted: 05/14/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE The emergency department (ED) is a demanding environment, and critical events have been identified as contributors to stress. Debriefing is a possible intervention for staff, but there is little information regarding formulation and implementation. A needs assessment was conducted to describe the emotions of pediatric ED (PED) staff following critical events and assess opinions regarding debriefing. METHOD This mixed methods study used convergent design for triangulation. After critical cases, PED staff members were given the Peritraumatic Distress Inventory (PDI). Additionally, a questionnaire with 2 open-ended questions on debriefing was administered. Themes were extracted from the questionnaire using directed content analysis. RESULTS A total of 719 responses were collected for 142 critical cases. Physical reactions were often endorsed in the PDI, and these reactions were mirrored in the qualitative data, which included physiological responses such as stress, adrenaline high, anxiety, fatigue, and overwhelm. Helplessness and grief were 2 of the emotional PDI items frequently endorsed, which were reflected in the qualitative strand by themes such as helplessness, sadness, disheartenment, and regret. There was considerable variability between critical cases such that not every critical case elicited a desire for a debrief. CONCLUSIONS PED staff report measurable levels of stress after critical patient cases that warrant follow-up. Formal debriefing immediately after critical patient cases with specific caveats may be valuable for the reduction of stress. Any formal debriefing program will need to balance various goals with attention to the session length, setting, and timing.
Collapse
Affiliation(s)
- Arshad J Jiffry
- Division of Emergency and Transport Medicine (AJ Jiffry, CS Cho, AR Schmidt, PK Pham, and AL Nager), Children's Hospital Los Angeles, Los Angeles, Calif; Department of Pediatrics (AJ Jiffry, CS Cho, and AL Nager), Keck School of Medicine, University of Southern California, Los Angeles, Calif.
| | - Christine S Cho
- Division of Emergency and Transport Medicine (AJ Jiffry, CS Cho, AR Schmidt, PK Pham, and AL Nager), Children's Hospital Los Angeles, Los Angeles, Calif; Department of Pediatrics (AJ Jiffry, CS Cho, and AL Nager), Keck School of Medicine, University of Southern California, Los Angeles, Calif
| | - Anita R Schmidt
- Division of Emergency and Transport Medicine (AJ Jiffry, CS Cho, AR Schmidt, PK Pham, and AL Nager), Children's Hospital Los Angeles, Los Angeles, Calif
| | - Phung K Pham
- Division of Emergency and Transport Medicine (AJ Jiffry, CS Cho, AR Schmidt, PK Pham, and AL Nager), Children's Hospital Los Angeles, Los Angeles, Calif
| | - Alan L Nager
- Division of Emergency and Transport Medicine (AJ Jiffry, CS Cho, AR Schmidt, PK Pham, and AL Nager), Children's Hospital Los Angeles, Los Angeles, Calif; Department of Pediatrics (AJ Jiffry, CS Cho, and AL Nager), Keck School of Medicine, University of Southern California, Los Angeles, Calif
| |
Collapse
|
6
|
Schiff J, Schmidt AR, Pham PK, Pérez JB, Pannaraj PS, Chaudhari PP, Liberman DB. Parental attitudes in the pediatric emergency department about the COVID-19 vaccine. Vaccine 2022; 40:7328-7334. [PMID: 36344362 PMCID: PMC9597585 DOI: 10.1016/j.vaccine.2022.10.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 10/11/2022] [Accepted: 10/14/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND COVID-19 vaccinations are now recommended in the United States (U.S.) for children ≥ 6 months old. However, pediatric vaccination rates remain low, particularly in the Hispanic/Latinx population. OBJECTIVE Using the 4C vaccine hesitancy framework (calculation, complacency, confidence, convenience), we examined parental attitudes in the emergency department (ED) towards COVID-19 vaccination, identified dimensions of parental vaccine hesitancy, and assessed parental willingness to have their child receive the COVID-19 vaccine. METHODS As part of a larger multi-methods study examining influenza vaccine hesitancy, we conducted interviews that included questions about COVID-19 vaccine authorization for children. We used directed content analysis to extract qualitative themes from 3 groups of parents in the ED: Hispanic/Latinx Spanish speaking (HS), Hispanic/Latinx English speaking (HE), non-Hispanic/non-Latinx White English speaking (WE). Themes were triangulated with the Parent Attitudes about Childhood Vaccines (PACV) survey, where higher scores indicate increased vaccine hesitancy. RESULTS Factors influencing vaccine hesitancy were mapped to the 4C framework from 58 sets of interviews and PACVs. HE and HS parents, compared to WE parents, had less knowledge about COVID-19 and its vaccine, and more beliefs in COVID-19 vaccine myths. However, both HS and HE parent groups were more inclined to endorse COVID-19 vaccine effectiveness as a reason to have their children vaccinated. HS parents felt that COVID-19 increased their fear of illnesses in general and were worried about confusing COVID-19 with other infections. Median PACV scores of HS (Mdn = 20) and HE (Mdn = 20) parent groups were higher than of WE parents (Mdn = 10), but parental willingness to have their child receive COVID-19 vaccination was similar across groups. CONCLUSIONS Higher COVID-19 vaccine hesitancy among HS and HE parents compared to WE parents may be attributed to insufficient knowledge about COVID-19, its vaccine, along with COVID-19 vaccine myths. Efforts to provide targeted vaccine education to different populations is warranted.
Collapse
Affiliation(s)
- Jared Schiff
- Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Los Angeles, CA, USA,Corresponding author at: Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, 4650 Sunset Blvd. Mailstop #113, Los Angeles, CA, USA
| | - Anita R. Schmidt
- Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Los Angeles, CA, USA
| | - Phung K. Pham
- Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Los Angeles, CA, USA,Division of Behavioral and Organizational Sciences, Claremont Graduate University of the Claremont Colleges, Claremont, CA, USA
| | - Jocelyn B. Pérez
- Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Los Angeles, CA, USA
| | - Pia S. Pannaraj
- Division of Infectious Disease, Children’s Hospital Los Angeles, Los Angeles, CA, USA,Department of Pediatrics and Molecular Microbiology and Immunology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Pradip P. Chaudhari
- Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Los Angeles, CA, USA,Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Danica B. Liberman
- Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Los Angeles, CA, USA,Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA,Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| |
Collapse
|
7
|
Hall JE, Pham PK, Liberman DB. Describing the Patient Population of a Pediatric Emergency Department Based on Visit Frequency. Pediatr Emerg Care 2022; 38:e1620-e1625. [PMID: 36173434 DOI: 10.1097/pec.0000000000002615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE A small number of children in the United States use a disproportionate share of emergency healthcare services. Our study objective was to examine characteristics associated with frequent pediatric emergency department (PED) utilization. METHODS A retrospective cohort-sequential study of patients seen in the PED of an urban children's hospital was conducted. Patients were categorized into 2 groups: infrequent users (<4 visits during index year 2017) and frequent users (≥4 visits in 2017). Frequent PED users were further divided into persistent frequent (≥4 visits in the year before and after 2017) and incidental frequent (≥4 visits in 2017). Patient- and visit-level characteristics were analyzed for associations with PED utilization. RESULTS In 2017, there were 82,361 visits by 56,767 patients to our PED. Frequent users comprised 4% of the total patient volume but accounted for 13% of visits. Compared with infrequent users, frequent users were younger, more likely publicly insured, and English speaking. Frequent user visits were more likely to occur outside clinic hours, be triaged as emergent, and involve subspecialists. Compared with visits by incidental frequent users, visits by persistent frequent users were more likely to be emergent or urgent, and involve subspecialists, diagnostic imaging, laboratory testing, and medication administration. CONCLUSIONS Although the percentage of frequent users to a PED in 2017 was low, they made up a disproportionate share of total visits. Differences between persistent and incidental frequent PED users suggest that these subgroups may benefit from tailored interventions to reduce frequent PED utilization.
