General Emergency Medicine Physicians Research Articles

Perspectives of Adolescents and Young Adults with Sickle Cell Disease and Clinicians on Improving Transition Readiness and a Videogame Intervention

Background Adolescents and young adults with sickle cell disease (AYA-SCD) have higher rates of mortality and the highest rates of healthcare utilization compared with older and younger SCD patients. The transition period between pediatric and adult care for AYA-SCD is well recognized as a critical window because it represents the intersection of normal adolescent development, change in healthcare access and increased clinical manifestations of disease. Interventions that support AYA-SCD during this time are crucial to improving outcomes. Hallmarks of transition readiness amongst AYA-SCD include self-efficacy (i.e., patients' ability to manage their disease), active participation in shared decision-making (SDM), and adequate disease specific knowledge. Although videogames have been shown to positively affect adolescents' behavior and health outcomes, there has been no study evaluating this technology for improving transition readiness in AYA-SCD. Our objective was to learn AYA-SCD patients' and clinicians' experiences with AYA-SCD managing their disease at home and making medical decisions as they transition from pediatric to adult care, including whether a videogame intervention can positively impact these skills. Methods We conducted individual, semi-structured interviews with purposively sampled patients (AYA-SCD ages 15 to 26 with any genotype of SCD) and clinicians who provide care or support to AYA-SCD (pediatric and adult hematology providers, pediatric and general emergency medicine physicians and nurses, child life specialists) at an urban, quaternary care hospital. Interviews elicited patients' and clinicians' experiences with AYA-SCD in the clinic, emergency department, and/or hospital, including the transition from pediatric to adult care, barriers and facilitators to successful home management, and their perspectives on SDM and a videogame intervention. To identify themes related to patients' and clinicians' experiences with AYA-SCD managing their disease at home and making medical decisions, we conducted an inductive analysis following the principles of grounded theory until data saturation was reached for both groups. For patients' and clinicians' perspectives on a videogame intervention, we used a deductive analysis. Three investigators independently coded all transcripts to identify themes, with discrepancies resolved by consensus. Results We interviewed 16 patients and 21 clinicians. Participants identified two main themes: 1) self-efficacy to manage their disease successfully as they transition from pediatric to adult care, and 2) the importance of patient engagement in making medical decisions (Table 1; representative quotations). Sub-themes were environmental, clinician, and patient factors that served as barriers and facilitators to achieving self-efficacy and patient engagement in decision-making. Facilitators including having social support, the importance of education about SCD and SDM before adolescence, clinicians having good communication, building trust, listening, and involving patients in medical decisions, and patient self-advocacy by voicing their needs and being empowered to actively participate in medical decisions. Barriers included lack of support and resources, adolescent behaviors/traits, co-dependency on a parent/caregiver, pediatric vs. adult culture, and stigma/implicit bias/provider judgement (Figure 1; conceptual model). Participants were supportive of a videogame intervention to improve self-efficacy and engagement in decision-making (Table 1), with the primary goal being education and insight into SCD, and the secondary goal being distraction during pain crises. Conclusions AYA-SCD patients and their clinicians identified self-efficacy in successful disease management and patient engagement in medical decision-making as two primary areas of importance in the transition from pediatric to adult care. Several barriers and facilitators to achieving self-efficacy and patient engagement are potential targets for interventions to improve these skills in AYA-SCD. Overall, patients and clinicians supported the concept of a videogame to support self-efficacy and patient engagement to improve transition readiness. Future studies will focus on the design, development, and implementation of a videogame intervention which centers the key themes identified in this study.

Pediatric emergency medicine literature 2020.

Most children are treated at general Emergency Departments (EDs) and not specialized pediatric EDs. Therefore, it is crucial for emergency medicine physicians to be aware of recent developments in pediatric emergency medicine. Often impactful articles on pediatric emergency medicine are not published in the journals regularly studied by general emergency medicine physicians. We selected ten studies that we found impactful, robust, and relevant for practicing general emergency physicians. This review includes studies of status epilepticus, cardiac arrest, asthma, infant fever, wound care, rapid sequence intubation, coronavirus, and trauma.

