Pediatric Critical Care Fellows Research Articles

Spiritual Care in PICUs: A U.S. Survey of 245 Training Fellows 2020-2021.

To understand the perspectives of pediatric fellows training in critical care subspecialties about providing spiritual care. Cross-sectional survey of United States National Residency Matching Program pediatric fellows training in critical care specialties. Online survey open from April to May 2021. A total of 720 fellows (165 cardiology, 259 critical care, and 296 neonatology) were contacted, with a response rate of 245 of 720 (34%). None. We assessed fellows' survey responses about spiritual care in neonatal and pediatric critical care units. Categorical data were compared using chi-square test or Fisher exact tests. The Wilcoxon rank-sum test was used to compare the percentage correct on ten multiple-choice questions about world religions. Free-text responses were independently coded by two research investigators. A total of 203 of 245 (83%) responding fellows had never received training about spiritual care and 176 of 245 (72%) indicated that they would be likely to incorporate spiritual care into their practice if they received training. Prior training was associated with increased familiarity with a framework for taking a spiritual history ( p < 0.001) and increased knowledge of spiritual practices that could influence medical care ( p = 0.03). Prior training was also associated with increased self-reported frequency of taking a spiritual history ( p < 0.001) and comfort in referring families to spiritual care resources ( p = 0.02). Lack of time and training were the most reported barriers to providing spiritual care. Providing spiritual care for families is important in critical care settings. In 2020-2021, in the United States, 245 pediatric critical care fellows responded to a survey about spiritual care in their practice and reported that they lacked training in this subject. An opportunity exists to implement spiritual care curricula into pediatric fellowship training.

Survey of Pediatric Critical Care Fellows on Postresuscitation Debriefing.

Current guidelines recommend debriefing following medical resuscitations to improve patient outcomes. The goal of this study was to describe national trends in postresuscitation debriefing practices among pediatric critical care medicine (PCCM) fellows to identify potential gaps in fellow education. A 13-item survey was distributed to fellows in all 76 ACGME-accredited PCCM programs in the United States in the spring of 2021. The online survey addressed frequency and timing of debriefings following medical resuscitations, whether formal training is provided, which medical professionals are present, and providers' comfort level leading a debriefing. Results were analyzed using descriptive statistics. A total of 102 responses (out of a possible N of 536) were gathered from current PCCM fellows. All fellows (100%) reported participation in a medical resuscitation. Only 21% stated that debriefings occurred after every resuscitation event, and 44% did not follow a structured protocol for debriefing. While 66% reported feeling very or somewhat comfortable leading the debriefing, 19% felt either somewhat uncomfortable or very uncomfortable. A vast majority (92%) of participating fellows believed that debriefing would be helpful in improving team member performance during future resuscitations, and 92% expressed interest in learning more about debriefing. The majority of PCCM fellows do not receive formal training on how to lead a debriefing. Given that 74% of fellows in our study did not feel very comfortable leading a debriefing but almost universally expressed that this practice is useful for provider well-being and performance, there is a clear need for increased incorporation of debriefing training into PCCM curricula across the United States.

Development and Implementation of a Quick Response (QR) Code System to Streamline the Process for Fellows' Evaluation in the Pediatric Intensive Care Unit (PICU) and the Neonatal Intensive Care Unit (NICU) at a Large Academic Center.

Useful feedback and evaluation are critical to a medical trainee's development. While most academic physicians understand that giving feedback to learners is essential, many do not consider the components of feedback to be truly useful, and there are barriers to implementation. We sought to use a quick reader (QR) system to solicit feedback for trainees in two pediatric subspecialties (pediatric critical care and neonatal-perinatal medicine) at one institution to increase the quality and quantity of feedback received. New valuations were modified from the existing evaluations and imported into online systems with QR code capability. Each fellow was given a QR code linking to evaluations and encouraged to solicit feedback and evaluations in a variety of clinical settings and scenarios. Evaluation numbers and quality of evaluations were assessed and compared both pre- and post-intervention. There were increases in the number of evaluations completed for both the pediatric critical care fellows and the neonatal-perinatal medicine fellows. There was no overall change in the quality of written evaluations received. Satisfaction with the evaluation system improved for both faculty and fellows of both training programs. In our critical care units, we were successfully able to implement a QR code-driven evaluation for our fellows that improved access for the faculty and offered the ability of the learner to solicit evaluations, without compromising the number or quality of evaluations. What's new: Quick reader (QR) codes can be used by learners to solicit evaluations and feedback from faculty. They can increase the quantity of written evaluations received without affecting their quality.