Collapse
|
8
|
Liberman DB, Pham PK, Semple-Hess JE. Social Emergency Medicine: Capitalizing on the Pediatric Emergency Department Visit to Screen and Connect Patients and Families to Community Resources. Acad Pediatr 2022; 22:1049-1056. [PMID: 34995821 DOI: 10.1016/j.acap.2021.12.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 12/20/2021] [Accepted: 12/26/2021] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To describe the social needs of families screened by the Community Health Advocates Team (CHAT) Desk, situated within a pediatric emergency department (PED); and to evaluate the effectiveness of this help desk in connecting families to community resources. METHODS Trained undergraduates, onsite in the PED 30 hours/week during daytime and evening hours, weekdays and weekends, screened a convenience sample of families of patients in the PED for social needs, and provided information on available community resources. Families were offered a follow-up phone call several weeks after their PED visit to assess program satisfaction and success, and identify remaining social needs. RESULTS Between January 2019 and March 2020, CHAT Desk screened and assisted 682 families. CHAT routinely provided resources about free outdoor recreational activities for families, but after that, the most commonly provided informational resources pertained to: health care (n = 200), housing (n = 143), and food (n = 137). Of families who completed the follow-up phone call (n = 294), almost half (n = 134, 46%) reported being able to contact at least one of the resources; 100 reported that the resource was able to assist them, and 99 families planned to continue using the resource. When asked about satisfaction, 93% (n = 274) reported being very satisfied or somewhat satisfied with CHAT; 94% (n = 276) said they would recommend it to others. CONCLUSIONS The PED of a busy tertiary care children's hospital is an opportune location to screen families for social needs, and provide them with information on requested community resources.
Collapse
Affiliation(s)
- Danica B Liberman
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles (DB Liberman, PK Pham, and JE Semple-Hess), Los Angeles, Calif; Department of Pediatrics, Keck School of Medicine, University of Southern California (DB Liberman and JE Semple-Hess), Los Angeles, Calif; Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California (DB Liberman), Los Angeles, Calif.
| | - Phung K Pham
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles (DB Liberman, PK Pham, and JE Semple-Hess), Los Angeles, Calif; Division of Behavioral and Organizational Sciences, Claremont Graduate University of the Claremont Colleges (PK Pham), Claremont, Calif
| | - Janet E Semple-Hess
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles (DB Liberman, PK Pham, and JE Semple-Hess), Los Angeles, Calif; Department of Pediatrics, Keck School of Medicine, University of Southern California (DB Liberman and JE Semple-Hess), Los Angeles, Calif
| |
Collapse
|
9
|
Moskalewicz RL, Pham PK, Liberman DB, Hall JE. Leaving Without Being Seen From a Pediatric Emergency Department: Identifying Caregivers' Perspectives Using Q-methodology. Pediatr Emerg Care 2021; 37:615-620. [PMID: 30985630 DOI: 10.1097/pec.0000000000001792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE National rates of left (or leaving) without being seen (LWBS) in pediatric emergency departments (PED) are higher than general emergency departments. We investigated coexisting perspectives on LWBS. METHODS Q-methodology was implemented through a mixed-methods design. Semistructured interviews elicited a concourse of caregivers' thoughts on waiting in the PED and their consideration of LWBS. Themes from the concourse were identified and framed as statements. Caregivers sorted these statements, which ranged from choosing to stay versus leave the PED before their child is seen by a physician. Sorted data were analyzed through centroid factor analysis. RESULTS Seventy-seven caregivers contributed interview data, from which 31 themes were identified and framed as statements. Thirty-one different caregivers contributed Q-sort data, from which 2 factors were revealed, each representing a unique perspective on LWBS. Most caregivers (26 of 31) shared the following perspective: "I would leave the PED before my child is seen by a doctor if there are no reassessments for my child while we are in the queue, no updates on our queue position, or no explanations for wait time." The remaining caregivers (5 of 31) perceived feelings of uncertainty and helplessness, lack of updates, and competing obligations as primary influences on LWBS. CONCLUSIONS Elements that factor into caregivers' decision to LWBS from a PED include lack of reassessments, lack of updates on queue position, and lack of information about the triage process. Quality improvement interventions for decreasing LWBS rates should account for diverse coexisting perspectives such as these.
Collapse
Affiliation(s)
- Risha L Moskalewicz
- From the Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Los Angeles
| | | | | | | |
Collapse
|
10
|
Abstract
OBJECTIVES Infant cardiopulmonary resuscitation (CPR) has been taught to caregivers of infants in inpatient settings. There are no studies to date that look at teaching infant CPR in the emergency department (ED). Using a framework of cognitive load theory, we compared teaching infant CPR to caregivers in a pediatric ED versus an inpatient setting. METHODS Knowledge tests, 1-minute infant CPR performances on a Resusci Baby QCPR (Laerdal) manikin, and self-reported questionnaires were completed before and after caregivers were self-taught infant CPR using Infant CPR Anytime kits. The proportions of chest compression depth and rate that met quality standards from the American Heart Association's Basic Life Support program were measured. RESULTS Seventy-four caregivers participated. Mean knowledge scores (out of a total score of 15) increased in both settings (ED preintervention: Mean (M) = 4.53 [SD = 1.97]; ED postintervention: M = 10.47 [SD = 2.90], P < 0.001; inpatient preintervention: M = 4.83 (SD = 2.08); inpatient postintervention: M = 10.61 [SD = 2.79], P < 0.001). Improvement in the proportion of chest compression that met high quality standards for depth increased in the inpatient group only. Neither groups had improvements in compression rates. There were no statistically significant differences in the difficulty of learning CPR, frequency of interruptions/distractions, or difficulty staying concentrated in learning CPR between the 2 settings. CONCLUSIONS Caregivers in the ED and inpatient settings after a self-instructional infant CPR kit did not demonstrate adequate infant CPR performance. However, both groups gained infant CPR knowledge. Differences in cognitive loads between the 2 settings were not significant.
Collapse
Affiliation(s)
- Joo Lee Song
- From the Division of Emergency and Transport Medicine
| | - Todd P Chang
- From the Division of Emergency and Transport Medicine
| | | | - Theodora A Stavroudis
- Fetal and Neonatal Institute, Division of Neonatology, Department of Pediatrics, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Phung K Pham
- From the Division of Emergency and Transport Medicine
| | - Alan L Nager
- From the Division of Emergency and Transport Medicine
| |
Collapse
|
11
|
Assaf RR, Pham PK, Schmidt AR, Gorab A, Chang TP, Liu DR. Pediatric emergency department shift experiences and moods: An exploratory sequential mixed-methods study. AEM Educ Train 2021; 5:e10572. [PMID: 34124518 PMCID: PMC8171774 DOI: 10.1002/aet2.10572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 12/18/2020] [Accepted: 01/04/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE The objective was to investigate the impact of affective, social, behavioral, and cognitive factors on pediatric emergency department (PED) provider mood changes during clinical shifts, with the introduction of a novel on-shift measure. METHODS The nominal group technique was used to generate the ED experience survey (EDES), encompassing factors that may influence PED provider mood. Providers were alerted via experience sampling method to complete the EDES and positive and negative affect schedule at randomly generated times. Analyses were conducted using multilevel modeling of moods within shifts within persons. RESULTS Measures were completed 221 times during 137 shifts by 52 PED providers. Positive mood tended to increase with higher self-rated capacity to deal with challenging patient situations (p < 0.001). Having to repeat patient assessments was negatively associated with positive mood during the beginning, but not rest of shift (p = 0.01). Changes in positive mood varied across provider groups (p < 0.001). Negative mood tended to decrease with higher self-rated quality of interactions with patients/families (p < 0.001). Needing a restroom break during any time on duty was associated with negative mood (p < 0.001). Furthermore, negative mood was associated with the need to process emotions during the shift beginning (p = 0.01). Finally, not knowing about patients' outcomes was associated with negative mood during the shift end (p < 0.001). CONCLUSIONS PED providers' mood during shifts are impacted by ED-specific factors spanning physical, social, behavioral, affective, and cognitive features. Future research may explore potential entry points for mitigation of clinician stress to support provider well-being and ultimately improve patient care.
