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Biomedical subjects

Carol Carraccio

Publications and source records attributed to Carol Carraccio.

11 recordsLinked to original sources
PubMed2005

The paradox of the nested pediatric emergency department.

OBJECTIVES: Nested pediatric emergency departments (nPEDs) are defined as dedicated treatment areas operating during peak pediatric hours within general emergency departments (EDs). This study examined three staffing models for nPEDs and their impact on pediatric encounters. METHODS: Three models were applied to children younger than 37 months presenting to the ED of an urban community hospital over one year. In the nPED, physicians cared only for nPED patients. In the restricted (rPED) model, physicians cared only for pediatric patients presenting outside nPED hours. In the total ED (tED) model, physicians treated all pediatric patients regardless of time. Full-time equivalent pediatric encounters, potential neonatal lumbar punctures, and illness severity were determined for all models. Statistical analysis was performed by analysis of variance and chi-square test. RESULTS: For the 3,389 eligible ED visits, the number of annual patient encounters per full-time equivalent was 1,236 for the nPED, 805 for the tED, and 336 for the rPED (p < 0.001). Physicians practicing only in the nPED treated 3.7 times the number of children younger than 37 months than did physicians in the rPED model and 1.5 times the number than did physicians in the tED model. Spending 10% of total practice hours in the nPED would increase pediatric encounters 26% for rPED physicians, while practicing 25% of time in the nPED would increase pediatric encounters 67% and equate to 45% of nPED encounters. An nPED physician could expect to perform 17 neonatal lumbar punctures, compared with ten for a tED physician and four for an rPED physician (p < 0.001). There was no significant difference in severity of illness for the three models. CONCLUSIONS: Physicians practicing in facilities that include an nPED must dedicate some portion of their practice to the nPED to maintain equivalent pediatric encounters.

Emergency Service, Hospital↗
PubMed2005

Sedation for pediatric CT scanning: is radiology becoming a drug-free zone?

INTRODUCTION: Cooperation for a diagnostic study is a frequent indication for pediatric procedural sedation. This study examines the continued need for sedation in the era of fast helical computerized tomography (CT) scanners. METHODS: Medical records of children younger than 72 months undergoing CT scans were systematically reviewed to identify the use of procedural sedation to complete their diagnostic studies. Statistical analysis was through ANOVA and regression modeling. RESULTS: A total of 104 patients underwent 122 CT studies. Requests originated from 3 sources: 59.8% ED (n = 73), 38.5% Neonatal Intensive Care Unit (n = 47), and 1.6% Pediatric Ward (n = 2). Studies performed included: 79.5% head/facial (n = 97), 15.6% abdomen/pelvis (n = 19), and 5.9% other (n = 6). The mean ages of all study patients was 23.4 (+/-2.4) months with a median of 14 months. Only 8.6% patients (n = 9) received any sedation. The mean age of sedated patients was 18.8 (+/-2.7) months with a median of 21 months. With the exception of one 4-month-old, all other sedated children were between 12 and 30 months. Sedative use occurred in 36.4% of patients in this age group, which was significantly greater than the remainder of the study group (OR 56.5, 95% CI 9-1091, P < 0.001) Sedative agents used included: diphenhydramine (4), pentobarbital (1), propofol (1), ketamine (1), midazolam (1), diphenhydramine/pentobarbital (1). CONCLUSIONS: Procedural sedation is infrequently used in infants and young children undergoing helical CT studies.

Child, Preschool↗
PubMed2005

Family members do not disrupt care when present during invasive procedures.

OBJECTIVE: To determine whether family members (FMs) remaining with pediatric patients during invasive procedures interfere with delivery of care. METHODS: The authors conducted a prospective observational study of consecutive patients <18 years of age undergoing invasive procedures in the emergency department (ED) over a one-year period. Behaviors of FMs remaining during invasive procedures were recorded as any of six categorical descriptions (stood quietly, asked questions, soothed patient, helped restrain patient, interfered with care, other). All observations were made through direct observation by two study attending physicians on FMs of patients under their direct care, or during their supervision of resident care. RESULTS: Fifty-four FMs were observed during the ED care of 37 patients [mean age 1.5 years (+/-0.25), median age 0.4 years]. Invasive procedures included: lumbar puncture (n = 28), endotracheal intubation (n = 5), fracture reduction (n = 2), shoulder reduction (n = 1), and tube thoracostomy (n = 1). Seventy-one FM activities were recorded: stood bedside, 22 (31%); soothed child, 21 (30%); asked questions, 11 (16%); helped restrain, 5 (7%); interfered with care, 2 (3%); and other, 10 (15%). The two "interfered with care" events were minor and did not significantly alter patient management. One mother experienced a near-syncope event standing during a lumbar puncture of her child and was seated without further incident. One mother stopped reduction of a shoulder dislocation because she felt the pain control was inadequate even though the child was deeply sedated with propofol. Expected patient behavior was described to the mother and reduction was completed. CONCLUSIONS: In this study, family members remaining with children during invasive procedures were not a risk for disruption of patient care.