691: VISUALIZING PEDIATRIC CRITICAL CARE FELLOW TRACHEAL INTUBATION LEARNING CURVES

Introduction: Tracheal intubation (TI) is a life-saving procedure for pediatric intensivists. Developing proficiency in TI is one of the goals in the PCCM fellowship. We aim to develop a dashboard for PCCM fellows to visualize their own learning curves and proactively identify educational needs. We hypothesize majority of the fellows will achieve TI competence during first 12 months of training. Methods: Using the local airway management quality improvement database (a part of National Emergency Airway Registry for Children: NEAR4KIDS), we built a data field for each fellow’s training ID. Using REDCap and R, we developed a cumulative sum (CUSUM) learning curve visualization to achievement of competence level. We piloted the data visualization in a cohort of first year PCCM fellows starting in one of academic year 2019-2021 for their TIs in the PICU for first 12 months. Two levels of TI competence thresholds were a priori defined: 80% success for the first attempt, and 80% success for the course (course is defined as one approach to secure an airway) with both alpha and beta at 0.1. Results: Seventy-one TI courses were performed by six first year fellows (mean 22 TIs, range 14-30 per fellow) with 87 intubation attempts. First attempt success rate was mean 73% (range 57-85%), course success rate was 85% (range 79-93%). CUSUM curves were successfully plotted from the database. Three of six fellows (50%) achieved the competence threshold for the first attempt (80% first attempt success) after 12, 15, and 18 TIs. Five fellows (83%) achieved the competence threshold for the TI course (80% overall success) after 8, 8, 12, 12, 12 TIs. One fellow who did not achieve competence had the lowest number of intubations (n=14). When an alternative competence threshold at 70% for first attempt success is used, five fellows achieved the first attempt competence after 4,4,4,4,7 TIs. Conclusions: The number of tracheal intubations needed to achieve procedural competence amongst first year pediatric critical care fellows is likely variable. Only half of the first year PCCM fellows met the criteria for competence level (80% first attempt success). While repeated procedural attempts may lead to competency for some fellows, individualized educational strategies may be necessary for others.

858: THE IMPLEMENTATION OF A HEALTH EQUITY CURRICULUM IN A PEDIATRIC CRITICAL CARE FELLOWSHIP

Introduction: Bias and racism in medicine perpetuate health disparities. In response, the Accreditation Council for Graduate Medical Education has instituted program requirements to address diversity, equity, and inclusion (DEI) in training programs. Little guidance has been given regarding the structure and content of these curricula. As such, we aim to describe the structure and function of an integrated health equity curriculum at the pediatric critical care medicine (PCCM) fellowship program at the Children’s Hospital of Philadelphia (CHOP) and present our curriculum as a model for other training programs. Methods: Attendings, fellows, research assistants, and administrators serve on the Health Equity Committee (HEC). HEC is divided into three domains: education, research, and community engagement. Education topics include understanding institutional racism in medicine, mitigating bias and microaggressions, and local patterns of disparate outcomes (i.e. violence, asthma, etc). The research domain incorporates health equity into research and quality improvement projects. The community engagement domain is involved in patient education in Philadelphia and recruitment initiatives for medical students who are underrepresented in medicine. Results: Over the first 24 months, HEC has conducted nine lectures, four journal clubs, three health equity case conferences, and an interactive session regarding a structured response to microaggressions. Nationally, HEC directed a PCCM survey to assess diversity engagement across fellowship programs and identify areas for improvement; locally, HEC is working to improve the utilization of interpreters and partnering with CHOP’s Center for Health Equity to increase CPR teaching in Philadelphia. Most importantly, HEC activities are fully integrated into existing fellow education with high expectations for participation and accountability. Conclusions: The CHOP PCCM HEC is a feasible and generalizable model for implementing a DEI curriculum. HEC fosters an environment that integrates DEI into the education of pediatric critical care fellows. Integrating DEI-focused education, research, and community engagement sustainably modeled by HEC can contribute to the elimination of disparities and bias in the care of critically ill children.