Collapse
Affiliation(s)
- Raymen R. Assaf
- Pediatric Emergency DepartmentHarbor UCLA Medical CenterTorranceCaliforniaUSA
| | - Phung K. Pham
- Division of Emergency and Transport MedicineChildren's Hospital Los AngelesLos AngelesCaliforniaUSA
| | - Anita R. Schmidt
- Division of Emergency and Transport MedicineChildren's Hospital Los AngelesLos AngelesCaliforniaUSA
| | | | - Todd P. Chang
- Division of Emergency and Transport MedicineChildren's Hospital Los AngelesLos AngelesCaliforniaUSA
- Department of PediatricsKeck School of Medicine at University of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Deborah R. Liu
- Division of Emergency and Transport MedicineChildren's Hospital Los AngelesLos AngelesCaliforniaUSA
- Department of PediatricsKeck School of Medicine at University of Southern CaliforniaLos AngelesCaliforniaUSA
| |
Collapse
|
12
|
Goldberg BS, Hall JE, Pham PK, Cho CS. Text messages by wireless mesh network vs voice by two-way radio in disaster simulations: A crossover randomized-controlled trial. Am J Emerg Med 2021; 48:148-155. [PMID: 33906052 DOI: 10.1016/j.ajem.2021.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 03/30/2021] [Accepted: 04/01/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Communication failures secondary to damaged infrastructure have caused difficulties in coordinating disaster responses. Two-way radios commonly serve as backup communication for hospitals. However, text messaging has become widely adopted in daily life and new technologies such as wireless mesh network (WMN) devices allow for text messaging independent of cellular towers, Wi-Fi networks, and electrical grids. OBJECTIVE To examine the accuracy of communication using text-based messaging transmitted over WMN devices (TEXT-WMN) compared to voice transmitted over two-way radios (VOICE-TWR) in disaster simulations. Secondary outcomes were patient triage accuracy, perceived workload, and device preference. METHODS 2 × 2 Latin square crossover design: 2 simulations (each involving 15 min of simulated hospital-wide disaster communication) by 2 modalities (TEXT-WMN and VOICE-TWR). Physicians were randomized to one of two sequences: VOICE-TWR first and TEXT-WMN second; or TEXT-WMN first and VOICE-TWR second. Analyses were conducted using linear mixed effects modeling. RESULTS On average, communication accuracy significantly improved with TEXT-WMN compared to VOICE-TWR. Communication accuracy also significantly improved, on average, during the second simulation compared to the first. There was no significant change in triage accuracy with either TEXT-WMN or VOICE-TWR; however, triage accuracy significantly improved, on average, during the second simulation compared to the first. On average, perceived workload was significantly lower with TEXT-WMN compared to VOICE-TWR, and was also significantly lower during the second simulation compared to the first. Most participants preferred TEXT-WMN to VOICE-TWR. CONCLUSION TEXT-WMN technology may be more effective and less burdensome than VOICE-TWR in facilitating accurate communication during disasters.
Collapse
Affiliation(s)
- Bradley S Goldberg
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd., Mail Stop 113, Los Angeles, CA 90027, United States of America; Department of Pediatrics, Keck School of Medicine, University of Southern California, 1975 Zonal Ave., Los Angeles, CA 90033, United States of America.
| | - Jeanine E Hall
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd., Mail Stop 113, Los Angeles, CA 90027, United States of America; Department of Pediatrics, Keck School of Medicine, University of Southern California, 1975 Zonal Ave., Los Angeles, CA 90033, United States of America
| | - Phung K Pham
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd., Mail Stop 113, Los Angeles, CA 90027, United States of America; Division of Behavioral & Organizational Sciences, School of Social Science, Policy, & Evaluation, Claremont Graduate University, 150 E. Tenth St., ACB Mail Room, Claremont, CA 91711, United States of America
| | - Christine S Cho
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd., Mail Stop 113, Los Angeles, CA 90027, United States of America; Department of Pediatrics, Keck School of Medicine, University of Southern California, 1975 Zonal Ave., Los Angeles, CA 90033, United States of America
| |
Collapse
|
13
|
Schmidt AR, Pham PK, Liu DR, Goldberg BS. Surge activation by the emergency department for COVID-19. Am J Emerg Med 2020; 38:2130-2133. [PMID: 33071090 PMCID: PMC7363617 DOI: 10.1016/j.ajem.2020.07.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 07/08/2020] [Accepted: 07/09/2020] [Indexed: 11/16/2022] Open
Abstract
In March 2020, the American College of Emergency Physicians (ACEP) published a national strategic plan for COVID-19, which provides general guidelines yet leaves logistical details for institutions to determine. Key capabilities from this plan provided a crucial foundation for a 16-day Emergency Department (ED) surge planning process at one pediatric institution. This paper describes critical milestones and lessons learned during this brief period, including derivation of criteria for ED surge activation, a full-scale surge drill, and the resultant ED surge protocol. The framework of real-time evaluation was used throughout the planning process and involved constant and iterative synthesis of real-time feedback from multidisciplinary stakeholders for responsive decision-making. Ultimately, the objective of this paper is to provide timely and readily actionable information to other institutions seeking guidance to apply the ACEP strategic plan for COVID-19.
Collapse
Affiliation(s)
- Anita R Schmidt
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd., Mail Stop 113, Los Angeles, CA 90027, United States of America
| | - Phung K Pham
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd., Mail Stop 113, Los Angeles, CA 90027, United States of America; Division of Behavioral & Organizational Sciences, School of Social Science, Policy, & Evaluation, Claremont Graduate University, 150 E. Tenth St., ACB Mail Room, Claremont, CA 91711, United States of America
| | - Deborah R Liu
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd., Mail Stop 113, Los Angeles, CA 90027, United States of America; Department of Pediatrics, Keck School of Medicine, University of Southern California, 1975 Zonal Ave., Los Angeles, CA 90033, United States of America
| | - Bradley S Goldberg
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd., Mail Stop 113, Los Angeles, CA 90027, United States of America; Department of Pediatrics, Keck School of Medicine, University of Southern California, 1975 Zonal Ave., Los Angeles, CA 90033, United States of America.
