Resident Workshop to Improve Inpatient Documentation Using the Progress Note Assessment and Plan Evaluation (PNAPE) Tool

Progress notes communicate providers' assessments of patients' diagnoses, progress, and treatment plans; however, providers perceive that note quality has degraded since the introduction of electronic health records. In this study, we aimed to (1) develop a tool to evaluate progress note assessments and plans with high interrater reliability and (2) assess whether a bundled intervention was associated with improved intern note quality without delaying note file time. An 8-member stakeholder team developed a 19-item progress note assessment and plan evaluation (PNAPE) tool and bundled intervention consisting of a new note template and intern training curriculum. Interrater reliability was evaluated by calculating the intraclass correlation coefficient. Blinded assessors then used PNAPE to evaluate assessment and plan quality in pre- and postintervention notes (fall 2017 and 2018). PNAPE revealed high internal interrater reliability between assessors (intraclass correlation coefficient = 0.86; 95% confidence interval: 0.66-0.95). Total median PNAPE score increased from 13 (interquartile range [IQR]: 12-15) to 15 (IQR: 14-17; P = .008), and median file time decreased from 4:30 pm (IQR: 2:33 pm-6:20 pm) to 1:13 pm (IQR: 12:05 pm-3:59 pm; P < .001) in pre- and postintervention notes. In the postintervention period, a higher proportion of assessments and plans indicated the primary problem requiring ongoing hospitalization and progress of this problem (P = .0016 and P < .001, respectively). The PNAPE tool revealed high reliability between assessors, and the bundled intervention may be associated with improved intern note assessment and plan quality without delaying file time. Future studies are needed to evaluate whether these improvements can be sustained throughout residency and reproduced in future intern cohorts and other inpatient settings.

Abstract: Introduction: A medical residency is the specialization par excellence in medical training and the program is responsible for ensuring that the recently graduated doctor reaches the established level of competence. A well-prepared assessment system with feedback is an effective tool to enhance the performance of future specialists and guarantee their qualification. Objective: To analyze the assessment system for pediatric residents at a university hospital, aiming to promote teaching training in assessment methods. Methodology: educational action research (research-teaching), conducted with teachers and preceptors in the pediatric residency of a university hospital. The stages consisted of: a) the application of a questionnaire on participant profile and assessment methods used to evaluate the medical residents; b) intervention (workshop) on the assessment of clinical skills and feedback; c) immediate assessment after the workshop, by applying another questionnaire based on level 1 of the Kirkpatrick model. Simple statistical analysis was used for the objective data and the content analysis, according to recommendations by Malheiros (2011) and Bardin (2013), for the qualitative part. Result: Ten (48%) of the 21 participants declared not being formally trained in assessment and that they applied the more traditional methods learned from personal experience. Regarding the assessment methods, 81% (17/21) of the participants used more than one, aiming to obtain a more encompassing and reliable assessment. However, none of the teachers/preceptors used a systematized assessment of the clinical skills or provided feedback to the medical residents. After the workshop, with a focus on assessing performance in a simulated ‘Objective Structured Clinical Examination’ (OSCE) environment, all the participants were favorable to apply the OSCE in their teaching-learning practice with residents and undergraduate students, reaching Kirkpatrick level 3. Conclusion: The action research helped identify limitations in the assessment and feedback system of the pediatric resident physician. The methodology used revealed an aggregating effect and contributed to the development of the collaborative and integrative sense in the group. However, it was not enough to positively interfere with the pediatric medical residency assessment in the short term.

BackgroundMedical trainees play a critical role in the prescribing of antimicrobials. Prescriber education is one of the CDC core elements of antimicrobial stewardship programs. Optimal strategies for educating residents about antimicrobials have not been identified; however, the common practice of teaching all classes of available antibiotics over a short period of time (usually a single 1–2 hour lecture or “bolus”) is generally not well received and likely ineffective.MethodsWe developed a novel antibiotic of the month (AOTM) education program (“continuous infusion”) for pediatric residents. It included a monthly 10-minute presentation by an infectious diseases physician or fellow about a single commonly prescribed antibiotic, a handout summarizing important aspects of the antibiotic and a display posted in the resident workroom. An anonymous survey was sent to all pediatric residents before and 6 months after implementation of the AOTM program. The survey consisted of questions on demographics, satisfaction with the program, and antibiotic knowledge. Responses were tabulated and analyzed using Microsoft Excel. Responses were summarized and reported as a proportion of total responses.ResultsBoth pre- and post-implementation surveys were completed by 21 pediatric residents (51% response rate). Prior to the AOTM program, 55% of respondents felt very or somewhat uncomfortable about their current level of knowledge about antimicrobials and antimicrobial prescribing. Six months after initiation of the program, 86% and 76% agreed or strongly agreed that their knowledge of antimicrobials and antimicrobial resistance, respectively, had improved. After introduction of the program, 81% felt more comfortable or much more comfortable with antimicrobial prescribing. Fifty-seven percent had referenced the handout at some point after the teaching session and 100% agreed that the program was worthwhile continuing in the next academic year.ConclusionA continuous infusion of antimicrobial education in the form of an AOTM education program was well received among pediatric residents and increased their knowledge and comfort level with antimicrobial prescribing. Further studies to measure knowledge retention with this strategy are required.DisclosuresAll authors: No reported disclosures.

