Creation and Validation of Tool to Assess Resident Competence in Neonatal Resuscitation

BackgroundThe American Board of Pediatrics requires that pediatricians be able to initiate stabilization of a newborn. After residency, 45% of general pediatricians routinely attend deliveries. However, there is no standard approach or tool to measure resident proficiency in newborn resuscitation across training programs. In a national survey, we found a large variability in faculty assessment of the amount of supervision trainees need for various resuscitation scenarios. Objective documentation of trainee performance would permit competency-based decisions on the level of supervision required and facilitate feedback on trainee performance.MethodsA simplified tool was created following the Neonatal Resuscitation Program (NRP) algorithm, with emphasis on communication, leadership, knowledge of equipment, and initial stabilization. To achieve content validity, the tool was evaluated by the NRP steering committee. To assess internal structure of the tool, we filmed 10 simulated resuscitation scenarios, 9 of which contained errors. Experienced resuscitation team members used the tool to assess performance of the team leader in the videos. To evaluate the response process, the tool was used to assess experienced resuscitators in real time at academic and non-academic sites.ResultsThe NRP steering committee approved the tool, providing evidence of content validity. Performance of the team leader in the simulated videos was assessed by 16 evaluators using the tool. There was an intraclass coefficient of 0.86, showing excellent agreement. There was no statistical difference in scores between 102 resuscitations led by experienced resuscitators at academic and nonacademic hospitals (P = .98), which demonstrates generalizability.ConclusionsThe tool we have developed to assess performance in initiating newborn resuscitation shows evidence of construct validity based on assessment of content and internal structure (interobserver agreement, response processes, and generalizability).     

Adolescent Contraception in the Emergency Department: Abnormal Uterine Bleeding and Beyond

The emergency department (ED) is a frequent and important site for gynecologic care, and many women present to the ED for reproductive health concerns such as abnormal menses. Due to early menstrual age and increased incidence of sexually transmitted infections, adolescents are particularly prone to abnormal menses, but are also disproportionately affected by unintended pregnancy. While EDs have long been used for the evaluation and initial management of abnormal uterine bleeding, general contraceptive provision in the ED is a novel approach to addressing unmet contraceptive needs among adolescent women. We review normal menstruation and the evaluation and management of abnormal uterine bleeding in adolescents, including the use of combined oral contraceptives. Expanding on this established indication for contraceptive use in the ED, we present attitudes, barriers, and approaches to ED provision of contraceptives for adolescent pregnancy prevention.     

The Use and Impact of Professional Interpretation in a Pediatric Emergency Department

Background and ObjectivePatients with limited English proficiency (LEP) experience worse health care outcomes compared to English proficient (EP) patients, and professional interpretation is underutilized in clinical settings. The objectives of this study were to describe patterns of interpreter use in a pediatric emergency department (ED), to determine factors associated with its use, and to examine differences in outcomes between EP families and those with LEP.MethodsED encounters for LEP and EP patients were reviewed in a retrospective cohort study design over a 15 month period. Generalized estimating equations were used to compare patient encounters and factors associated with interpreter use.ResultsInterpreter use for families who preferred a non-English language was 45.4%. Use of interpretation was less likely during busier times of day (odds ratio [OR] 0.85, confidence interval [CI] 0.78–0.93), with a lower triage acuity (OR 0.66, CI 0.62–0.70), and with each increasing year of patient age (OR 0.97, CI 0.96–0.98). LEP patients who did not receive interpretation were less likely to be admitted than EP patients (OR 0.69, 0.62–0.78). Patients of LEP families, with or without interpretation, were more likely to be transferred to the ICU within 24 hours of admission than patients of EP families (OR 1.76, 1.07–2.90; 1.85, 1.08–3.18) suggesting that an aspect of clinical severity may have been missed in the ED.ConclusionsProfessional interpretation is currently underutilized in this ED for patients with LEP, and important differences in outcomes exist between LEP and EP patients. Factors associated with interpreter use will inform ongoing improvement efforts.     

Temperature-Adjusted Respiratory Rate for the Prediction of Childhood Pneumonia

ObjectivesAs both fever and pneumonia can be associated with tachypnea, we investigated the relationship between body temperature and respiratory rate (RR) in young children and whether temperature-adjusted RR enhances the prediction of pneumonia.MethodsIn this retrospective cross-sectional analysis of 91,429 children < 5 years of age presenting to an urban pediatric emergency department, the relationship between triage RR and temperature was analyzed using regression analysis. We assessed the predictive value of temperature-adjusted RR for the diagnosis of pneumonia; diagnostic performance was evaluated for continuous RR as well as World Health Organization (WHO) age-based RR thresholds.ResultsThe mean RR increased 2.6 breaths/minute for each 1°C increase in temperature. Interpatient variability was comparatively large; at any temperature, the interquartile range (75th percentile minus 25th percentile) varied from 4 to 16 breaths/minute. For predicting pneumonia, temperature- and age-adjusted RR was superior to age-adjusted RR: area under the curve (AUC) = 0.76 (95% confidence interval [CI], 0.75–0.78) versus AUC = 0.73 (95% CI, 0.72–0.75), respectively. Using WHO RR criteria, temperature-adjusted RR improved diagnostic discrimination, as the AUC increased from 0.58 (95% CI, 0.57–0.59) to 0.72 (95% CI, 0.70–0.73).ConclusionsThe effects of temperature on respiratory rate are modest, with a mean increase of 2.6 breaths/minute for each 1°C rise in temperature. Despite considerable interpatient variability in respiratory rates by temperature, temperature adjustment improves the diagnostic value of respiratory rate for pneumonia.