Transport Medical Control Education for Pediatric Critical Care Fellows: A National Needs Assessment Study.

Characterize transport medical control education in Pediatric Critical Care Medicine fellowship. Cross-sectional survey study. Pediatric Critical Care Medicine fellowship programs in the United States. Pediatric Critical Care Medicine fellowship program directors. None. We achieved a 74% (53/72) response rate. A majority of programs (85%) require fellows to serve as transport medical control, usually while carrying out other clinical responsibilities and sometimes without supervision. Fellows at most programs (80%) also accompany the transport team on patient retrievals. Most respondents (72%) reported formalized transport medical control teaching, primarily in a didactic format (76%). Few programs (25%) use a standardized assessment tool. Transport medical control was identified as requiring all six Accreditation Council for Graduate Medical Education competencies, with emphasis on professionalism and interpersonal and communication skills. Transport medical control responsibilities are common for Pediatric Critical Care Medicine fellows, but training is inconsistent, assessment is not standardized, and supervision may be lacking. Fellow performance in transport medical control may help inform assessment in multiple domains of competencies. Further study is needed to identify effective methods for transport medical control education.

Online Learning and Echocardiography Boot Camp: Innovative Learning Platforms Promoting Blended Learning and Competency in Pediatric Echocardiography.

Mastering pediatric echocardiography (PE) requires a substantial knowledge base of echo theory and congenital heart disease (CHD), along with technical proficiency. Online self-directed learning has become increasingly utilized among medical trainees to promote competency within medical subspecialties. We sought to evaluate the impact of online learning combined with lecture-based and hands-on teaching on the acquisition of PE knowledge and confidence in pediatric cardiology and pediatric critical care fellows. We prospectively enrolled 124 learners from 2016 to 2019. These included 40 incoming cardiology and critical care fellows at Texas Children's Hospital (TCH) as well as 84 national and international participants recruited from our online echo education website. All participants completed online learning modules through our website ( www.pedecho.org ), which covers pediatric echo physics, Doppler, technique, normal anatomy, atrial septal defects, and ventricular septal defects. TCH cardiology and critical care fellows subsequently participated in an Echo Boot Camp (BC), a 3-day training program with hands-on workshops and didactic lectures. Knowledge was assessed using an 80-question pre and post-test multiple choice exams. The online learning group demonstrated improvement in exam scores following online learning (PRE 49.1 ± 15.3 vs. POST 67.8 ± 17%; p ≤ 0.01). Echo Boot Camp fellows were noted to have further incremental improvement in test scores following BC (PRE 48% ± 13% vs. POST MODULE 68.6% ± 15% vs. POST BC 75.7% ± 13%; p ≤ 0.01). Self-assessment regarding confidence in context areas showed a substantial gain in self perceived interpretive confidence across all groups as well as procedural confidence in BC participants. Online learning significantly promotes the acquisition of echocardiography knowledge. Additional lecture-based and hands-on teaching in the form of an Echo Boot Camp can further enhance knowledge and interpretative skills. Both of these learning platforms appear to work in concert as powerful and effective tools in fellow education.

Pathophysiology for the Pediatric Critical Care Fellow: Three Representative Simulation Cases

