Implementation and Maturity of Clinical Learning Environment Components Across Pediatric Residency Programs

OBJECTIVE

Pediatric residency programs prioritize clinical learning environment components depending on resource availability, institutional constraints and culture, and accreditation requirements. However, there is limited literature on the landscape of implementation and maturity of clinical learning environment components across programs nationally.

METHODS

We used Nordquist's clinical learning environment conceptual framework to craft a survey around the implementation and maturity of learning environment components. We performed a cross-sectional survey of all pediatric program directors enrolled in the Pediatric Resident Burnout-Resiliency Study Consortium.

RESULTS

Components with the highest implementation rates were resident retreats, in-person social events, and career development, while components least likely to be implemented were scribes, onsite childcare, and hidden curriculum topics. The most mature components were resident retreats, anonymous systems for reporting patient safety events, and faculty-resident mentoring programs, while the least mature components were use of scribes and formalized mentorship for trainees underrepresented in medicine. Learning environment components included in the Accreditation Council of Graduate Medical Education Program Requirements were significantly more likely to be implemented and mature than nonrequired components.

CONCLUSIONS

To our knowledge, this is the first study to use an iterative and expert process to provide extensive and granular data about learning environment components for pediatric residencies.

The impacts of porous rock check dams on a semiarid alluvial fan

Low-tech rock check dams are widely used to address land degradation; however, assessments of their impacts on runoff and sediment are lacking and are often limited to the first few years after construction. In 2008, two small (4.0 and 3.1 ha) instrumented watersheds located 300 m apart on an alluvial fan on the Santa Rita Experimental Range in southern Arizona were treated with 37 porous, loose rock check dams. Ten years after construction, the watersheds are experiencing contrasting responses to treatment. The ratio of runoff to precipitation was higher after check dam construction on one watershed and lower on the other, but not significantly in either case. Statistically significant changes in peak runoff rate are not detectable 10 years after construction at either watershed. However, a statistically significant reduction in sediment concentration was found on one watershed and no change was found at the other. The check dams have altered channel grades. However, backfilling of the dams is nearly complete on one watershed and the other has remaining capacity. The alluvial fan setting poses a complex restoration environment due to high sediment loads that deposit in response to vegetated areas of accumulated sediment creating conditions for channel avulsion and new incising concentrated flow paths. Check dams have a lesser impact on watershed outlet runoff and sediment than on internal watershed channel morphology and vegetation establishment. With monitoring and maintenance, check dams can be an effective tool for grade stabilization, but watershed restoration requires additional practices to address degraded interfluve areas.

Availability and Perceived Competence of Pediatricians to Serve as Child Protection Team Medical Consultants: A Survey of Practicing Pediatricians

OBJECTIVES

The effectiveness of multidisciplinary child protection teams has been demonstrated. This study is an attempt to assess the level of this commitment and the perceived competence of primary care pediatricians to provide this service.

METHODS

A questionnaire survey was mailed to primary care pediatricians practicing in the state of Alabama.

RESULTS

Among respondents who did not consider themselves competent to conduct sexual abuse or physical abuse examinations, 27% and 19%, respectively, were called on to conduct such examinations. Approximately half of respondents expressed a willingness to serve as consultants under a time commitment obligation of less than 2 hours per week or 1 day per month, and under a reimbursement provision of $200 per examination or less. Respondents recognized a need for, and expressed a desire for, more training in this area.

CONCLUSIONS

Primary care pediatricians are willing to serve as multidisciplinary child protection team medical consultants if provided appropriate training and support.

Phenothiazine, butyrophenone, and other psychotropic medication poisonings in children and adolescents

OBJECTIVE

To describe the presentation, epidemiology, management, and outcome of phenothiazine and butyrophenone ingestions in children requiring hospitalization.

METHOD

Retrospective case series in two pediatric hospitals.

RESULTS

Eighty-six cases were identified among 83 patients. The majority (69.7%) of ingestions occurred in children <6 years of age and there was no gender predominance. These ingestions were more common in African Americans (65.1%). They occurred more commonly in the patient's (64.0%) or a relative's (22.1%) home and haloperidol and thioridazine accounted for 58.1% of exposures. Depressed levels of consciousness and dystonia were the most common presenting signs, present in 90.7% and 51.2% of patients, respectively. Miosis occurred in only 13.9% of the patients. Fluid boluses were administered to 28.7% of the patients but about a quarter of these had coingested potentially cardiotoxic drugs. In addition, 2 of the 12 (13.9%) patients with abnormal electrocardiograms had also ingested potentially cardiotoxic drugs. Numerous diagnostic tests were performed in these patients including electrolyte panels (80.2%), complete blood counts (69.8%), liver function tests (31.4%), serum osmolality (20.9%), blood cultures (10.5%), lumbar punctures (17.4%), head computed tomographies (15.1%), and electroencephalograms (3.5%). The median length of hospitalization was 1.78 (range 1-9) days and there were no deaths. Patients presenting with dystonias were more likely to have extensive diagnostic testing for neurologic disease than those presenting without dystonias.

