BACKGROUND: Interest in global health (GH) among pediatric residents continues to grow. GH opportunities in pediatric fellowship programs in the United States are poorly described. We aimed to evaluate GH offerings among accredited general and subspecialty pediatric fellowship programs and identify implementation barriers.METHODS: This was a cross-sectional study by pediatric GH educators from the Association of Pediatric Program Directors Global Health Learning Community and the American Board of Pediatrics Global Health Task Force. Fellowship program directors and GH educators at accredited US pediatric fellowship programs were surveyed. Data were analyzed by using descriptive and comparative statistics.RESULTS: Data were obtained from 473 of 819 (57.8%) fellowship programs, representing 111 institutions. Nearly half (47.4%) offered GH opportunities as GH electives only (44.2%) or GH tracks and/or fellowships (3.2%) (GHT/Fs). Pretravel preparation and supervision were variable. Programs offering GH opportunities, compared to those without, were more likely to report that GH training improves fellow education (81.9% vs 38.3%; P , .001) and recruitment (76.8% vs 35.9%; P , .001). Since 2005, 10 programs with GHT/Fs have graduated 46 fellows, most of whom are working in GH. Of those with GHT/Fs, 71% believe national accreditation of GH fellowships would define minimum programmatic standards; 64% believe it would improve recruitment and legitimize GH as a subspecialty.CONCLUSIONS: GH experiences are prevalent in accredited US pediatric fellowship programs, and programs offering GH perceive that these opportunities improve fellow education and recruitment. Responses suggest that standards for GH opportunities during fellowship would be useful, particularly regarding pretravel preparation and mentorship for trainees.WHAT'S KNOWN ON THIS SUBJECT: Over the past 2 decades, there has been robust growth in global health (GH) opportunities during pediatric residency training. The extent to which this trend has also occurred in accredited pediatric fellowship training programs is not yet well understood nor described.WHAT THIS STUDY ADDS: This is the most comprehensive description to date of GH offerings in pediatric fellowship programs. Of 473 pediatric fellowship programs accredited by the Accreditation Council for Graduate Medical Education and Academic Pediatric Association, nearly half offer GH training during fellowship in the setting of increased fellow interest.
Background: Chloral hydrate use in children has fallen out of favor as a primary sedation agent due to unpredictable sedation properties, prolonged recovery times, and the potential for severe adverse effects. Utilization declined across the nation after commercial production of the oral solution was discontinued in 2012. Despite the growing use of alternative sedatives, many pharmacies continue to compound chloral hydrate solution from raw ingredients. This compounding process is associated with more frequent sedation failures and requires the ingestion of larger suspension volumes. Fatalities associated with chloral hydrate use continue to occur.Objective: To evaluate the use of chloral hydrate as the primary agent for procedural sedation.Methods: We conducted a cross-sectional study of patients that received chloral hydrate for procedural sedation from October 2010 to December 2016 at two freestanding children's hospitals. Demographic data, procedure characteristics, location, provider specialty, and related complications were collected. The hospital pharmacy database of chloral hydrate utilization was matched to procedure billing data.Results: There were 5874 chloral hydrate sedations during the study period (Figure 1). The highest rates of use occurred in 2014, when chloral hydrate was used for 1420 procedures. Cardiac procedures had the highest use (4250, 72.4%), most of which were echocardiography. Audiology clinic (681, 11.6%), neonatal care units (255, 4.3%) and pulmonary lab (168, 2.9%) accounted for the most common locations. Procedural sedation policy change in the classification of chloral hydrate from a minimal to moderate sedation agent occurred during the study period.Conclusions: Despite significant declines in the use of chloral hydrate for procedural sedation across the country, local use of chloral hydrate remains high. The high rate of decline after 2014 was attributed to transition of high-use clinical sites to alternatives such as intranasal dexmedetomidine and the reclassification of chloral hydrate as a moderate sedation agent.
BACKGROUND: Delivering difficult news to patients and families is an essential but challenging communication skill. Pediatric trainees report limited training, competence, or comfort in this skill, and when tested, perform poorly.OBJECTIVE: To assess the effectiveness of a modified American Academy of Pediatrics (AAP) Resiliency Curriculum (Part B) to improve skills and self-efficacy of pediatric trainees in delivering bad news.METHODS: A quantitative research design was used to study the impact of the modified curriculum, offered at one institution with 78 residents and 48 fellows. The course consisted of interactive didactics with faculty role modeling. Fellows also participated in role playing and in novel simulations and self-reflection activities. Self-efficacy surveys were used to assess knowledge, confidence, and comfort with delivering difficult news. Objective performance was assessed during simulations with standardized patients using a bad news delivery framework checklist ("SPIKES") and the mini Master Interview Rating Scale (mMIRS). Self-efficacy was analyzed using hierarchical mixed effects linear modeling and simulation performance was evaluated using Wilcoxon signed-rank tests.RESULTS: Pediatric trainees (n=67, 29 residents, 38 fellows) improved their scores on each of the 13 self-efficacy items (p=0.007 to <0.001), as well as in the skill categories of displaying empathy (3.8 to 4.0, p=0.016), managing emotions (3 to 3.5, p<0.001), and conversation skills (3.4 to 3.8, p<0.001). For fellows (n=19), objective skill in delivering bad news improved; the median score on the "SPIKES" checklist improved from 78% to 90% completion (p<0.001; Fig. 1) and mMIRS from 4.2 to 4.6 (p<0.001; Fig. 1).CONCLUSION: Pediatric residents had significant improvement in self-efficacy and fellows in both self-efficacy and observable skill in delivering difficult news after participation in an AAP modified Resiliency course, with the use of simulation for fellows. These learning activities could serve as a model for other institutions to address gaps in training for difficult news delivery.
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