IntroductionDuring the course of fellowship training, pediatric critical care fellows are expected to develop a broad and in-depth understanding of the pathophysiology of multiple disease processes. The simulation-based pediatric critical care pathophysiology curriculum we present uses scenarios created by pediatric critical care fellows to teach complex pathophysiology.MethodsEach of the three representative cases presented covered a specific pathophysiologic process and required participants to acutely manage (1) an 18-year-old patient with altered mental status in the setting of hepatic encephalopathy; (2) an 8-year-old patient with sepsis, coagulopathy, and acute kidney injury; or (3) a 12-year-old patient with status epilepticus. Each case could be conducted in a simulation suite or an acute care unit bed. We assessed learners' knowledge and attitudes at the end of these simulations with a structured debriefing session and via completion of an evaluation form. The simulations were then followed by a 30-minute interactive didactic session on the topic.ResultsEach scenario had six fellow participants who completed evaluations. After completing each of the three case scenarios presented, the majority of participating pediatric critical care fellows indicated that the content was relevant and sufficiently challenging. They also indicated that these simulation scenarios would improve their clinical practice.DiscussionThis fellow-developed simulation curriculum is novel, highlighting the relevance for critical care fellows' understanding of realistic clinical scenarios while promoting advanced management skills with a pathophysiology focus.

Exploring End of Life Care Education in Pediatric Critical Care: A Need to Improve Fellow Education

Purpose: End of life (EOL) care is a vital and inevitable aspect of pediatric critical care training. Efforts to provide EOL education to pediatric critical care fellows can aid in improving the quality of palliative care delivered in the pediatric intensive care unit (PICU). To date, limited research exploring the experiences and attitudes that have shaped critical care fellows’ perspectives of EOL care is available. Additionally, there are limited studies investigating methods to provide EOL education for PICU fellows. We aim to identify the current education …

A National Survey on Physician Trainee Participation in Pediatric Interfacility Transport*

To ascertain the national experience regarding which physician trainees are allowed to participate in pediatric interfacility transports and what is considered adequate education and training for physician trainees prior to participating in the transport of children. Self-administered electronic survey. Pediatric transport teams listed with the American Academy of Pediatrics Section on Transport Medicine. Leaders of U.S. pediatric transport teams. None. Forty-four of the 90 U.S. teams surveyed (49%) responded. Thirty-nine (89%) were university hospital-affiliated. Most programs (26/43, 60%) allowed trainees to participate in pediatric transport in some capacity. Mandatory transport rotations were reported for pediatric critical care (PICU) fellows (9/42, 21%), neonatology (neonatal ICU) fellows (6/42, 14%), pediatric emergency medicine fellows (4/41, 10%), emergency medicine residents (3/43, 7%), and pediatric residents (2/43, 5%). Fellow participation was reported by 19 of 28 programs (68%) with PICU fellowships, 12 of 25 programs (48%) with pediatric emergency medicine fellowships, and 10 of 34 programs (29%) with neonatal ICU fellowships. Transport programs with greater than or equal to 1,000 annual incoming transports were more likely to include PICU and pediatric emergency medicine fellows as providers (p = 0.04; 95% CI, 1.04-25.71 and p = 0.02; 95% CI, 1.31-53.75). Most commonly, trainees functioned as medical control physicians (86%), provided minute-to-minute medical direction for critically ill patients (62%), performed intubations (52%), and were code leaders for patients undergoing cardiopulmonary resuscitation during transport (52%). Most transport programs required pediatric residents, PICU, and pediatric emergency medicine fellows to complete a PICU rotation prior to participating in pediatric transports. The majority of transport programs did not use any metrics to determine airway proficiency of physician trainees. There is heterogeneity with regard to the types of physician trainees allowed to participate in pediatric interfacility transports, the roles played by physician trainees during pediatric transport, and the training (or lack thereof) provided to physician trainees prior to their participating in pediatric transports.

Assessing Competence in Central Venous Catheter Placement by Pediatric Critical Care Fellows: A National Survey Study.