| |
Collapse
|
14
|
Moriel G, Tran T, Pham PK, Liberman DB. Reducing Abdominal Radiographs to Diagnose Constipation in the Pediatric Emergency Department. J Pediatr 2020; 225:109-116.e5. [PMID: 32553869 DOI: 10.1016/j.jpeds.2020.06.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 05/19/2020] [Accepted: 06/09/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To determine the frequency of abdominal radiographs obtained in healthy children aged 6 months to 18 years to diagnose constipation in a pediatric emergency department, and evaluate the impact of quality improvement (QI) interventions on their use. STUDY DESIGN QI study over 2.5 years at a large urban quaternary care children's hospital emergency department. Interventions consisted of educational presentations and individualized abdominal radiograph data reporting. The primary outcome measure was the percentage of abdominal radiographs performed on healthy patients discharged home with a diagnosis of constipation before and after QI interventions. RESULTS The baseline total percentage of abdominal radiographs performed in otherwise healthy children discharged home with a diagnosis of constipation was 36% (October 2016 to January 2018). According to questionnaire results, ruling out obstruction was the most common reason for ordering an abdominal radiograph. After the QI interventions, the total percentage of abdominal radiograph decreased to 18% (April 2018 to March 2019). This 18% decrease was significant (P < .001) and sustained over a 12-month follow-up period. Throughout the study period, the average length of stay was 1.07 hours longer for children who had an abdominal radiograph. Clinically important return visits to the emergency department were uncommon during the postintervention phase (125/1830 [6.8%]), and not associated with whether or not an abdominal radiograph was performed at the initial visit. CONCLUSION After these QI interventions, we noted a significant and sustained decrease in the percentage of abdominal radiographs obtained for otherwise healthy patients discharged home with a diagnosis of constipation.
Collapse
Affiliation(s)
- Gabriela Moriel
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA.
| | - Theresa Tran
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA
| | - Phung K Pham
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA; Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Danica B Liberman
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA; Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Los Angeles, CA; Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA
| |
Collapse
|
15
|
Stein Duker LI, Schmidt AR, Pham PK, Ringold SM, Nager AL. Use of Audiobooks as an Environmental Distractor to Decrease State Anxiety in Children Waiting in the Pediatric Emergency Department: A Pilot and Feasibility Study. Front Pediatr 2020; 8:556805. [PMID: 33585358 PMCID: PMC7874121 DOI: 10.3389/fped.2020.556805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 12/07/2020] [Indexed: 11/13/2022] Open
Abstract
Objectives: Anxiety and anticipatory stressors are commonly experienced by children visiting the Pediatric Emergency Department (PED), but little research exists that addresses the efficacy of interventions to decrease this stress. This one-sample pretest-postest pilot study gathered preliminary data on the feasibility and effectiveness of utilizing audiobooks to reduce fear and state anxiety in children in the PED. Methods: Participants were 131 children in kindergarten through 8th grade (M = 9.4 years, 54% female), triaged urgent or emergent, presenting to the PED. Participants self-reported fear (Children's Fear Scale) and state anxiety (modified State-Trait Anxiety Inventory for Children; mSTAIC) before and after listening to an age-appropriate audiobook (two options). Data regarding patient experience were also collected. Paired samples t-test was used to examine pre-post intervention changes in fear and state anxiety. Results: Significant, albeit small, improvements in fear and the mSTAIC states of nervous, calm, happy, and relaxed were found after use of the audiobook (Cohen's d z = 0.22-0.35). Small, yet significant correlations were found between child age/grade level and improvements in fear and in the mSTAIC states of scared and relaxed, suggesting that the audiobook was more beneficial for older participants. Over 60% of participants liked the audiobook content "a lot" as well as enjoyed listening to the audiobook "a lot." Without prompting, 15% of participants requested to listen to an additional audiobook. Conclusions: Listening to an audiobook is feasible and could be effective in decreasing fear and state anxiety for children during a waiting period in the PED. The technology is low-cost, simple, and portable. The results of this study should be interpreted with prudence due to the lack of a control group and results that, although significant, were modest based on effect size conventions; future studies should explore the impact of audiobooks on patient stress with an expanded sample size and control group.
Collapse
Affiliation(s)
- Leah I Stein Duker
- Division of Occupational Science and Occupational Therapy, University of Southern California, Los Angeles, CA, United States
| | - Anita R Schmidt
- Division of Emergency and Transport Medicine, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, United States
| | - Phung K Pham
- Division of Emergency and Transport Medicine, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, United States
| | - Sofronia M Ringold
- Division of Emergency and Transport Medicine, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, United States
| | - Alan L Nager
- Division of Emergency and Transport Medicine, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, United States.,Keck School of Medicine at the University of Southern California, Los Angeles, CA, United States
| |
Collapse
|
16
|
Perniciaro JL, Schmidt AR, Pham PK, Liu DR. Defining "Swarming" as a New Model to Optimize Efficiency and Education in an Academic Emergency Department. AEM Educ Train 2020; 4:43-53. [PMID: 31989070 PMCID: PMC6965688 DOI: 10.1002/aet2.10388] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 07/03/2019] [Accepted: 07/26/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Academic emergency medicine is a constant balance between efficiency and education. We developed a new model called swarming, where the bedside nurse, resident, and attending/fellow simultaneously evaluate the patient, including initial vital signs, bedside triage, focused history and physical examination, and discussion of the treatment plan, thus creating a shared mental model. OBJECTIVES To combine perceptions from trainee physicians, supervising physicians, nurses, and families with in vivo measurements of emergency department swarms to better conceptualize the swarming model. METHODS This mixed methods study was conducted using a convergent design. Qualitative data from focus groups with nurses, residents, and attendings/fellows were analyzed using directed content analysis. Swarming encounters were observed in real time; durations of key aspects and family satisfaction scores were analyzed using descriptive statistics. The qualitative and quantitative findings were integrated a posteriori. RESULTS From the focus group data, 54 unique codes were identified, which were grouped together into five larger themes. From 39 swarms, mean (±SD) time (minutes) spent in patient rooms: nurses = 6.8 (±3.0), residents = 10.4 (±4.1), and attendings/fellows = 9.4 (±4.3). Electronic documentation was included in 67% of swarms, and 39% included orders initiated at the bedside. Mean (±SD) family satisfaction was 4.8 (±0.7; Likert scale 1-5). CONCLUSIONS Swarming is currently implemented with significant variability but results in high provider and family satisfaction. There is also consensus among physicians that swarming improves trainee education in the emergency setting. The benefits and barriers to swarming are underscored by the unpredictable nature of the ED and the observed variability in implementation. Our findings provide a critical foundation for our efforts to refine, standardize, and appraise our swarming model.
Collapse
Affiliation(s)
- Jessica L. Perniciaro
- Division of Emergency and Transport MedicineChildren's Hospital Los AngelesLos AngelesCA
- Department of PediatricsKeck School of MedicineUniversity of Southern CaliforniaLos AngelesCA
| | - Anita R. Schmidt
- Division of Emergency and Transport MedicineChildren's Hospital Los AngelesLos AngelesCA
| | - Phung K. Pham
- Division of Emergency and Transport MedicineChildren's Hospital Los AngelesLos AngelesCA
| | - Deborah R. Liu
- Division of Emergency and Transport MedicineChildren's Hospital Los AngelesLos AngelesCA
- Department of PediatricsKeck School of MedicineUniversity of Southern CaliforniaLos AngelesCA
| |
Collapse
|
17
|
Semple-Hess JE, Pham PK, Cohen SA, Liberman DB. Community Resource Needs Assessment Among Families Presenting to a Pediatric Emergency Department. Acad Pediatr 2019; 19:378-385. [PMID: 30471361 DOI: 10.1016/j.acap.2018.11.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 11/13/2018] [Accepted: 11/17/2018] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To identify community resource needs among families presenting to a pediatric emergency department (PED). METHODS A convenience sample of English- and Spanish-speaking caregivers residing in Los Angeles County who presented to the PED of a large urban children's hospital were surveyed. The needs assessment survey assessed demographics, food insecurity, and previous and anticipated need for 12 common community resources. RESULTS Of 768 caregivers who completed the survey, 75% identified as Hispanic/Latinx. Across all survey participants, 83% used at least 1 resource in the past, and 67% anticipated needing at least 1 resource in the next 12 months. Low-cost/free health clinics were the most common resources used in the past and needed for the future. Caregivers with younger children tended to need baby formula/breastfeeding and women's health resources, whereas caregivers with older children tended to need safe housing, subsidized utilities, and counseling/therapy. Many families who needed resources in the past and for the future resided south of the children's hospital where median household income was relatively lower than in other areas of the county. A pattern of heightened use emerged among caregivers who primarily spoke Spanish. On average, caregivers reported feeling comfortable approaching hospital staff about community resources. CONCLUSIONS We found significant needs for community resources among families who presented to an urban PED. Needs were particularly salient among Spanish-speaking families and families living in close proximity to the children's hospital. Findings from this study help to inform future work connecting families to community resources.