Assessment of general emergency medicine physicians’ medical education regarding management of pediatric emergencies in western Normandy, France

ObjectivesGeneral emergency medicine physicians sometimes have to deal with acute management of pediatric emergencies. The objectives of this study were to assess the pediatric medical education background of emergency physicians, how often they encounter pediatric emergencies, as well as the knowledge and organizational gaps regarding the management of children in general emergency departments. MethodsA survey was conducted from March 25 to June 25, 2017, by emailing an anonymized questionnaire to all senior emergency physicians of the 22 general emergency departments of western Normandy public hospitals. ResultsA total of 81 responses were analyzed. In all, 83% percent of respondents had previously worked in a pediatric department. In total, 90% of the respondents reported caring for children within their emergency department and 93% out-of-hospital (100% of them during primary interventions and 39% during secondary interventions such as inter-hospital transfers). Fourteen percent of the respondents considered that the pediatric medical education they received was adapted to their current practice, while 73% reported experiencing difficulties during management of pediatric emergencies (technical difficulties, unsuitable material and therapeutics, relational problems, personal apprehension, disease- or age-specific difficulties, especially with children under the age of 2–3 years). ConclusionMost general emergency physicians report caring for children despite a lack of medical education in pediatrics. Pediatric medical education as well as collaborations between general practitioners and specialized pediatric teams should be enhanced to better match the needs of general emergency departments and improve the quality of primary and acute care for children.

Emergency Medicine Physicians' Perceptions of Pediatric Tele-Emergency Services.

Introduction: This study evaluated general emergency medicine (GEM) physicians' opinions on the barriers, perceptions, and utility of pediatric tele-emergency services, or the use of telemedicine for critically ill children in the emergency department (ED). Methods: Based on previously published surveys, a 27-item survey was created to assess GEM physicians' perspective on tele-emergency services provided by a regional group of pediatric critical care physicians. The survey was distributed to ED medical directors at 15 hospitals who actively participate in tele-emergency services. Results: Twelve of the 15 medical directors responded to the survey (80%). Results demonstrated that GEM physicians consider the pediatric critical care tele-emergency consultations clinically helpful (92%), particularly for the management of patients with respiratory distress, congenital anomalies, and cardiovascular processes. The most common barriers to using tele-emergency services included limited time (42%), integrating new technology and processes in existing workflows (42%), and the lack of clinical utility (42%), particularly for patients with nonacute and/or routine conditions. Lastly, half of GEM physicians felt that families preferred telemedicine to telephone consultations (50%). Conclusion: GEM physicians support the premise that pediatric tele-emergency services help with the clinical management of critically ill children. However, physicians do not consistently believe that tele-emergency services are always clinically necessary and time constraints continue to be a significant barrier. Selected use on specific clinical conditions and improving the integration in workflow processes would help increase the appropriate use of tele-emergency services in the ED.

Pediatric Emergency Medicine Quality of Care: Strategies for Continued Improvement

Pediatric emergency care is conducted primarily outside of academic medical centers. This care is variable among and between pediatric based providers and general emergency medicine physicians. As studies have noted these variations, there has been focus on ways to broadly improve this care and decrease variation in the non-academic community hospital setting. Initial successes have been realized in pediatric emergency preparedness, learning collaboratives and telemedicine. Although these initiatives show promise in building improvements of care for the community pediatric population, the focus towards maintaining and increasing quality in this population requires additional attention. We review current successes and offer perspective for possible future directions.

Physicians' and Nurses' Perspectives on the Decision to Perform Lumbar Punctures on Febrile Infants ≤8 Weeks Old.