To describe the current approach to initial training, ongoing skill maintenance, and assessment of competence in central venous catheter placement by pediatric critical care medicine fellows, a subset of trainees in whom this skill is required. Cross-sectional internet-based survey with deliberate sampling. United States pediatric critical care medicine fellowship programs. Pediatric critical care medicine program directors of Accreditation Council for Graduate Medical Education-accredited fellowship programs. None. A working group of the Education in Pediatric Intensive Care Investigators research collaborative conducted a national study to assess the degree of standardization of training and competence assessment of central venous catheter placement across pediatric critical care medicine fellowship programs. After piloting, the survey was sent to all program directors (n = 67) of Accreditation Council for Graduate Medical Education-accredited pediatric critical care medicine programs between July 2017 and September 2017. The response rate was 85% (57/67). Although 98% of programs provide formalized central venous catheter placement training for first-year fellows, only 42% of programs provide ongoing maintenance training as part of fellowship. Over half (55%) of programs use a global assessment tool and 33% use a checklist-based tool when evaluating fellow central venous catheter placement competence under direct supervision. Only two programs (4%) currently use an assessment tool previously published and validated by the Education in Pediatric Intensive Care group. A majority (82%) of responding program directors believe that a standardized approach to assessment of central venous catheter competency across programs is important. Despite national mandates for skill competence by many accrediting bodies, no standardized system currently exists across programs for assessing central venous catheter placement. Most pediatric critical care medicine programs use a global assessment and decisions around the ability of a fellow to place a central venous catheter under indirect supervision are largely based upon subjective assessment of performance. Further investigation is needed to determine if this finding is consistent in other specialties/subspecialties, if utilization of standardized assessment methods can improve program directors' abilities to ensure trainee competence in central venous catheter insertion in the setting of variable training approaches, and if these findings are consistent with other procedures across critical care medicine training programs, adult and pediatric.

Simulation-Based Palliative Care Communication for Pediatric Critical Care Fellows.

Pediatric palliative care (PPC) education is lacking in pediatric critical care medicine (PCCM) fellowships, despite the desire of many program directors and fellows to expand difficult conversation training. Simulation-based training is an experiential method for practicing challenging communication skills such as breaking bad news, disclosing medical errors, navigating goals of care, and supporting medical decision-making. We describe a simulation-based PPC communication series for PCCM fellows, including presimulation session, simulation session, debriefing, and evaluation methods. From 2011 to 2017, 28 PCCM fellows participated in a biannual half-day simulation session. Each session included 3 scenarios (allowing for participation in up to 18 scenarios over 3 years). Standardized patients portrayed the child's mother. PCCM and interprofessional PPC faculty cofacilitated, evaluated, and debriefed the fellows after each scenario. Fellows were evaluated in 4 communication categories (general skills, breaking bad news, goals of care, and resuscitation) using a 3-point scale. A retrospective descriptive analysis was conducted. One hundred sixteen evaluations were completed for 18 PCCM fellows. Median scores for general communication items, breaking bad news, and goals of care ranged from 2.0 to 3.0 (interquartile range [IQR]: 0-1) with scores for resuscitation lower at 1.0 (IQR: 1.5-2). This experiential simulation-based PPC communication curriculum taught PCCM fellows valuable palliative communication techniques although revealed growth opportunities within more complex communication tasks. The preparation, methods, and lessons learned for an effective palliative simulation curriculum can be expanded upon by other pediatric training programs, and a more rigorous research program should be added to educational series.

4) Teaching the Skill of Shared Decision Making to Pediatric Critical Care Physicians

Purpose: To assess the effectiveness of an open, online curriculum teaching the skills of shared decision making to Pediatric Critical Care Fellows and other pediatric trainees who help care for critically ill children. Methods: Pediatric Fellows from the PICU, NICU, Heme/Onc, and Pulmonology fellowships were recruited and randomized to intervention and control groups. All participants were video-recorded in a simulated patient encounter in which parents were deciding to either go forward with a life-extending procedure for their child or transition to …

(53) Career Development Support Curriculum for Pediatric Critical Care Fellows: A National Survey

(53) Career Development Support Curriculum for Pediatric Critical Care Fellows: A National Survey

Design and Implementation of a Curriculum to Teach Communication Skills to Pediatric Critical Care Fellows

Design and Implementation of a Curriculum to Teach Communication Skills to Pediatric Critical Care Fellows

Defining leadership competencies for pediatric critical care fellows: Results of a national needs assessment