CONCLUSION

The presentation of phenothiazine and butyrophenone ingestions in children and adolescents may be nonspecific and confounded by coingestants. Patients with dystonias had more extensive neurologic testing than patients without dystonias, suggesting that physicians may not recognize dystonias as a clinical finding characteristic of phenothiazine or butyrophenone exposure.

Evaluation of emergency department referrals by telephone triage

OBJECTIVE

Telephone triage programs are becoming very common at children's hospitals across the nation. One of the proposed benefits of these programs is the more efficient use of health care resources by triaging patients to the appropriate level of health care. The purpose of this study is to examine the appropriateness of referrals to a pediatric emergency department (ED) by the Pediatric Health Information Line (PHIL), a hospital-based telephone triage program, versus all other sources of referrals.

METHODS

A blinded Delphi rating system was used to review the physician's sheets of 133 consecutive ED referrals by PHIL for medical appropriateness. A total of 260 randomly selected control patients seen in the ED during the same period were similarly reviewed. If 2 of 3 pediatric emergency medicine physicians agreed that an ED visit was appropriate, then it was considered appropriate. A comparison of the 2 groups' ED appropriateness was made using a contingency table chi(2) test. An odds ratio with confidence limits was also calculated. Demographic data were collected for both groups including age, race, gender, and insurance status.

RESULTS

The PHIL group had an appropriateness rate of 80.2%, compared with 60.5% for the control group (chi(2) = 14.6369; odds ratio = 2.65; 95% confidence interval [1.5759,4.5008]).

CONCLUSIONS

This demonstrated that for the period studied, PHIL referrals to the ED had a 33% higher rate of appropriateness than controls. This evidence supports telephone triage as an efficient gatekeeper for health care resources.

Clonidine poisoning in Jefferson County, Alabama

STUDY OBJECTIVE

To describe the epidemiology of clonidine-related hospitalization in children, to evaluate the efficacy of naloxone, and to review the clinical effects of clonidine toxicity.

METHODS

This was a retrospective analysis in an urban teaching pediatric emergency department with an annual census of 55,000 involving 80 children younger than 6 years who were admitted for clonidine ingestion during a 6-year period.

RESULTS

Clonidine commonly belonged to the patient's grand-mother (54%). Black children were twice as likely to be hospitalized for clonidine ingestion than white children compared with children hospitalized for any injury. Average time to onset of symptoms was 35 minutes. Decreased level of consciousness was the most common presenting symptom (96%). Mean ED vital signs were systolic blood pressure, 102 mm Hg; pulse, 98; respirations, 25 (six patients intubated); and temperature, 36.6 degrees C, Naloxone was administered to 49% of patients, 84% of whom demonstrated no response.

CONCLUSION

Clonidine ingestion is endemic in our area. Serious clinical effects mandate that all children with clonidine ingestion be triaged to a health care facility. Naloxone as an antidote for clonidine remains controversial.

Effectiveness of child-resistant packaging on toxin procurement in young poisoning victims

The objective of this study was to determine how often and how children < 5 y-of-age involved in unintentional poisonings gained access to those poisons by opening properly secured child-resistant packages. From June 1994 through February 1995 we surveyed caretakers of children < 5 y-of-age presenting with the chief complaint of ingestion, inhalation, or ocular or dermal exposure of potential or perceived toxins. Excluded were exposures to plants, bites or stings, or patients inadvertently overdosed by a caretaker. The survey was administered to caretakers of 168 patients. Mean age was 26 mo (range 9 mo to 56.9 mo). The toxin was in its original container in 71% and transferred to another container or found outside of its container in 29% of cases; 33% involved a child-resistant closure. The child gained access by opening a properly closed child-resistant closure in 20% of the exposures and in 18.5% by opening a properly closed non-child-resistant closure. Child-resistance did not ensure child impenetrability. This suggests the need to reevaluate child-resistant closure testing protocols or retest currently used closures. Packaging misuse, including improper closure use or transferring medications or household products from the original container accounts for a large percentage of pediatric toxin exposures, thus emphasizing the importance of poison prevention education.

