Reforming procedural skills training for pediatric residents: a randomized, interventional trial

BACKGROUND

Pediatric housestaff are required to learn basic procedural skills and demonstrate competence during training. To our knowledge, an evidenced-based procedural skills curriculum does not exist.

OBJECTIVE

To create, implement, and evaluate a modular procedural skills curriculum for pediatric residents.

METHODS

A randomized, controlled trial was performed. Thirty-eight interns in the Boston Combined Residency Program who began their training in 2005 were enrolled and randomly assigned. Modules were created to teach residents bag-mask ventilation, venipuncture, peripheral intravenous catheter (PIV) insertion, and lumbar puncture skills. The curriculum was administered to participants in the intervention group during intern orientation. Interns in the control group learned procedural skills by usual methods. Subjects were evaluated by using a structured objective assessment on simulators immediately after the intervention and 7 months later. Success in performing live-patient procedures was self-reported by subjects. The primary outcome was successful performance of the procedure on the initial assessment. Secondary outcomes included checklist and knowledge examination scores, live-patient success, and qualitative assessment of the curriculum.

RESULTS

Participants in the intervention group performed PIV placement more successfully than controls (79% vs 35%) and scored significantly higher on the checklist for PIV placement (81% vs 61%) and lumbar puncture (77% vs 68%) at the initial assessment. There were no differences between groups at month 7, and both groups demonstrated declining skills. There were no statistically significant differences in success on live-patient procedures. Those in the intervention group scored significantly higher on knowledge examinations.

CONCLUSIONS

Participants in the intervention group were more successful performing certain simulated procedures than controls when tested immediately after receiving the curriculum but demonstrated declining skills thereafter. Future efforts must emphasize retraining, and residents must have sufficient opportunities to practice skills learned in a formal curriculum.

Adverse events after administration of tetanus-diphtheria-acellular pertussis vaccine to healthcare workers

Healthcare workers who received the tetanus-diphtheria-acellular pertussis (Tdap) vaccine were surveyed about adverse events. Local adverse events were more common among women and among those who received the Tdap vaccine less than 5 years after they had received the tetanus-diphtheria vaccine. Systemic adverse events were more common among healthcare workers aged less than 30 years. These findings provide guidance for counseling of healthcare workers who receive Tdap vaccine.

Tetanus-diphtheria-acellular pertussis vaccination of adults in the USA

Pertussis is an important cause of morbidity and mortality, and its incidence has been increasing in adolescents and adults over the past two decades. Waning immunity in adolescents and adults may be partially responsible. Adults can suffer significant illness from pertussis and its complications, such as pneumonia, rib fractures and syncope. Moreover, adults serve as a source of disease for infants, who are more vulnerable to severe complications and even death. The economic burden of pertussis is substantial, in terms of both medical and nonmedical costs. Fortunately, the burden of pertussis disease can now be safely and effectively reduced by vaccinating adults with tetanus-diphtheria-acellular pertussis (Tdap) vaccine. Further research is needed to elucidate the role of vaccination in pregnant women and those over 65 years of age, and also to determine whether further booster doses of Tdap are needed.

Reducing absenteeism from gastrointestinal and respiratory illness in elementary school students: a randomized, controlled trial of an infection-control intervention

BACKGROUND

Students often miss school because of gastrointestinal and respiratory illnesses. We assessed the effectiveness of a multifactorial intervention, including alcohol-based hand-sanitizer and surface disinfection, in reducing absenteeism caused by gastrointestinal and respiratory illnesses in elementary school students.

METHODS

We performed a school-based cluster-randomized, controlled trial at a single elementary school. Eligible students in third to fifth grade were enrolled. Intervention classrooms received alcohol-based hand sanitizer to use at school and quaternary ammonium wipes to disinfect classroom surfaces daily for 8 weeks; control classrooms followed usual hand-washing and cleaning practices. Parents completed a preintervention demographic survey. Absences were recorded along with the reason for absence. Swabs of environmental surfaces were evaluated by bacterial culture and polymerase chain reaction for norovirus, respiratory syncytial virus, influenza, and parainfluenza 3. The primary outcomes were rates of absenteeism caused by gastrointestinal or respiratory illness. Days absent were modeled as correlated Poisson variables and compared between groups by using generalized estimating equations. Analyses were adjusted for family size, race, health status, and home sanitizer use. We also compared the presence of viruses and the total bacterial colony counts on several classroom surfaces.

RESULTS

A total of 285 students were randomly assigned; baseline demographics were similar in the 2 groups. The adjusted absenteeism rate for gastrointestinal illness was significantly lower in the intervention-group subjects compared with control subjects. The adjusted absenteeism rate for respiratory illness was not significantly different between groups. Norovirus was the only virus detected and was found less frequently on surfaces in intervention classrooms compared with control classrooms (9% vs 29%).