Introduction: Physicians in training, including those in Pediatric Critical Care Medicine, must develop clinical leadership skills in preparation to lead multidisciplinary teams during their careers. This study seeks to identify multidisciplinary perceptions of leadership skills important for Pediatric Critical Care Medicine fellows to attain prior to fellowship completion.Methods: We performed a multi-institutional survey of Pediatric Critical Care Medicine attendings, fellows, and nurses. Subjects were asked to rate importance of 59 leadership skills, behaviors, and attitudes for Pediatric Critical Care practitioners and to identify whether these skills should be achieved before completing fellowship. Skills with the highest ratings by respondents were deemed essential.Results: Five hundred and eighteen subjects completed the survey. Of 59 items, only one item (“displays honesty and integrity”) was considered essential by all respondents. When analyzed by discipline, nurses identified 21 behaviors essential, fellows 3, and attendings 1 (p < 0.05). Nurses differed (p < 0.05) from attendings in their opinion of importance in 64% (38/59) of skills.Conclusions: Despite significant variability among Pediatric Critical Care attendings, fellows, and nurses in identifying which clinical leadership competencies are important for graduating Pediatric Critical Care fellows, they place the highest importance on skills in self-management and self-awareness. Leadership skills identified as most important may guide the development of interventions to improve trainee education and interprofessional care.

A Practical Application of Educational Theories in Developing a Boot Camp Program for Pediatric Critical Care Fellows

A Practical Application of Educational Theories in Developing a Boot Camp Program for Pediatric Critical Care Fellows

Design and Implementation of a Curriculum to Teach Communication Skills to Pediatric Critical Care Fellows

Design and Implementation of a Curriculum to Teach Communication Skills to Pediatric Critical Care Fellows

Physician Communication in Pediatric End-of-Life Care: A Simulation Study.

The objective of this exploratory study is to describe communication between physicians and the actor parent of a standardized 8-year-old patient in respiratory distress who was nearing the end of life. Thirteen pediatric emergency medicine and pediatric critical care fellows and attendings participated in a high-fidelity simulation to assess physician communication with an actor-parent. Fifteen percent of the participants decided not to initiate life-sustaining technology (intubation), and 23% of participants offered alternatives to life-sustaining care, such as comfort measures. Although 92% of the participants initiated an end-of-life conversation, the quality of that discussion varied widely. Findings indicate that effective physician-parent communication may not consistently occur in cases involving the treatment of pediatric patients at the end of life in emergency and critical care units. The findings in this study, particularly that physician-parent end-of-life communication is often unclear and that alternatives to life-sustaining technology are often not offered, suggest that physicians need more training in both communication and end-of-life care.

Development of learning objectives and a validated testing tool for management of pediatric mechanical ventilation*.

Graduate medical education is shifting toward an outcome-based paradigm, where physicians are evaluated for competency using well-defined criteria. Our aim was to learning objectives and a testing tool to assess competency in the management of mechanical ventilation for infants, children, and adolescents and to verify that the test was reliable and valid. Prospective reliability and validity study. Large, university-affiliated academic hospital. Sixty-one total subjects from five different academic centers divided into three groups of varying experience. The groups were second- and third-year pediatric residents (Novice), second- and third-year pediatric critical care fellows (Advanced), and pediatric critical care faculty (Expert). None. Ten learning objectives considered important for the management of pediatric mechanical ventilation were developed from expert opinion and current evidence. Based on these objectives, a 35-question multiple choice, knowledge- and case-based test was created. Content validity was achieved by consensus of three experts in pediatric critical care medicine evaluating whether the questions reflected the learning objectives and the responses were consistent with current practice and evidence-based medicine. The test was then administered to the three groups to establish construct validity. The "Novice" group scored a mean of 34.6% (95% CI, 28-41%), the "Advanced" group a mean of 59.4% (95% CI, 53-65%), and the "Expert" group a mean of 74.8% (95% CI, 69-80%), with p less than 0.01 for all comparisons. As determined by Hoyt's analysis, the reliability coefficient was 0.89, reflecting excellent reliability. This is the first description of specific learning objectives for management of pediatric mechanical ventilation and the first validated and reliable testing tool for assessing knowledge. This tool could be used by fellowship programs to assess fellow competency and identify knowledge gaps in this area prior to completion of training. Further work must be done to determine the criteria for determination of competency.