“The curriculum brings equity to the forefront”: Pediatric residents’ perspectives and experiences in a longitudinal EDI curriculum

Inverse planned intensity modulated radiation therapy (IMRT) has helped many centers implement highly conformal treatment planning with beamlet-based techniques. The many comparisons between IMRT and 3D conformal (3DCRT) plans, however, have been limited because most 3DCRT plans are forward-planned while IMRT plans utilize inverse planning, meaning both optimization and delivery techniques are different. This work avoids that problem by comparing 3D plans generated with a unique inverse planning method for 3DCRT called inverse-optimized 3D (IO-3D) conformal planning. Since IO-3D and the beamlet IMRT to which it is compared use the same optimization techniques, cost functions, and plan evaluation tools, direct comparisons between IMRT and simple, optimized IO-3D plans are possible. Though IO-3D has some similarity to direct aperture optimization (DAO), since it directly optimizes the apertures used, IO-3D is specifically designed for 3DCRT fields (i.e., 1-2 apertures per beam) rather than starting with IMRT-like modulation and then optimizing aperture shapes. The two algorithms are very different in design, implementation, and use. The goals of this work include using IO-3D to evaluate how close simple but optimized IO-3D plans come to nonconstrained beamlet IMRT, showing that optimization, rather than modulation, may be the most important aspect of IMRT (for some sites). The IO-3D dose calculation and optimization functionality is integrated in the in-house 3D planning/optimization system. New features include random point dose calculation distributions, costlet and cost function capabilities, fast dose volume histogram (DVH) and plan evaluation tools, optimization search strategies designed for IO-3D, and an improved, reimplemented edge/octree calculation algorithm. The IO-3D optimization, in distinction to DAO, is designed to optimize 3D conformal plans (one to two segments per beam) and optimizes MLC segment shapes and weights with various user-controllable search strategies which optimize plans without beamlet or pencil beam approximations. IO-3D allows comparisons of beamlet, multisegment, and conformal plans optimized using the same cost functions, dose points, and plan evaluation metrics, so quantitative comparisons are straightforward. Here, comparisons of IO-3D and beamlet IMRT techniques are presented for breast, brain, liver, and lung plans. IO-3D achieves high quality results comparable to beamlet IMRT, for many situations. Though the IO-3D plans have many fewer degrees of freedom for the optimization, this work finds that IO-3D plans with only one to two segments per beam are dosimetrically equivalent (or nearly so) to the beamlet IMRT plans, for several sites. IO-3D also reduces plan complexity significantly. Here, monitor units per fraction (MU/Fx) for IO-3D plans were 22%-68% less than that for the 1 cm × 1 cm beamlet IMRT plans and 72%-84% than the 0.5 cm × 0.5 cm beamlet IMRT plans. The unique IO-3D algorithm illustrates that inverse planning can achieve high quality 3D conformal plans equivalent (or nearly so) to unconstrained beamlet IMRT plans, for many sites. IO-3D thus provides the potential to optimize flat or few-segment 3DCRT plans, creating less complex optimized plans which are efficient and simple to deliver. The less complex IO-3D plans have operational advantages for scenarios including adaptive replanning, cases with interfraction and intrafraction motion, and pediatric patients.

Patient safety is recognized as an important part of pediatric resident education. There is a lack of published safety curricula targeting pediatric residents. A local needs assessment showed that while residents felt safety was an important part of their current and future jobs, they did not feel prepared to apply safety principles to their future careers or participate in a root cause analysis (RCA). This curriculum was delivered to senior-level pediatric and multiple-board residents during five monthly, hour-long, multidisciplinary sessions. Sessions covered systems-based thinking, terminology, the second victim phenomenon, RCA, and medication errors, while providing feedback on recent event reports filed by residents. Resident knowledge, attitudes, and reporting behavior were evaluated prior to and following the curriculum. Attendees showed statistically significant improved safety attitudes and preparedness to apply safety to their future endeavors; conversely, there were no significant changes in nonattendees. There were no significant changes in knowledge scores or event reporting. Answers to qualitative questions identified learning about the reporting process, RCAs, and follow-up on filed event reports as valuable parts of the curriculum. Residents desired more time to debrief about safety events. The curriculum succeeded in engaging residents in patient safety and making them feel prepared for future practice. Residents showed a dissonance between their intentions to report and their actual reporting behaviors, the reasons for which require further exploration. Residents desired a forum to deal with the emotions involved in errors. This curriculum is easily transferable to other institutions with minor modifications.

