Are We Doing Enough to Reduce Ionizing Radiation Exposure in Children?: An Analysis of Current Approaches to Pediatric Appendicitis Imaging at a Major Urban Medical Center
OBJECTIVE:The aim of this study was to evaluate current imaging approaches in children with suspected appendicitis (AP) in the pediatric emergency department (ED) of a major urban medical center. METHODS:Children aged 6 to 18 years who presented to a pediatric ED in 2016 with possible AP were identified by a keyword search. Charts were reviewed for the following: age, sex, time of evaluation, imaging study, results of imaging study, disposition, and outcome. RESULTS:We calculated mean values and SD for continuous data. Initially, 503 charts were identified. Of these 503, 292 children were identified as having possible AP. Mean age was 10.7 years (SD, 2.7); 50.6% presented between 5:00 PM and 8:00 AM the next morning. Of the 287 US studies performed, 114 (39.7%) were definitively positive or negative. Of these, 46 (16.0%) were negative for AP and 68 (23.7%) were positive. There were 173 (60.3%) ultrasounds that were equivocal. Computed tomography scans were performed in 41 (13.9%) of the total 292 patients, and 2 (0.7%) of the 292 received magnetic resonance imaging. Patient dispositions were as follows: discharged home, 163 (55.8%); admitted for appendectomy, 69 (23.6%); admitted for observation, 37 (12.7%); and extended observation in ED, 10 (3.4%). There were 83 (28.4%) total surgical and interventional radiology cases and 209 (71.6%) nonsurgical cases. Of the 81 appendectomies, 79 (97.5%) had an abnormal appendix, and 2 (2.5%) had no AP. Of the 79 abnormal appendices, 22 (27.8%) were perforated, 55 (69.6%) were not, and 2 (2.6%) were unclear. CONCLUSIONS:Computed tomography scans were performed in 13.9% of patients with suspected AP. The overall AP rate was 28.4%. We plan to increase the use of magnetic resonance imaging and other modalities to reduce overall computed tomography usage.
Benefits of Brain Magnetic Resonance Imaging Over Computed Tomography in Children Requiring Emergency Evaluation of Ventriculoperitoneal Shunt Malfunction: Reducing Lifetime Attributable Risk of Cancer
OBJECTIVES: The rapid growth of computed tomography (CT) has resulted in increased concerns of ionizing radiation exposure and its subsequent risk of cancer development. We evaluated the impact of a new protocol using rapid sequence magnetic resonance imaging (rsMRI) instead of CT in children presenting with possible ventriculoperitoneal shunt (VPS) malfunction to promote patient safety. METHODS: This is a retrospective case series of pediatric patients who received a neuroimaging study for emergency evaluation of possible VPS malfunction at New York University's Tisch Hospital Emergency Department between January 2010 and July 2011. Radiology Charge Master was queried to identify the patient database. The trend in the use of rsMRI and CT was calculated for 3 patient age groups and compared across 3 chronological intervals. The effective dose of ionizing radiation per CT scan was calculated using the CT dose index and dose-length product for each patient. RESULTS: Total of 365 patients with the mean age of 8.87 years received either rsMRI or CT study during the study period. One hundred forty-four of these patients required the imaging studies because of VPS malfunction. Overall, 62% of all VPS malfunction cases used rsMRI instead of CT. The ratio of the number of patients receiving rsMRI divided by CT studies has progressively increased from 1.4:1 to 2.1:1 over 3 chronologic periods. CONCLUSIONS: Children with VPS are subject to multiple neuroimaging studies throughout their lifetime. Rapid sequence MRI is an effective alternative to CT while providing no ionizing radiation exposure or risk of developing radiation-induced cancer.