Herbs and HIV: the health food industry's answer

Patients with tragic diseases such as AIDS (acquired immunodeficiency syndrome) may be at risk for using herbal remedies and other alternative medical therapies. To ascertain what products may be available for use among AIDS patients in our community, we surveyed 20 local health food stores. Store employees were asked the question, "What do you recommend for people with AIDS?" Many herbal products, as well as other alternative medicinal preparations, were being recommended by store employees. Physicians caring for patients with AIDS should be aware of the potential for herbal use among their patients and the possible side effects of these products.

A comparison of cathartics in pediatric ingestions

OBJECTIVE

To compare the mean time to first stool, number of stools, and side effects of three commonly used cathartics in pediatric ingestions.

DESIGN

This prospective clinical trial was a randomized, double-blinded comparison of sorbitol, magnesium citrate, magnesium sulfate, and water, administered with activated charcoal in the treatment of pediatric patients 1 to 5 years of age with acute ingestions. Outcome parameters were mean time to first stool, mean number of stools during 24 hours, and side effects.

RESULTS

One hundred sixteen patients completed the study. Significant differences in mean time to the first stool were detected among cathartic agents (F = 9.29), with sorbitol-treated patients having a shortest mean time to the first stool (mean, 8.48 hours). Sorbitol produced a significantly higher number of stools (mean, 2.79) in the 24-hour follow-up period than other cathartics (F = 3.49). The most common side effect of cathartic administration was emesis, which occurred more commonly in sorbitol-treated patients.

CONCLUSION

Sorbitol, when administered with activated charcoal in the treatment of children with acute ingestions, produced a shorter time to first stool and more stools than magnesium citrate, magnesium sulfate, or water.

Baking soda: a potentially fatal home remedy

We present a case of a six-week-old infant who developed life-threatening complications after unintentional sodium bicarbonate intoxication. Baking soda was being used by the mother as a home remedy to "help the baby burp." A review of the literature regarding the use (or misuse) of baking soda follows. Our patient, along with the other noted case reports, emphasizes the need for warnings on baking soda products whose labels recommend its use as an antacid. Poisonings must be high in the differential diagnosis of any patient, regardless of age, who presents with altered mental status or status epilepticus.

Urban/rural differences in child passenger deaths

Motor vehicle crashes are the leading cause of death for Alabama children. This fact persists despite a child restraint law and an amendment designed to prevent such deaths in preschoolers. This study compared cumulative motor vehicle-passenger death rates by county and by urban and rural residence. Rural children had twice the rate of death of urban children. Additionally, these death rates demonstrated a sharp negative gradient when residence areas were ordered by increasing population densities (rural agricultural, rural manufacturing, suburban, and urban, respectively). Because child passenger death rates are significantly higher among rural children, future research should focus on hazards associated with the rural environment. A list of key study elements is provided.

Time series analyses of global change data

The hypothesis that statistical analyses of historical time series data can be used to separate the influences of natural variations from anthropogenic sources on global climate change is tested. Point, regional, national, and global temperature data are analyzed. Trend analyses for the period 1901-1987 suggest mean annual temperatures increased (in degrees C per century) globally at the rate of about 0.5, in the USA at about 0.3, in the south-western USA desert region at about 1.2, and at the Walnut Gulch Experimental Watershed in south-eastern Arizona at about 0.8. However, the rates of temperature change are not constant but vary within the 87-year period. Serial correlation and spectral density analysis of the temperature time series showed weak periodicities at various frequencies. The only common periodicity among the temperature series is an apparent cycle of about 43 years. The temperature time series were correlated with the Wolf sunspot index, atmospheric CO(2) concentrations interpolated from the Siple ice core data, and atmospheric CO(2) concentration data from Mauna Loa measurements. Correlation analysis of temperature data with concurrent data on atmospheric CO(2) concentrations and the Wolf sunspot index support previously reported significant correlation over the 1901-1987 period. Correlation analysis between temperature, atmospheric CO(2) concentration, and the Wolf sunspot index for the shorter period, 1958-1987, when continuous Mauna Loa CO(2) data are available, suggest significant correlation between global warming and atmospheric CO(2) concentrations but no significant correlation between global warming and the Wolf sunspot index. This may be because the Wolf sunspot index apparently increased from 1901 until about 1960 and then decreased thereafter, while global warming apparently continued to increase through 1987. Correlation of sunspot activity with global warming may be spurious but additional analyses are required to test this hypothesis. Given the inconclusive correlation between temperature and solar activity, the significant intercorrelation between time, temperature, and atmospheric CO(2) concentrations, and the suggestion of weak periodicity in the temperature data, additional research is needed to separate the anthropogenic component from the natural variability in temperature when assessing local, regional, and global warming trends.