A 2011 study evaluating oral health training in pediatric medical residency programs highlighted opportunities to improve residents' oral health competence. The aim of this 2017 follow-up study was to assess progress since 2011 in promoting development of pediatric residents' oral health competence. A survey was sent to all 281 pediatric and med-peds medical residency program directors to assess the structure and determinants of oral health training in their programs. A total of 110 program directors responded to the 2017 survey (response rate 40%). Just over half (54%) of the respondents reported that their residents received one to two hours of oral health education during residency, while 38% received ≥3 hours (compared to 47% and 48%, respectively, in 2011). There was improvement in the proportion of respondents reporting that their residents integrated fluoride varnish application training in 2017 vs. 2011 (83% vs. 43%; p<0.001). Departmental support for integrating oral health and having an oral health elective were significantly associated with satisfaction with residents' oral health competence. These findings suggest that pediatric and med-peds medical residency programs have improved their residents' oral health awareness and training through integration of at least one hour of oral health education and fluoride varnish training. However, given deficiencies in program structure and uneven perceptions of residents' oral health competence found in this study, opportunities remain to improve pediatric residency programs' oral health curricula.

A pediatrician’s approach to newborn screening (NBS) impacts patient care. Some physicians have reported not being well prepared to inform families about a positive NBS and recommend further follow-up. The knowledge and approach of categorical pediatric residents (RES) in the United States regarding NBS is not known. They were anonymously surveyed via listserv maintained by American Academy of Pediatrics. A total of 655 responses were analyzed. The mean composite knowledge score (CKS) was 17.7 (SD 1.8), out of maximum 21. Training level (p = 0.001) and completing NICU rotation (p < 0.001) predicted higher CKS. Most RES agreed that NBS is useful and pediatricians play an important role in the NBS process, however, only 62% were comfortable with counseling. Higher level RES were more likely to follow NBS results in clinic (p = 0.0027) and know the contact agency for results (p < 0.001). Most RES wanted more NBS training during residency and were not aware of clinical algorithms like ACTion sheets developed by American College of Medical Genetics. We concluded that although RES have sufficient knowledge about NBS, there is a need for earlier RES education on available tools for NBS to enhance their comfort level and improve practices such as educating parents about the NBS process.

Background Timely and periodic pubertal assessment in children is vital to identify puberty related disorders. Pediatricians need to have working knowledge of puberty time and tempo. Pediatric residency is an important platform to acquire physical examination skills including pubertal assessment. Objective An educational intervention for teaching pubertal assessment was piloted on pediatric residents at our institution. Methods The intervention comprised of interactive lecture series, ID badge size Tanner stage cards and Tanner posters placed in residents' continuity clinics. Pre-intervention, post-intervention and 3 months post-intervention surveys for participating trainees were administered to determine the effectiveness of the intervention. Attitudes, practices, knowledge scores, and barriers to Tanner staging conduct were analyzed. Results Forty-three residents participated in the intervention. Knowledge scores of PGY1 (5.95 ± 1.6 vs. 7.47 ± 1.4, p < 0.01) improved right after the intervention, as did self-reported clinical practices of all trainees 3 months post- intervention with regards to conducting external genital examination and performing pubertal assessment. Confidence levels of pediatric trainees in conducting pubertal assessment and comfort levels in assessing the need for endocrine referral based on abnormal Tanner staging improved after the intervention, although the effect was not statistically significant. Conclusion Our intervention is a worthwhile technique for teaching pubertal assessment to residents as it is simple to conduct, easily reproducible, provides baseline knowledge needed for recognition of normal pubertal development and puberty related conditions, and instills confidence in residents.