A randomized trial of simulation-based deliberate practice for infant lumbar puncture skills
BACKGROUND: : Infant lumbar puncture (LP) is mandated by the Accreditation Council for Graduate Medical Education for all pediatric trainees. Current training usually involves the apprenticeship model of 'see one, do one, teach one' where a trainee's first LP attempt occurs in a high-stakes environment. Simulation training promotes skill development in a safe environment before patient contact. OBJECTIVE: : To demonstrate that deliberate practice simulation-based training after audiovisual training (AV) improves infant LP skills compared with a control group receiving AV training only. DESIGN/METHODS: : This was a randomized trial of simulation-based training + AV versus AV only for pediatric residents. On enrollment, the subjects' infant LP skills were evaluated through their performance on a simulator. A questionnaire and brief quiz were administered to collect information on the subjects' infant LP experience, knowledge, and confidence. All subjects viewed an educational AV presentation. The intervention group went on to participate in a simulation-based deliberate practice session on the infant LP simulator while the control group did not. Our primary outcome was self-reported clinical success on the first infant LP after training. Secondary outcomes were rates of traumatic clinical LPs, infant LP skills (measured via observed structured clinical examinations on the simulator 6 months after training), and change in participants' knowledge and confidence. RESULTS: : Fifty-one residents reported 32 clinical encounters. Sixteen of 17 subjects (94%) in the intervention group who performed a clinical infant LP obtained cerebrospinal fluid compared with 7 of 15 subjects (47%) in the control group (difference = 47%; 95% CI = 16%-70%). There was no difference between groups at 6 months on observed structured clinical examination performance, knowledge, or confidence. CONCLUSIONS: : Participation in a simulation-based deliberate practice intervention can improve infant LP skill
Repetitive pediatric simulation resuscitation training
OBJECTIVE: : The objective of the study was to compare the effectiveness of repetitive pediatric simulation (RPS) training (scenario-debriefing-scenario) to standard pediatric simulation (STN) training (scenario-debriefing). METHODS: : Pediatric and emergency medicine residents prospectively participated in simulated pediatric resuscitation training sessions in an in situ simulation room. Residents anonymously reported their knowledge, skills, and confidence after each session. Four learners and 2 faculty preceptors (1 pediatric emergency medicine attending physician and 1 pediatric emergency medicine fellow) participated in each session. Scenarios were performed on a high-fidelity simulator (SimBaby; Laerdal Medical, Stavanger, Norway), and video debriefing was used for all training sessions. Standard pediatric simulation was used in the initial 6 months of the study, whereas RPS was used in the second 6 months of the study. RESULTS: : One hundred fifteen subjects completed simulation sessions during the study period. The RPS group reported higher overall debriefing quality and were more likely to report that the simulation session was an excellent method of teaching. The RPS group reported greater improvement in knowledge and skills than did the STN group. Similar scores were reported for confidence, overall performance, stress levels, and realism of the simulator in both the STN and RPS groups. CONCLUSIONS: : Feedback is a key feature of effective medical simulation. Repetitive pediatric simulation provides learners with a discrete opportunity to apply the knowledge and skills discussed during debriefing in an immediate second simulation session and thereby complete Kolb's experiential learning cycle. In this study, the RPS debriefing format was associated with higher self-reported knowledge and skills. The RPS group reported more positive attitudes toward simulation than the STN group
The effect of a simulation-based mastery learning intervention on pediatric interns procedural skills performance: a multicenter randomized trial [Meeting Abstract]
Purpose: To demonstrate that mastery learning through hands-on deliberate practice using bench-top task trainers improves intern clinical performance in infant lumbar puncture (ILP) and child intravenous line placement (CIV). Methods: Interns from 10 pediatric training programs were randomized to either (1) ILP or (2) CIV. All subjects completed a data collection instrument evaluating their knowledge, experience and attitudes related to ILP and CIV. Subjects completed an audiovisual training module describing both procedures and demonstrating expert modeling of ILP and CIV (40 minutes). Subjects participated in mastery learning on the bench-top partial task trainer to which they were randomized (1) ILP or (2) CIV. Mastery learning sessions involved deliberate practice on the simulator until the subject achieved a pre definedlevel of skill mastery. All coaches were clinician educators who participated in a 30 minute train-the-trainer session prior to the study. Clinical performance indicators were captured via self-report by interns each time they attempted CIV or ILP during a real patient encounter over the next six months. Results: 210 interns were approached for consent and 201 agreed to participate (107 in ILP group 103 in CIV group). Groups were similar with respect to ILP and CIV knowledge and confidence in the procedure. Infant Lumbar Puncture A total of 182 clinical ILP attempts were reported from 85 interns. Interns in the ILP group were successful for 66% of reported ILP attempts compared to 65% in the CIV group. There was no statistically significant difference for first attempt success rate between groups (56% LP vs 60% IV). Child Intravenous Line placement A total of 251 clinical CIV events were reported from 62 interns. Interns in the CIV group were successful for 65% of reported CIVattempts compared to 66% in the ILP group. There was also no statistically significant difference for first attempt success rate between the groups (66% LP 60% IV). Conclusion: A single hands-on mastery learning session is not sufficient to impact an intern's clinical success. Further research is needed into best educational methods for improving procedural skills prior to patient contact. Future studies should focus on training that is more proximal to clinical events
Evaluation of ventriculoperitoneal shunt emergencies
Reassessment: neuroimaging in the emergency patient presenting with seizure (an evidence-based review): report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology
OBJECTIVE: To reassess the value of neuroimaging of the emergency patient presenting with seizure as a screening procedure for providing information that will change acute management, and to reassess clinical and historical features associated with an abnormal neuroimaging study in these patients. METHODS: A broad-based panel with topic expertise evaluated the available evidence based on a structured literature review using a Medline search from 1966 until November 2004. RESULTS: The 15 articles meeting criteria were Class II or III evidence since interpretation was not masked to the patient's clinical presentation; most were series including 22 to 875 patients. There is evidence that for adults with first seizure, cranial CT will change acute management in 9 to 17% of patients. CT in the emergency department for children presenting with first seizure will change acute management in approximately 3 to 8%. There is no clear difference between rates of abnormal emergent CT for patients with chronic seizures vs first. Children <6 months presenting with seizures have clinically relevant abnormalities on CT scans 50% of the time. Persons with AIDS and first seizure have high rates of abnormalities, and CNS toxoplasmosis is frequently found. Abnormal neurologic examination, predisposing history, or focal seizure onset are probably predictive of an abnormal CT study in this context. CONCLUSIONS: Immediate noncontrast CT is possibly useful for emergency patients presenting with seizure to guide appropriate acute management especially where there is an abnormal neurologic examination, predisposing history, or focal seizure onset.