Development and Implementation of an End-of-Life Curriculum for Pediatric Residents

Background:

Caring for a child near the end of life (EOL) can be a stressful experience. Resident physicians are often the frontline providers responsible for managing symptoms, communicating difficult information, and pronouncing death, yet they often receive minimal education on EOL care.

Objective:

To develop and implement an EOL curriculum and to study its impact on resident comfort and attitudes surrounding EOL care.

Design:

Kern’s 6-step approach to curriculum development was used as a framework for curriculum design and implementation.

Setting/Participants:

Categorical and combined pediatric residents at a large quaternary care children’s hospital were exposed to the curriculum.

Measurements:

A cross-sectional survey was distributed pre- and postimplementation of the curriculum to evaluate its impact on resident comfort and attitudes surrounding EOL care.

Results:

One-hundred twenty-six (49%) of 258 residents completed the preimplementation survey, and 65 (32%) of 201 residents completed the postimplementation survey. Over 80% of residents reported caring for a dying patient, yet less than half the residents reported receiving prior education on EOL care. Following curriculum implementation, the percentage of residents dissatisfied with their EOL education fell from 36% to 14%, while the percentage of residents satisfied with their education increased from 14% to 29%. The postimplementation survey identified that resident comfort with communication-based topics improved, and they sought additional training in symptom management.

Conclusions:

The implementation of a longitudinal targeted multimodal EOL curriculum improved resident satisfaction with EOL education and highlighted the need for additional EOL education.

Improving resident handoffs for children transitioning from the intensive care unit

BACKGROUND AND OBJECTIVE

Handoffs ensure patient safety during patient care transitions in the hospital setting. At our institution, verbal handoffs communicated by resident physicians are suggested practice for patients transferring from the PICU to the hospital medicine (HM) service. Despite their importance, these verbal handoffs occurred only 76% of the time before patient arrival on HM units. Our goal was to increase the completion rate of verbal handoffs to 100% within 5 months.

METHODS

Baseline data were collected in a daily survey of HM residents. Interventions were developed and tested on small, incremental change cycles. Key interventions included education about the importance of handoffs, standardization of the handoff process, standardization of handoff documentation, and identification and mitigation of handoff documentation failures. We tracked handoff completion rates by using statistical control charts. After success with improving the completion rate of patient handoffs to the HM service, we applied our process to handoffs from the PICU to all inpatient services.

RESULTS

Median completion of verbal patient handoff increased from 76% to 100% within 6 weeks, with improvement sustained for 15 months. Physician compliance with electronic medical record documentation increased from 58% to 94% within 8 months. After spreading to all patients transferring out of the PICU, documentation of patient handoffs increased from 76% to 94% in 5 months.

CONCLUSIONS

A system using improvement science methods was successful in increasing the reliability of resident verbal patient handoffs. Consistent documentation and internal redundancy with checklists were associated with sustained improvement.

Common medical terms defined by parents: are we speaking the same language?

OBJECTIVES

Physicians often assume that a patient understands frequently utilized medical words and patient management may be based on these assumptions. The objective of this study was to determine the public's definition of regularly used medical terminology.

METHODS

A cross-sectional convenience survey was conducted for guardians of children presenting to an urban pediatric emergency department. The orally completed, open-ended questionnaire included parental demographic information and their definition of eleven commonly used medical terms. The words chosen represent common chief complaints given in our emergency department. Definitions were grouped, and a concordance rate of 75% was chosen to consider responses similar.

RESULTS

One hundred twenty-two guardians completed the survey (89% parents, 88% female, and 55% high school graduates). Caregivers agreed on the definitions of diarrhea, constipation, dehydration, fever, and seizure. However, diarrhea and constipation were mainly defined by either stool consistency or frequency, not both. Dehydration was appropriately defined as lack of body fluids (92%), but many parents had difficulty identifying more than one sign of dehydration. Fever was thought to be an elevated body temperature (76%), yet 69% felt that a temperature less than 100.5 degrees F was considered a fever. Most respondents did not know the definitions of meningitis (70%), lethargy (64%), and virus (40%).

CONCLUSIONS

Although commonly used in everyday conversation, there seems to be a large disparity between a caregiver's perception and the actual definition of medical terms. More precise communication may help both parties to understand the true situation.

Clinical Predictors for the Selective Use of Chest Radiographs in Pediatric Blunt Trauma Evaluations

BACKGROUND

Chest radiographs continue to be a routine part of the evaluation of children sustaining blunt trauma. This study sought to determine those clinical markers associated with an abnormal chest radiograph in nonintubated, pediatric, blunt trauma victims.

METHODS

A retrospective case-control study was performed for severely injured pediatric trauma patients presenting to our emergency department between January 1, 1996, and December 31, 1997. Abnormal chest radiographs were identified through the trauma registry and four controls were matched to each case. Radiographs were reevaluated by our study radiologist. Variables associated with an abnormal chest radiograph were grouped to develop a set of clinical markers that could predict an abnormal chest radiograph with a high degree of sensitivity.

RESULTS

An initial chest radiograph was obtained in 457 of 587 trauma patients. Thirty study patients with an abnormal radiograph that met inclusion criteria were analyzed with 133 controls. The presence of either an abnormal respiratory rate for age, chest tenderness, or back abrasions had a sensitivity of 1.0 (95% confidence interval, 0.86-1.0) and a specificity of 0.38 (95% confidence interval, 0.30-0.47).

CONCLUSION

In pediatric trauma patients, the presence of chest tenderness, back abrasions, or an abnormal respiratory rate identified all abnormal chest radiographs.