Adult↗
PubMed2004

Evaluating competence using a portfolio: a literature review and web-based application to the ACGME competencies.

BACKGROUND: The Accreditation Council for Graduate Medical Education is shifting its focus from a structure and process system of graduate medical education to one that is outcomes based, requiring all residents in training to achieve competence in six broad domains and presenting educators with the challenge of evaluation. SUMMARY: We searched the literature and reviewed all articles relating to portfolio assessment in medicine. In addition, we reviewed articles that addressed standard tools currently in use for resident performance assessment. The use of a portfolio allows one to incorporate a variety of assessment tools needed to evaluate the diverse domains of competence and also fosters reflective learning, which is key to professional development. From lessons learned through this review, we developed a Web-based evaluation portfolio for residency training that we describe here in the hope of facilitating this process for others. CONCLUSIONS: Web-based portfolio assessment provides an ideal venue for the evaluation of competence and has the ability to provide educators with a research infrastructure to practice evidence-based education.

Benchmarking↗
PubMed2004

Educating the pediatrician of the 21st century: defining and implementing a competency-based system.

PURPOSE: The final product of the Accreditation Council for Graduate Medical Education (ACGME) Outcomes Project is to improve health care through ensuring the competence of physicians during their training and beyond. Its success depends on a paradigm shift to a competency-based model of medical education. This article presents an overview of the model and describes the first stages of this multistep transition in a university setting. Our hope is to raise awareness of the impact on the pediatric community at large and provide a foundation on which other educators can continue to build. METHODS: The ACGME established 6 domains of competence as the first step in the paradigm shift. To begin work on the second step of establishing benchmarks for evaluation of competence and thresholds at which they should be achieved, the educational leadership from the primary care departments formed a work group with the support of a Health Resources and Services Administration grant. RESULTS: Review of the literature led us to embark on a stepwise process for initiating a competency-based system of medical education. We established the benchmarks by a process of individual effort followed by group consensus. These benchmarks, in the aggregate, permit an evaluator to determine whether a given competency has been achieved. The next phases of step 2 required setting thresholds for the demonstration of competence and finally establishing consensus regarding the threshold for competence at each level of training for each specific benchmark. To accomplish the latter, we surveyed the program directors of the 202 accredited pediatric training programs that are members of the Association of Pediatric Program Directors. Eighty-one members (40%) completed our survey. Although some controversy existed for thresholds during the postgraduate-year-1 level, majority consensus was reached for nearly all benchmarks at the upper levels of training. Impact of the shift to competencies for medical students and practicing physicians is also reviewed. CONCLUSION: Having defined the benchmarks and thresholds for the 6 ACGME domains of competence, we are well positioned to move to step 3: developing the necessary tools to evaluate competence. The move to competency-based education impacts the entire pediatric community. Lessons learned from our experience may be generalized and thus be of value to the community at large.

Benchmarking↗
PubMed2004

The state of pediatrics residency training: a period of transformation of graduate medical education.

Graduate medical education is in a period of transformation. This article reviews the state of pediatrics residency training by summarizing the changing demographics within training programs, examining the new educational paradigm with an emphasis on competency-based education and continuous professional development, and describing forces influencing the workplace and the focus on work-life balance. Strategies are suggested for leaders in graduate medical education to meet the challenges experienced during this period of transformation.

Career Choice↗
PubMed2003

Procedural sedation for children with special health care needs.

Children with special health care needs represent a growing percentage of pediatric patients treated in all emergency departments. Substantial literature exists concerning the medical treatment of these patients, but there is little written describing the management of procedural sedation or analgesia in this population. This article examines the unique anatomic and physiologic implications of procedural sedation or analgesia management in children with special health care needs.