Collapse
Affiliation(s)
- Janet E Semple-Hess
- Division of Emergency and Transport Medicine (JE Semple-Hess, PK Pham, and DB Liberman), Children's Hospital Los Angeles; Department of Pediatrics (JE Semple-Hess and DB Liberman), Keck School of Medicine, University of Southern California, Los Angeles.
| | - Phung K Pham
- Division of Emergency and Transport Medicine (JE Semple-Hess, PK Pham, and DB Liberman), Children's Hospital Los Angeles; Division of Behavioral and Organizational Sciences (PK Pham), Claremont Graduate University of the Claremont Colleges, Claremont
| | - Samuel A Cohen
- Department of Preventive Medicine (SA Cohen), Keck School of Medicine, University of Southern California, Los Angeles
| | - Danica B Liberman
- Division of Emergency and Transport Medicine (JE Semple-Hess, PK Pham, and DB Liberman), Children's Hospital Los Angeles; Department of Pediatrics (JE Semple-Hess and DB Liberman), Keck School of Medicine, University of Southern California, Los Angeles
| |
Collapse
|
18
|
Tarango SM, Pham PK, Chung D, Festekjian A. Prediction of clinical deterioration after admission from the pediatric emergency department. Int Emerg Nurs 2019; 43:1-8. [DOI: 10.1016/j.ienj.2018.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 03/21/2018] [Accepted: 05/31/2018] [Indexed: 10/14/2022]
|
19
|
Liberman DB, Pham PK. Parent activation in the pediatric emergency department: Theory vs. reality. Patient Educ Couns 2018; 101:1116-1122. [PMID: 29329727 DOI: 10.1016/j.pec.2018.01.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 01/05/2018] [Accepted: 01/07/2018] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To measure parent activation and test for its associations with sociodemographics, clinical factors, and short-term outcomes. METHODS By convenience sampling, 246 parents of children treated in an emergency department (ED) of a children's hospital completed the Parent-Patient Activation Measure (P-PAM) and answered sociodemographic questions. Clinical information was abstracted from medical records. Phone calls to parents and primary care physician offices were conducted within one-month post-ED visit for information about short-term outcomes. RESULTS We discovered higher than expected activation among our sample (mean = 73), higher activation scores by Spanish language and child chronic illness status, and associations between activation scores and ED visit and discharge instruction comprehension and filling prescriptions (short-term outcomes). However, the theory of parent activation did not adequately fit the data. CONCLUSION Before the P-PAM in pediatric clinical care becomes widespread, further research is necessary to better understand parent activation and its associations with pediatric outcomes. PRACTICE IMPLICATIONS Although the PAM has shown promise in accurately measuring patient activation across various populations and disease processes, the same is not yet true of the P-PAM. To date, pediatric studies using the P-PAM have called its psychometric properties into question. Further research is needed to understand and measure parent activation.
Collapse
Affiliation(s)
- Danica B Liberman
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA.
| | - Phung K Pham
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA; School of Social Science, Policy and Evaluation, Claremont Graduate University of the Claremont Colleges, Claremont, CA, USA
| |
Collapse
|
20
|
Fierro LA, Codd H, Gill S, Pham PK, Grandjean Targos PT, Wilce M. Evaluative Thinking in Practice: The National Asthma Control Program. New Dir Eval 2018; 2018:49-72. [PMID: 29950803 PMCID: PMC6016392 DOI: 10.1002/ev.20322] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Although evaluative thinking lies at the heart of what we do as evaluators and what we hope to promote in others through our efforts to build evaluation capacity, researchers have given limited attention to measuring this concept. We undertook a research study to better understand how instances of evaluative thinking may present in practice-based settings-specifically within four state asthma control programs funded by the Centers for Disease Control and Prevention's National Asthma Control Program. Through content analyses of documents as well as interviews and a subsequent focus group with four state asthma control programs' evaluators and program managers we identified and defined twenty-two indicators of evaluative thinking. Findings provide insights about what practitioners may wish to look for when they intend to build evaluative thinking and the types of data sources that may be more or less helpful in such efforts.
Collapse
|
21
|
Chang TP, Schrager SM, Rake AJ, Chan MW, Pham PK, Christman G. The effect of multimedia replacing text in resident clinical decision-making assessment. Adv Health Sci Educ Theory Pract 2017; 22:901-914. [PMID: 27752842 DOI: 10.1007/s10459-016-9719-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 10/06/2016] [Indexed: 06/06/2023]
Abstract
Multimedia in assessing clinical decision-making skills (CDMS) has been poorly studied, particularly in comparison to traditional text-based assessments. The literature suggests multimedia is more difficult for trainees. We hypothesize that pediatric residents score lower in diagnostic skill when clinical vignettes use multimedia rather than text for patient findings. A standardized method was developed to write text-based questions from 60 high-resolution, quality multimedia; a series of expert panels selected 40 questions with both a multimedia and text-based counterpart, and two online tests were developed. Each test featured 40 identical questions with reciprocal and alternating modality (multimedia vs. text). Pediatric residents and rising 4th year medical students (MS-IV) at a single residency were randomized to complete either test stratified by postgraduate training year (PGY). A mixed between-within subjects ANOVA analyzed differences in score due to modality and PGY. Secondary analyses ascertained modality effect in dermatology and respiratory questions using Mann-Whitney U tests, and correlations on test performance to In-service Training Exam (ITE) scores using Spearman rank. Eighty-eight residents and rising interns completed the study. Overall multimedia scores were lower than text-based scores (p = 0.047, η p2 = 0.04), with highest disparity in rising interns (MS-IV); however, PGY had a greater effect on scores (p = 0.001, η p2 = 0.16). Respiratory questions were not significantly lower with multimedia (n = 9, median 0.71 vs. 0.86, p = 0.09) nor dermatology questions (n = 13, p = 0.41). ITEs correlated significantly with text-based scores (ρ = 0.23-0.25, p = 0.04-0.06) but not with multimedia scores. In physician trainees with less clinical experience, multimedia-based case vignettes are associated with significantly lower scores. These results help shed light on the role of multimedia versus text-based information in CDMS, particularly in less experienced clinicians.