There is wide variation in the decision of whether to perform lumbar punctures (LPs) on well-appearing febrile infants ≤8 weeks old. Our objectives were to identify factors that influence that decision and the barriers and facilitators to shared decision-making about LP with parents of febrile infants. We conducted semistructured interviews with 15 pediatric and general emergency medicine physicians and 8 pediatric emergency medicine nurses at an urban, academic medical center. Through interviews, we assessed physicians' practices and physicians' and nurses' perspectives about communication and decision-making with parents of febrile infants. Two researchers independently reviewed the transcripts, coded the data using the constant comparative method, and identified themes. Five themes emerged for factors that influence physicians' decisions about whether to perform an LP: (1) the age of the infant; (2) the physician's clinical experience; (3) the physician's use of research findings; (4) the physician's values, particularly risk aversion; and (5) the role of the primary care pediatrician. Barriers and facilitators to shared decision-making identified by physicians and by nurses included factors related to their perceptions of parents' understanding and acceptance of risks, parents' emotions, physicians' assessment of whether there is clinical equipoise, and availability of follow-up with the primary care pediatrician. Differences in physicians' values, use of research findings, and clinical experience likely contribute to decisions of whether to perform an LP on well-appearing febrile infants. Incorporation of parents' preferences through shared decision-making may be indicated, although there are barriers that would need to be overcome.

Profile of Interfacility Emergency Department Transfers

The aim of this study was to determine the reasons for pediatric emergency department (ED) transfers and the professional characteristics of transferring providers. We performed a multicenter, cross-sectional survey of ED medical providers transferring patients younger than 18 years to 1 of 4 tertiary care children's hospitals. Referring providers completed surveys detailing the primary reasons for transfer and their medical training. The survey data were collected for 25 months, during which 641 medical providers completed 890 surveys, with an overall response rate of 25%. Most pediatric patients were seen by physicians (89.4%) with predominantly general emergency medicine training (64.2%). The median age of patients seen was 5.6 years. The 3 most common diagnoses were closed extremity fracture (12.2%), appendicitis (11.6%), and pneumonia (3.7%). The 3 most common reasons for transfer were need for medical/surgical subspecialist consultation (62.6%), admission to the inpatient unit (17.1%), and admission to the intensive care unit (6.5%). When asked about the need for supportive pediatric services, referring providers ranked pediatric subspecialty and pediatric inpatient unit availability as the highest. Most pediatric interfacility ED transfers are referred by general emergency medicine physicians who often transfer for inpatient admission or subspecialty consultation. Understanding the needs of the community-based ED providers is an important step to forming more collaborative efforts for regionalized pediatric emergency care.

Management of Fever in postpneumococcal vaccine era: comparison of management practices by pediatric emergency medicine and general emergency medicine physicians.

Background. The primary objective of this study was to compare management practices of general emergency physicians (GEMPs) and pediatric emergency medicine physicians (PEMPs) for well-appearing young febrile children. Methods. We retrospectively reviewed the charts of well-appearing febrile children aged 3–36 months who presented to a large urban children's hospital (PED), staffed by PEMPs, or a large urban general emergency department (GED), staffed by GEMPs. Demographics, immunization status, laboratory tests ordered, antibiotic usage, and final diagnoses were collected. Results. 224 cases from the PED and 237 cases from the GED were reviewed. Children seen by PEMPs had significantly less CXRs (23 (10.3%) versus 51 (21.5%), P = 0.001) and more rapid viral testing done (102 (45%) versus 40 (17%), P < 0.0001). A diagnosis of a viral infection was more common in the PED, while a diagnosis of bacterial infection (including otitis media) was more common in the GED. More GED patients were prescribed antibiotics (41% versus 27%, P = 0.002), while more PED patients were treated with oseltamivir (6.7% versus 0.4%, P < 0.001). Conclusions. Our findings identify important differences in the care of the young, well-appearing febrile child by PEMPs and GEMPs and highlight the need for standardization of care.

Bedside Ultrasound Education in Pediatric Emergency Medicine Fellowship Programs in the United States