CONCLUSIONS

A multifactorial intervention including hand sanitizer and surface disinfection reduced absenteeism caused by gastrointestinal illness in elementary school students. Norovirus was found less often on classroom surfaces in the intervention group. Schools should consider adopting these practices to reduce days lost to common illnesses.

Systematic intervention to reduce central line-associated bloodstream infection rates in a pediatric cardiac intensive care unit

OBJECTIVE

Our goal was to determine whether an intervention involving staff education, increased awareness, and practice changes would decrease central line-associated bloodstream infection rates in a pediatric cardiac ICU.

METHODS

A retrospective, interventional study using an interrupted time-series design was conducted to compare central line-associated bloodstream infection rates during 3 time periods for all patients admitted to our pediatric cardiac ICU between April 1, 2004, and December 31, 2006. During the preintervention period (April 2004 to December 2004), a committee was convened to track and prevent nosocomial infections. Pretesting demonstrated knowledge deficits regarding nosocomial infection prevention, and educational tools were developed. During the partial intervention period (January 2005 to March 2006), a comprehensive central line-associated bloodstream infection prevention initiative was implemented, including establishment of a unit-based infection control nurse position, education for physicians and nurses, real-time feedback on central line-associated bloodstream infection data, implementation of central venous line insertion, access, and maintenance bundles, and introduction of daily goal sheets on rounds that emphasized timely central venous line removal. Central line-associated bloodstream infection rates in the preintervention, partial intervention, and full intervention (April 2006 to December 2006) periods were compared.

RESULTS

The estimated mean preintervention central line-associated bloodstream infection rate was 7.8 infections per 1000 catheter-days, which decreased to 4.7 infections per 1000 catheter-days in the partial intervention period and 2.3 infections per 1000 catheter-days in the full intervention period. The preintervention central line-associated bloodstream infection rate was significantly higher than the median rate of 3.5 infections per 1000 catheter-days for multidisciplinary PICUs reporting to the National Healthcare Safety Network. During the full intervention period, our central line-associated bloodstream infection rate was lower than this pediatric benchmark, although statistical significance was not achieved.

CONCLUSIONS

A multidisciplinary, evidence-based initiative resulted in a significant reduction in central line-associated bloodstream infections in our pediatric cardiac ICU.

Assessing procedural skills training in pediatric residency programs

OBJECTIVE

The objective of this study was to assess the opinions of pediatric program directors regarding procedural skills training of pediatric residents.

METHODS

We developed a survey based on the Residency Review Committee's guidelines for procedural training. It included items about the importance of 29 procedures encountered in pediatric training, estimates of residents' competence in performing them, and the teaching of procedural skills. The survey was sent to members of the Association of Pediatric Program Directors. The primary outcome was the perceived importance for residents to achieve competence in these procedures, rated on a 10-point Likert scale. Secondary outcomes included perception of resident competence to perform procedures and educational methods used by respondents for teaching procedural skills. Associations between demographic characteristics and perceived importance or competence were also assessed.

RESULTS

Surveys were sent to 139 programs, and 112 responded. Thirteen procedures were rated 8 or higher by >75% of program directors. Seven skills that were prioritized by the Residency Review Committee did not achieve this level of consensus. Respondents reported that many residents failed to achieve competence by the end of training in 9 of 13 procedures that they rated as very important, including venipuncture, neonatal intubation, and administering injections. Residents who perform the majority of venipunctures and intravenous catheter placements at their institutions were more likely to be judged competent in performing these skills than residents who do not.

CONCLUSIONS

The Residency Review Committee's list of procedures does not necessarily reflect the opinions of pediatric program directors on the most essential skills for trainees. Many residents may not develop competence in several important procedures by the end of residency, most notably vascular access and life-saving skills. A more robust and standardized method is needed for teaching procedural skills and for documenting competence.

The association of television and video viewing with fast food intake by preschool-age children

OBJECTIVE

To examine the extent to which television (TV) and video viewing is associated with consumption of fast food by preschool-age children.

RESEARCH METHODS AND PROCEDURES

In a cross-sectional study of 240 parents of children ages 2.0 to 5.9 years, parents reported the number of hours their child watched TV/videos on an average weekday and weekend day in the past month; a daily, weighted average of TV/video viewing was then calculated. The main outcome was parents' report of their children's fast food intake, using the question, "How many times a week does your child eat at fast food restaurants such as McDonald's, Burger King, or Kentucky Fried Chicken?" dichotomized to (never/<1 vs. > or =1 time/wk). The association of TV/video viewing with fast food intake was evaluated by multiple logistic regression before and after adjusting for several potential confounders.