Collapse
Affiliation(s)
- Todd P Chang
- Division of Emergency Medicine and Transport, Children's Hospital Los Angeles and University of Southern California Keck School of Medicine, Los Angeles, CA, USA.
| | - Sheree M Schrager
- Division of Hospital Medicine, Children's Hospital Los Angeles and University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Alyssa J Rake
- Department of Critical Care and Anesthesiology, Children's Hospital Los Angeles and University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Michael W Chan
- Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago and Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Phung K Pham
- Division of Emergency Medicine and Transport, Children's Hospital Los Angeles and University of Southern California Keck School of Medicine, Los Angeles, CA, USA
- Division of Behavioral and Organizational Sciences, Claremont Graduate University, Claremont, CA, USA
| | - Grant Christman
- Division of Hospital Medicine, Children's Hospital Los Angeles and University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| |
Collapse
|
22
|
Liberman DB, Song E, Radbill LM, Pham PK, Derrington SF. Early introduction of palliative care and advanced care planning for children with complex chronic medical conditions: a pilot study. Child Care Health Dev 2016; 42:439-49. [PMID: 27028099 DOI: 10.1111/cch.12332] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 01/25/2016] [Accepted: 02/04/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Children with complex chronic medical conditions benefit from early introduction of palliative care services and advanced care planning for symptom management and to support quality of life and medical decision-making. This study evaluated whether introducing palliative care during primary care appointments (1) was feasible; (2) increased access and improved knowledge of palliative care; and (3) facilitated advanced care planning. METHODS Pilot study of a multi-modal intervention including targeted education for primary care providers (PCPs), an informational packet for families and presence of a palliative care team member in the outpatient clinic. PCPs completed pre- and post-surveys assessing experience, knowledge and comfort with palliative care. Enrolled families received an information packet; a subset also met a palliative care team member. All families were encouraged to make an appointment with the palliative care team, during which the team assessed palliative care needs and goals of care. Upon study completion, the investigators assessed family and PCP satisfaction and collected feedback on project feasibility. RESULTS Twenty families were enrolled and received the information packet; 15 met a palliative care team member. Of the 17 participating families who were reached and completed a post-study survey, 11 families had never heard of palliative care and 13 were unaware that the palliative care team existed. Most families perceived palliative care information as 'very helpful' and 'very important'. All would recommend palliative care team services to others. Nine families followed up with the palliative care team, but none was prepared to complete an advanced care plan. PCPs reported lack of training in communicating bad news and conducting goals of care discussions. However, they felt increasingly comfortable introducing palliative care to families and supported program continuation. CONCLUSIONS Initiating palliative care services in the outpatient primary care setting is logistically challenging but increases access to palliative care for children with complex chronic medical conditions and improves palliative care knowledge and comfort for PCPs.
Collapse
Affiliation(s)
- D B Liberman
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA.,Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - E Song
- Department of Biomedical Engineering, Yale University, New Haven, CT, USA
| | - L M Radbill
- Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA.,Division of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - P K Pham
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - S F Derrington
- Division of Critical Care and Program in Palliative Care, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| |
Collapse
|
23
|
Valente ME, Sherif JA, Azen CG, Pham PK, Lowe CG. Cerebral Oxygenation and Acceleration in Pediatric and Neonatal Interfacility Transport. Air Med J 2016; 35:156-60. [PMID: 27255878 DOI: 10.1016/j.amj.2016.01.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 01/26/2016] [Accepted: 01/31/2016] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The purpose of this study is to measure peak acceleration forces during interfacility transport; examine whether drops in cerebral oxygenation occurred; and test the associations between cerebral oxygenation, acceleration, and patient positioning. METHODS A cerebral oximeter (INVOS-5100C; Somanetics, Minneapolis, MN) monitored regional saturation of oxygen (rSO2 [cerebral oxygenation]) in pediatric and neonatal patients (N = 24) transported between facilities by ground ambulance, helicopter, or fixed wing aircraft. An accelerometer (GP1; SENSR, Georgetown, TX) bolted to the isolette or gurney recorded z-axis (aligned with the spine) accelerations. RESULTS The z-axis peak accelerations (absolute values of g) by transport type were as follows: ground ambulance takeoff mean = 0.16 and landing mean = 0.08, helicopter takeoff mean = 0.16 and landing mean = 0.05, fixed wing aircraft takeoff mean = 0.14 and landing mean = 0.20. During takeoff, 2 of 7 patients in the head-to-front of vehicle position experienced rSO2 drop. During landing, 4 of 13 patients in the head-to-back of vehicle position experienced rSO2 drop. There were no significant associations of rSO2 drop during takeoff and landing with patient positioning or with z-axis peak acceleration. CONCLUSION Acceleration forces of pediatric and neonatal interfacility transport are small and comparable in magnitude. The relationship between rSO2 drop and patient positioning was not significant in this pilot study.
Collapse
Affiliation(s)
- Michael E Valente
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, CA, USA
| | - Judy A Sherif
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, CA, USA
| | - Colleen G Azen
- Southern California Clinical and Translational Science Institute, Children's Hospital Los Angeles and University of Southern California, Los Angeles, CA, USA
| | - Phung K Pham
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, CA, USA
| | - Calvin G Lowe
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, CA, USA; Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
| |
Collapse
|
24
|
Nager AL, Kobylecka M, Pham PK, Johnson L, Gold JI. Effects of acupuncture on pain and inflammation in pediatric emergency department patients with acute appendicitis: a pilot study. J Altern Complement Med 2015; 21:269-72. [PMID: 25875844 DOI: 10.1089/acm.2015.0024] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Acupuncture has been shown to treat various medical conditions, including acute and chronic pain, and there is limited evidence that acupuncture produces anti-inflammatory effects. This pilot study evaluated the use of acupuncture to treat pain and determine if acupuncture can reduce the inflammatory response in pediatric patients diagnosed with acute appendicitis. DESIGN This pilot study used convenience sampling and was conducted in the Pediatric Emergency Department (PED) of an urban tertiary care children's hospital. Patients conventionally evaluated and definitively diagnosed with appendicitis were eligible to voluntarily participate. INTERVENTION The diagnostic homogeneity of the target population allowed for a standardized intervention protocol. A licensed acupuncturist performed a specific form of Japanese acupuncture known as the Kiiko Matsumoto Style on all study patients. OUTCOME MEASURES Subjective pain was assessed immediately before the intervention and 20 minutes postintervention, using 3 measures: Faces Pain Scale-Revised (FPS-R), colored analog scale (CAS), and visual analog scale (VAS). Evidence of inflammation was assessed using two biomarkers: white blood cell (WBC) count and C-reactive protein (CRP). WBC and CRP were drawn and recorded 3 times: before the intervention, 2 minutes before removal of needles, and 30 minutes after needling. RESULTS Six Latino/Hispanic patients (4 males, 2 females, median age=15 years) with no previous acupuncture experience participated in the study. Median pre/postacupuncture pain scores were as follows: FPS-R, 5 vs. 4; CAS, 6.1 vs. 4.8; VAS, 46 vs. 32. Median WBC (10(3)/μL) and CRP (mg/dL) across time were as follows: WBC, 13.2, 11.8, and 11.4; CRP, 4.5, 4.9, and 5.1. Median acupuncture duration was 28.5 minutes (range 22-32) and no complications were observed. CONCLUSIONS Pilot data suggest that acupuncture may be a feasible and effective treatment modality for decreasing subjective pain and inflammation as measured by WBC. Acupuncture may be a useful nonpharmacological PED intervention for treating patients with acute appendicitis pain.