As the use of bedside ultrasound becomes more prevalent in pediatric emergency departments, the need for a national curriculum for fellows' training in pediatric emergency medicine (PEM) has increased. The objectives of this study were to describe the current state of bedside ultrasound education among existing PEM fellowship programs and to explore the interest in a national curriculum. A 20-question survey was sent to all 57 PEM fellowship directors in the United States in February 2011. Weekly reminders were sent for 4 weeks. The response rate was 58% (33/57). Although 91% of respondents reported having an ultrasound machine available, only 16% reported an ultrasound curriculum designed specifically for PEM. Another 25% reported no curriculum, and 28% use a curriculum designed for general emergency medicine physicians. Most (>83%) directors thought an ultrasound curriculum for PEM fellows should include the focused assessment with sonography for trauma, bladder size assessment, soft tissue foreign body localization, skin and soft tissue infection evaluation, guidance for central and peripheral line insertion, and arthrocentesis. Some directors (40%-68%) thought that cardiac ultrasound, thoracic ultrasound, abdominal ultrasound, lumbar puncture guidance, fracture reduction, nerve blocks, and testicular ultrasounds should also be included. Forty-two percent plan to create a bedside ultrasound curriculum in the next 5 years, and 40% reported the lack of a national curriculum as a barrier to creating a curriculum. Bedside ultrasound use in pediatric emergency departments is very common, and PEM fellowship directors would welcome the development of a standard curriculum.

Bedside Ultrasound in Pediatric Emergency Medicine Fellowship Programs in the United States

Bedside ultrasound (BUS) can provide critical information in a rapid and noninvasive manner to the emergency physician. It is widely used in emergency departments (ED) throughout the nation. Literature shows that BUS shortens patient stay and increases patient satisfaction. General emergency medicine (EM) residencies incorporate BUS training in their curricula. However, there are limited data about the training that pediatric emergency medicine (PEM) fellows receive. To determine the extent of training and use of BUS in PEM fellowship programs. A 29-question survey was mailed to all (57) PEM fellowship program directors in the spring of 2006. The response rate was 81% (46/57). Fifty-seven percent (26/46) of the responding PEM fellowship program directors reported that their faculty used BUS in their departments. At 50% (23/46) of programs, fellows perform BUS studies. Sixty-five percent (30/46) of PEM fellowships reported that their fellows receive some BUS training, but only 15 of these programs included BUS training in the curriculum as a 2- to 4-week ultrasound rotation.Sixty-five percent (30/46) of PEM fellowship programs had access to an ultrasound machine, but only 28% (13/46) of programs had their own machine. The main reason not to own an ultrasound machine was a lack of ultrasound expertise in their department (67%, 22/33). Bedside ultrasound training was provided by general EM physicians in 57% (17/30) of programs. Eighty-seven percent of the directors agree that BUS training would benefit their practice.The 2 factors significantly associated with the likelihood of having formal BUS training were access to an ultrasound machine (87% vs 55% P=0.04) and presence of an adult ED with an EM residency at the program (80% vs 42% P=0.03). Pediatric emergency medicine fellowship programs at children's hospitals were significantly less likely to have formal training (33.3% vs 74.2%; P=0.01). Despite literature supporting the benefits of BUS in the ED, many PEM fellowship programs do not incorporate BUS training for their PEM fellows. Most PEM fellows who receive training in BUS are instructed by physicians trained in EM, not PEM.

Quality of Care of Children in the Emergency Department: Association with Hospital Setting and Physician Training

To investigate differences in the quality of emergency care for children related to differences in hospital setting, physician training, and demographic factors. This was a retrospective cohort study of a consecutive sample of children presenting with high-acuity illnesses or injuries at 4 rural non-children's hospitals (RNCHs) and 1 academic urban children's hospital (UCH). Two of 4 study physicians independently rated quality of care using a validated implicit review instrument. Hierarchical modeling was used to estimate quality of care (scored from 5 to 35) across hospital settings and by physician training. A total of 304 patients presenting to the RNCHs and the UCH were studied. Quality was lower (difference = -3.23; 95% confidence interval [CI] = -4.48 to -1.98) at the RNCHs compared with the UCH. Pediatric emergency medicine (PEM) physicians provided better care than family medicine (FM) physicians and those in the "other" category (difference = -3.34, 95% CI = -5.40 to -1.27 and -3.12, 95% CI = -5.25 to -0.99, respectively). Quality of care did not differ significantly between PEM and general emergency medicine (GEM) physicians in general, or between GEM and PEM physicians at the UCH; however, GEM physicians at the RNCHs provided care of lesser quality than PEM physicians at the UCH (difference = -2.75; 95% CI = -5.40 to -0.05). Older children received better care. The quality of care provided to children is associated with age, hospital setting, and physician training.