Analgesia↗
PubMed2003

Guiding medical students through the match: perspectives from recent graduates.

OBJECTIVE: Little has been written about the counseling of medical students as they go through the process of selecting and ranking residency programs for the National Resident Matching Program. The Association of Pediatric Program Directors (APPD) and the Council on Medical Student Education in Pediatrics jointly sought to evaluate the current status of advice and counseling for students going through the Match, and to elicit suggestions for improvement. METHODS: Surveys evaluating satisfaction with aspects of and advice received regarding the Match were sent to each of the 199 Accreditation Council for Graduate Medical Education accredited member programs of the APPD with a request that they be distributed to all first-year pediatric residents during the orientation process for the 2001-2002 academic year. Surveys were both voluntary and anonymous. Results were compiled by the administration of the APPD. RESULTS: We received responses from 42% of all US pediatric categorical or combined residents entering pediatric residency in July of 2001. Respondents included at least 1 representative from every US medical school. Ninety-seven percent of respondents were either very satisfied (88%) or somewhat satisfied (9%) with where they matched, whereas 82% were either very (42%) or somewhat (40%) satisfied with the advice they received regarding the match. The Fellowship and Residency Interactive Database, the faculty advisor, and resident-to-student counseling were the top 3 resources identified by the respondents. Of 12 resources listed in the survey, only the Green Book was rated as unhelpful. Four areas for improvement regarding the advising process were identified: timing, standardization, and quantity of advice and accuracy of online information resources, with specific suggestions given for each. CONCLUSIONS: Overall, recent medical school graduates are quite satisfied with both where they matched in pediatrics and the process that got them there. However, several areas for improvement in the advising/counseling system were identified. Potential approaches to these concerns or resources to develop approaches to them were identified.

Counseling↗
PubMed2002

Shifting paradigms: from Flexner to competencies.

Realizing medical education is on the brink of a major paradigm shift from structure- and process-based to competency-based education and measurement of outcomes, the authors reviewed the existing medical literature to provide practical insight into how to accomplish full implementation and evaluation of this new paradigm. They searched Medline and the Educational Resource Information Clearinghouse from the 1960s until the present, reviewed the titles and abstracts of the 469 articles the search produced, and chose 68 relevant articles for full review. The authors found that in the 1970s and 1980s much attention was given to the need for and the development of professional competencies for many medical disciplines. Little attention, however, was devoted to defining the benchmarks of specific competencies, how to attain them, or the evaluation of competence. Lack of evaluation strategies was likely one of the forces responsible for the three-decade lag between initiation of the movement and wide-spread adoption. Lessons learned from past experiences include the importance of strategic planning and faculty and learner buy-in for defining competencies. In addition, the benchmarks for defining competency and the thresholds for attaining competence must be clearly delineated. The development of appropriate assessment tools to measure competence remains the challenge of this decade, and educators must be responsible for studying the impact of this paradigm shift to determine whether its ultimate effect is the production of more competent physicians.

Clinical Competence↗
PubMedDate not supplied

Training in community pediatrics: a national survey of program directors.

OBJECTIVE: To describe the spectrum of residency training in community-based settings, assess the extent of resident education on community pediatrics topics, and determine whether educational activities vary by program size or availability of primary care tracks. METHODS: Survey of US pediatric residency program directors from May-September 2002. A 10-item self-administered questionnaire assessed the programs' extent of resident involvement in 15 selected community-based settings and inclusion of didactic or practical education regarding 13 community health topics. RESULTS: Of 168 programs surveyed (81% response rate), 40% were small (< or =30 residents), 35% were medium (31-50 residents), 25% were large (>50 residents), and 15% had primary care tracks. Frequently required community-based settings included schools (69%), child protection teams (62%), day care centers (57%), and home visiting (48%). Of 15 community-based settings, 28% required involvement in fewer than 4, 41% required involvement in 4-6, and 31% required involvement in 7 or more. More than two-thirds offered didactic teaching and practical experience on issues related to managed care, cultural competency, and the mental health and social service systems. There were no differences in the number of required community-based settings by program size or presence of primary care tracks. CONCLUSIONS: Most pediatric residency programs require exposure to community-based settings and provide education on various community health topics. Ongoing challenges include continued implementation amid work duty hour limitations, best practice models for practical implementation of community-based experience into residency training, and the impact of such training on future involvement in the community and physician practice.

Community Health Services↗