Collapse
Affiliation(s)
- Alan L Nager
- 1 Division of Emergency and Transport Medicine, Department of Pediatrics, Children's Hospital Los Angeles , Los Angeles, CA
| | | | | | | | | |
Collapse
|
25
|
Heilbrunn BR, Wittern RE, Lee JB, Pham PK, Hamilton AH, Nager AL. Reducing anxiety in the pediatric emergency department: a comparative trial. J Emerg Med 2014; 47:623-31. [PMID: 25271180 DOI: 10.1016/j.jemermed.2014.06.052] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Revised: 06/09/2014] [Accepted: 06/30/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Anxiety among patients in a pediatric emergency department (PED) can be significant, but often goes unaddressed. OBJECTIVE Our aim was to determine whether exposure to Child Life (CL) or hospital clowning (HC) can reduce anxiety in children presenting to a PED. METHODS Patients were randomized to CL, HC, or control and assessed upon entry to examination room (T1), before physician arrival (T2), and during physician examination (T3), using the modified Yale Preoperative Anxiety Scale (m-YPAS). CL and HC interventions occurred for 5 to 10 min before physician entry. Effects were analyzed using mixed analysis of variance. RESULTS m-YPAS scores ranged from 23 to 59, with a higher score indicating increased anxiety. Mixed analysis of variance on the study sample (n = 113) showed a significant interaction between groups (CL, HC, control) and time (p = 0.02). Additional analyses indicated effect of group only at T2 (CL: mean = 23.8; 95% confidence interval [CI] 23.2-24.5; HC: mean 25.2; 95% CI 24.2-26.2; control: mean = 26.1; 95% CI 24.2-27.9; p = .02). Subanalysis of patients with T1 m-YPAS score ≥ 28 (n = 56) showed a significant interaction between group and time (p = 0.01). Additional analysis showed effect of group only at T2 (CL: mean 24.4; 95% CI 23.3-25.6; HC: mean 27.0; 95% CI 25.2-28.7; control: mean 29.2; 95% CI 25.6-32.7; p = 0.003). CONCLUSIONS CL services can reduce state anxiety for patients presenting to a PED with heightened anxiety at baseline. This reduction occurred immediately after CL intervention, but was not observed in patients exposed to HC or during physician examination.
Collapse
Affiliation(s)
- Benjamin R Heilbrunn
- Department of Pediatrics, The University of Chicago Medicine, Comer Children's Hospital, Section of Pediatric Emergency Medicine, Chicago, Illinois
| | | | - Justin B Lee
- Clinical Trials Unit, Children's Hospital, Los Angeles, California
| | - Phung K Pham
- Division of Emergency and Transport Medicine, Children's Hospital, Los Angeles, California
| | - Anita H Hamilton
- Children's Orthopedic Center, Children's Hospital, Los Angeles, California; Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Alan L Nager
- Division of Emergency and Transport Medicine, Children's Hospital, Los Angeles, California; Keck School of Medicine, University of Southern California, Los Angeles, California
| |
Collapse
|
26
|
Abstract
OBJECTIVES To explore parents' and caregivers' experience, knowledge, and preferences regarding advance directives (ADs) for children who have chronic illness. METHODS We conducted a prospective, cross-sectional survey of parents and caregivers of children who have chronic illness. During ambulatory medical visits, participants were asked about previous AD experience and knowledge, future preferences regarding AD discussions, their child's past and current health status, and family demographics. RESULTS Among 307 participants surveyed, previous AD experience was low, with 117 (38.1%) having heard of an AD, 54 (17.6%) having discussed one, and 77 (25.1%) having known someone who had an AD. Furthermore, 27 (8.8%) participants had an AD or living will of their own, and 8 (2.6%) reported that their chronically ill child had an AD. Previous AD knowledge was significantly more likely among parents and caregivers who had a college degree than those who did not have a high school diploma, yet significantly less likely among primarily Spanish-speaking parents and caregivers than those primarily English-speaking. Interest in creating an AD for the child was reported by 151 (49.2%) participants, and was significantly more likely among families who had more frequent emergency department visits over the previous year. CONCLUSIONS The limited AD experience and knowledge of parents and caregivers of children who have chronic illness and their interest in creating an AD suggest an unmet need among families of children who have chronic illness, and an opportunity to enhance communication between families and medical teams regarding ADs and end-of-life care.
Collapse
Affiliation(s)
- Danica B Liberman
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Los Angeles, California; andDepartment of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Phung K Pham
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Los Angeles, California; and
| | - Alan L Nager
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Los Angeles, California; andDepartment of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles, California
| |
Collapse
|
27
|
Chang TP, Pham PK, Sobolewski B, Doughty CB, Jamal N, Kwan KY, Little K, Brenkert TE, Mathison DJ. Pediatric emergency medicine asynchronous e-learning: a multicenter randomized controlled Solomon four-group study. Acad Emerg Med 2014; 21:912-9. [PMID: 25154469 DOI: 10.1111/acem.12434] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Revised: 03/21/2014] [Accepted: 03/30/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Asynchronous e-learning allows for targeted teaching, particularly advantageous when bedside and didactic education is insufficient. An asynchronous e-learning curriculum has not been studied across multiple centers in the context of a clinical rotation. We hypothesize that an asynchronous e-learning curriculum during the pediatric emergency medicine (EM) rotation improves medical knowledge among residents and students across multiple participating centers. METHODS Trainees on pediatric EM rotations at four large pediatric centers from 2012 to 2013 were randomized in a Solomon four-group design. The experimental arms received an asynchronous e-learning curriculum consisting of nine Web-based, interactive, peer-reviewed Flash/HTML5 modules. Postrotation testing and in-training examination (ITE) scores quantified improvements in knowledge. A 2 × 2 analysis of covariance (ANCOVA) tested interaction and main effects, and Pearson's correlation tested associations between module usage, scores, and ITE scores. RESULTS A total of 256 of 458 participants completed all study elements; 104 had access to asynchronous e-learning modules, and 152 were controls who used the current education standards. No pretest sensitization was found (p = 0.75). Use of asynchronous e-learning modules was associated with an improvement in posttest scores (p < 0.001), from a mean score of 18.45 (95% confidence interval [CI] = 17.92 to 18.98) to 21.30 (95% CI = 20.69 to 21.91), a large effect (partial η(2) = 0.19). Posttest scores correlated with ITE scores (r(2) = 0.14, p < 0.001) among pediatric residents. CONCLUSIONS Asynchronous e-learning is an effective educational tool to improve knowledge in a clinical rotation. Web-based asynchronous e-learning is a promising modality to standardize education among multiple institutions with common curricula, particularly in clinical rotations where scheduling difficulties, seasonality, and variable experiences limit in-hospital learning.
Collapse
Affiliation(s)
- Todd P. Chang
- Division of Emergency Medicine and Transport; Children's Hospital Los Angeles; Los Angeles CA
- University of Southern California Keck School of Medicine; Los Angeles CA
| | - Phung K. Pham
- Division of Emergency Medicine and Transport; Children's Hospital Los Angeles; Los Angeles CA
| | - Brad Sobolewski
- Division of Emergency Medicine at Cincinnati Children's Hospital and Medical Center; Cincinnati OH
- University of Cincinnati; Cincinnati OH
| | - Cara B. Doughty
- Division of Emergency Medicine at Texas Children' Hospital; Houston TX
- Baylor College of Medicine; Houston TX
| | - Nazreen Jamal
- Division of Emergency Medicine and Trauma Center at Children's National Medical Center and George Washington University; Washington DC
| | - Karen Y. Kwan
- Division of Emergency Medicine and Transport; Children's Hospital Los Angeles; Los Angeles CA
- University of Southern California Keck School of Medicine; Los Angeles CA
| | - Kim Little
- Division of Emergency Medicine at Texas Children' Hospital; Houston TX
- Baylor College of Medicine; Houston TX
| | - Timothy E. Brenkert
- Division of Emergency Medicine at Cincinnati Children's Hospital and Medical Center; Cincinnati OH
- University of Cincinnati; Cincinnati OH
| | - David J. Mathison
- Division of Emergency Medicine and Trauma Center at Children's National Medical Center and George Washington University; Washington DC
| |
Collapse
|
28
|
Fortenberry KT, Berg CA, King PS, Stump T, Butler JM, Pham PK, Wiebe DJ. Longitudinal trajectories of illness perceptions among adolescents with type 1 diabetes. J Pediatr Psychol 2014; 39:687-96. [PMID: 24934247 DOI: 10.1093/jpepsy/jsu043] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To examine development in illness perceptions of type 1 diabetes across adolescence and relationships with intelligence, diabetes responsibility, and diabetes outcomes. METHODS Illness perceptions were measured via the Illness Perceptions Questionnaire at 3 times, every 6 months in 213 adolescents (M age = 13.00; SD = 1.54) with type 1 diabetes. Intelligence and adolescents' perceived responsibility for diabetes were examined, and adolescents' report of adherence and quality of life (QOL), and glycosylated hemoglobin (HbA1c) from medical records addressed diabetes-related outcomes. RESULTS Linear growth models showed significant increases in perceptions of diabetes coherence, chronicity, consequences, personal and treatment control, and decreases in diabetes cyclicality and parental control across time. More favorable illness perceptions were generally associated with adolescent intelligence at baseline, more adolescent responsibility for management, better adherence and QOL, and lower HbA1c at each time point. CONCLUSIONS Results suggest that adolescents develop complex illness perceptions, which are associated with better diabetes management.