RESULTS

Twenty-two percent of parents reported that their child ate at fast food restaurants at least once per week. After adjusting for parents' age, race/ethnicity, and household income as well as child's age and sex, for each 1-hour increase of TV/video watched per day, the odds ratio (OR) for consuming fast food > or =1 time per week was 1.60 (95% confidence interval, 1.03 to 2.49). After further adjustment for socio-environmental factors that might serve as proxies for the availability of healthy food options, such as parental time constraints and the availability and high cost of fresh fruits and vegetables in their neighborhoods, the OR for consuming fast food > or =1 time per week was minimally attenuated (OR, 1.55; 95% confidence interval, 1.04 to 2.31).

DISCUSSION

TV/video viewing was correlated with fast food consumption among preschool children in this study. Our findings raise the possibility that greater exposure to TV and videos may influence preschool children's consumption of unhealthful foods.

A randomized, controlled trial of a multifaceted intervention including alcohol-based hand sanitizer and hand-hygiene education to reduce illness transmission in the home

OBJECTIVE

Good hand hygiene may reduce the spread of infections in families with children who are in out-of-home child care. Alcohol-based hand sanitizers rapidly kill viruses that are commonly associated with respiratory and gastrointestinal (GI) infections. The objective of this study was to determine whether a multifactorial campaign centered on increasing alcohol-based hand sanitizer use and hand-hygiene education reduces illness transmission in the home.

METHODS

A cluster randomized, controlled trial was conducted of homes of 292 families with children who were enrolled in out-of-home child care in 26 child care centers. Eligible families had > or =1 child who was 6 months to 5 years of age and in child care for > or =10 hours/week. Intervention families received a supply of hand sanitizer and biweekly hand-hygiene educational materials for 5 months; control families received only materials promoting good nutrition. Primary caregivers were phoned biweekly and reported respiratory and GI illnesses in family members. Respiratory and GI-illness-transmission rates (measured as secondary illnesses per susceptible person-month) were compared between groups, adjusting for demographic variables, hand-hygiene practices, and previous experience using hand sanitizers.

RESULTS

Baseline demographics were similar in the 2 groups. A total of 1802 respiratory illnesses occurred during the study; 443 (25%) were secondary illnesses. A total of 252 GI illnesses occurred during the study; 28 (11%) were secondary illnesses. The secondary GI-illness rate was significantly lower in intervention families compared with control families (incidence rate ratio [IRR]: 0.41; 95% confidence interval [CI]: 0.19-0.90). The overall rate of secondary respiratory illness was not significantly different between groups (IRR: 0.97; 95% CI: 0.72-1.30). However, families with higher sanitizer usage had a marginally lower secondary respiratory illness rate than those with less usage (IRR: 0.81; 95% CI: 0.65-1.09).

CONCLUSIONS

A multifactorial intervention emphasizing alcohol-based hand sanitizer use in the home reduced transmission of GI illnesses within families with children in child care. Hand sanitizers and multifaceted educational messages may have a role in improving hand-hygiene practices within the home setting.

Pneumonia in hospitalized children

Pneumonia is one of the most common infections in the pediatric age group and one of the leading diagnoses that results in overnight hospital admission for children. Various micro-organisms can cause pneumonia, and etiologies differ by age. Clinical manifestations vary, and diagnostic testing is frequently not standardized. Hospital management should emphasize timely diagnosis and prompt initiation of antimicrobial therapy when appropriate. Issues of particular relevance to inpatient management are emphasized in this article.

Medical errors detected and corrected by a pediatric infectious diseases consultation service

Errors occur frequently in healthcare and can adversely affect outcomes. This prospective study demonstrates that pediatric consultants can detect a broad range of errors in the course of routine work. Many of these errors have the potential to cause harm and can be corrected by the intervention of an infectious diseases consultant.

Neonatal jaundice, animal-induced injuries, and immunizations

The authors describe recent developments in three areas of pediatrics commonly encountered by the office practitioner. First, clinical assessment of jaundice remains critically important as "early discharge" of newborns continues. Practitioners constantly balance clinical realities with an evidence-based approach in the management and follow-up of neonatal hyperbilirubinemia. Second, given the frequent exposure of children to animals, a thorough understanding of animal bites, pet-borne infections, and rabies prophylaxis is essential for every pediatrician. Finally, immunization status remains one of our leading health indicators. Recent changes in the routine immunization schedule and a renewed emphasis on vaccine safety provide insight into the future direction of vaccinology.