Collapse
Affiliation(s)
- Katherine T Fortenberry
- Department of Psychology, University of Utah and Division of Psychology, Department of Psychiatry, University of Texas Southwestern Medical Center at Dallas
| | - Cynthia A Berg
- Department of Psychology, University of Utah and Division of Psychology, Department of Psychiatry, University of Texas Southwestern Medical Center at Dallas
| | - Pamela S King
- Department of Psychology, University of Utah and Division of Psychology, Department of Psychiatry, University of Texas Southwestern Medical Center at Dallas
| | - Tammy Stump
- Department of Psychology, University of Utah and Division of Psychology, Department of Psychiatry, University of Texas Southwestern Medical Center at Dallas
| | - Jorie M Butler
- Department of Psychology, University of Utah and Division of Psychology, Department of Psychiatry, University of Texas Southwestern Medical Center at Dallas
| | - Phung K Pham
- Department of Psychology, University of Utah and Division of Psychology, Department of Psychiatry, University of Texas Southwestern Medical Center at Dallas
| | - Deborah J Wiebe
- Department of Psychology, University of Utah and Division of Psychology, Department of Psychiatry, University of Texas Southwestern Medical Center at Dallas
| |
Collapse
|
29
|
Marconi GP, Chang T, Pham PK, Grajower DN, Nager AL. Traditional nurse triage vs physician telepresence in a pediatric ED. Am J Emerg Med 2013; 32:325-9. [PMID: 24445223 DOI: 10.1016/j.ajem.2013.12.032] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Revised: 12/13/2013] [Accepted: 12/15/2013] [Indexed: 10/25/2022] Open
Abstract
OBJECTIVES The objective of the study is to compare traditional nurse triage (TNT) in a pediatric emergency department (PED) with physician telepresence (PTP). METHODS This is a prospective 2 × 2 crossover study with random assignment using a sample of walk-in patients seeking care in a PED at a large, tertiary care children's hospital, from May 2012 to January 2013. Outcomes of triage times, documentation errors, triage scores, and survey responses were compared between TNT and PTP. Comparison between PTP to actual treating PED physicians regarding the accuracy of ordering blood and urine tests, throat cultures, and radiologic imaging was also studied. RESULTS Paired samples t tests showed a statistically significant difference in triage time between TNT and PTP (P = .03) but no significant difference in documentation errors (P = .10). Triage scores of TNT were 71% accurate, compared with PTP, which were 95% accurate. Both parents and children had favorable scores regarding PTP, and most indicated that they would prefer PTP again at their next PED visit. Physician telepresence diagnostic ordering was comparable with the actual PED physician ordering, showing no statistical differences. CONCLUSIONS Using PTP technology to remotely perform triage is a feasible alternative to traditional nurse triage, with no clinically significant differences in time, triage scores, errors, and patient and parent satisfaction.
Collapse
Affiliation(s)
- Greg P Marconi
- Department of Pediatrics, Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Keck School of Medicine at the University of Southern California, Los Angeles, CA 90027, USA.
| | - Todd Chang
- Department of Pediatrics, Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Keck School of Medicine at the University of Southern California, Los Angeles, CA 90027, USA
| | - Phung K Pham
- Department of Pediatrics, Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Keck School of Medicine at the University of Southern California, Los Angeles, CA 90027, USA
| | - Daniel N Grajower
- Department of Pediatrics, Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Keck School of Medicine at the University of Southern California, Los Angeles, CA 90027, USA
| | - Alan L Nager
- Department of Pediatrics, Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Keck School of Medicine at the University of Southern California, Los Angeles, CA 90027, USA
| |
Collapse
|
30
|
Theologis A, Ecker JR, Palm CJ, Federspiel NA, Kaul S, White O, Alonso J, Altafi H, Araujo R, Bowman CL, Brooks SY, Buehler E, Chan A, Chao Q, Chen H, Cheuk RF, Chin CW, Chung MK, Conn L, Conway AB, Conway AR, Creasy TH, Dewar K, Dunn P, Etgu P, Feldblyum TV, Feng J, Fong B, Fujii CY, Gill JE, Goldsmith AD, Haas B, Hansen NF, Hughes B, Huizar L, Hunter JL, Jenkins J, Johnson-Hopson C, Khan S, Khaykin E, Kim CJ, Koo HL, Kremenetskaia I, Kurtz DB, Kwan A, Lam B, Langin-Hooper S, Lee A, Lee JM, Lenz CA, Li JH, Li Y, Lin X, Liu SX, Liu ZA, Luros JS, Maiti R, Marziali A, Militscher J, Miranda M, Nguyen M, Nierman WC, Osborne BI, Pai G, Peterson J, Pham PK, Rizzo M, Rooney T, Rowley D, Sakano H, Salzberg SL, Schwartz JR, Shinn P, Southwick AM, Sun H, Tallon LJ, Tambunga G, Toriumi MJ, Town CD, Utterback T, Van Aken S, Vaysberg M, Vysotskaia VS, Walker M, Wu D, Yu G, Fraser CM, Venter JC, Davis RW. Sequence and analysis of chromosome 1 of the plant Arabidopsis thaliana. Nature 2000; 408:816-20. [PMID: 11130712 DOI: 10.1038/35048500] [Citation(s) in RCA: 134] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The genome of the flowering plant Arabidopsis thaliana has five chromosomes. Here we report the sequence of the largest, chromosome 1, in two contigs of around 14.2 and 14.6 megabases. The contigs extend from the telomeres to the centromeric borders, regions rich in transposons, retrotransposons and repetitive elements such as the 180-base-pair repeat. The chromosome represents 25% of the genome and contains about 6,850 open reading frames, 236 transfer RNAs (tRNAs) and 12 small nuclear RNAs. There are two clusters of tRNA genes at different places on the chromosome. One consists of 27 tRNA(Pro) genes and the other contains 27 tandem repeats of tRNA(Tyr)-tRNA(Tyr)-tRNA(Ser) genes. Chromosome 1 contains about 300 gene families with clustered duplications. There are also many repeat elements, representing 8% of the sequence.
Collapse
Affiliation(s)
- A Theologis
- Plant Gene Expression Center/USDA-U.C. Berkley, Albany, California 94710, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|