Application of a Novel Dose-Uncertainty Model for Dose-Uncertainty Analysis in Prostate Intensity-Modulated Radiotherapy

INTRODUCTION: Simulation is a powerful learning tool for low frequency events. In 2015, 3.1% of all deliveries were operative vaginal deliveries and only 0.56% were forceps assisted vaginal deliveries (FAVD). The aim of this study is to create a simulation-based curriculum on FAVD and evaluate resident knowledge, confidence, and performance before and after training. METHODS: An IRB-approved prospective cohort study was conducted. Obstetrics and gynecology residents participated in three hours of a three-part simulation training including a video, didactic teaching, and hands-on simulation practice during the 2016-2017 academic year. A 26 item pre- and post-survey and skills assessments was conducted to assess confidence, knowledge, and ability to perform a forceps delivery. Our primary outcome was improvement in resident confidence and skill. RESULTS: Twenty residents consented to participate and 14 surveys were completed (70%). There was a 28.5% increase in self-perceived confidence before and after training for all residents (P&lt;.001). Significant differences in perceived confidence between resident classes were seen pre-simulation (P&lt;.001). Junior residents demonstrated an increase in perceived confidence (P&lt;.001), while senior residents did not (P=.13). There was an overall improvement in the percentage of residents who performed the required skills for an accurate forceps delivery post-simulation (P=.001). CONCLUSION: Our developed forceps simulation curriculum improves resident perceived confidence and skill. Additional simulation training will involve consenting training sessions. Future analysis will look at the number of forceps deliveries at our institution since the initiation of the simulation-based training curriculum.

91. ASSESSING PEDIATRIC RESIDENT READINESS TO SCREEN MOTHERS OF YOUNG CHILDREN FOR FAMILY PLANNING NEEDS

Respiratory syncytial virus (RSV) remains a significant global health challenge, particularly for young children and the elderly. This study examines Croatian pediatricians’ and pediatric residents’ knowledge, attitudes, and practices regarding RSV infection and its prevention. A cross-sectional survey was conducted among members of the Croatian Pediatric Association from June to August 2023. The survey included demographic data, knowledge about RSV, risk perception across age groups, and attitudes toward RSV vaccines and monoclonal antibodies (mAbs). Logistic regression analyses were conducted to identify factors influencing knowledge, attitudes, and practice outcomes. A total of 196 participants fulfilled the survey. General knowledge scores were comparable between pediatricians and residents. Pediatricians demonstrated higher risk perception for RSV in adults (OR = 4.89, 95% CI 1.91–12.54, p = 0.001). Attitudes toward RSV vaccines and mAbs were largely favorable, with prior experience in mAb use emerging as a key predictor of positive attitudes (OR = 2.10, 95% CI 1.07–4.12, p = 0.032). Regional differences were notable, with participants from Adriatic Croatia exhibiting more favorable attitudes toward mAb use than those in Pannonian Croatia (OR = 3.82, 95% CI 1.66–8.79, p = 0.002). Gender also influenced attitudes, with male physicians more likely to recognize mAb efficacy in preventing RSV infections (OR = 3.07, 95% CI 1.44–6.54, p = 0.004). The findings highlight favorable attitudes toward RSV prevention among Croatian pediatricians and residents, with variations influenced by mAb experience, regional factors, and gender. These insights emphasize the importance of targeted educational efforts to enhance the adoption of RSV preventive strategies.

Background Inborn errors of immunity (IEIs), formerly primary immune deficiencies (PIDs), are a group of rare yet profoundly impactful conditions that compromise immune function, leading to recurrent infections, autoimmunity, and malignancies. While early diagnosis is critical to improving outcomes, awareness of the Jeffrey Modell Foundation’s “10 Warning Signs of PID” remains insufficient among healthcare professionals. This study explores the knowledge and preparedness of pediatric residents at SUNY Downstate Health Sciences University to identify and manage IEIs. Objective To evaluate the baseline knowledge of IEIs among pediatric residents, highlight areas of strength and gaps, and assess the impact of training exposure on diagnostic confidence and accuracy. Methods An anonymous questionnaire assessing recognition of IEI warning signs, diagnostic protocols, and management strategies was distributed among pediatric residents. Out of the total 81 residents in the program, 43 completed the survey. Responses were analyzed by postgraduate year (PGY) and prior rotations in Allergy and Immunology (AI). Results Progressive knowledge growth: The overall percentage of correct answers improved with training level: PGY-1 residents answered 67.5% of questions correctly, PGY-2 residents 71%, and PGY-3 residents 79%. Specialized training matters: Residents with prior AI rotations had an accuracy rate of 79.5% compared with 69% among those without, emphasizing the value of targeted exposure. Key strengths: Most participants were able to recognize patterns of severe IEI presentations, such as persistent oral thrush (93%) and recurrent sepsis (97%). Critical gaps: Participants rate of recognizing cases with subtle signs such as frequent ear infections (27%) and recurrent sinusitis (54%) was lower, potentially delaying diagnoses. Misconceptions in management Misunderstandings about vaccine safety (70%) and universal immunoglobulin therapy (18%) further highlight the need for comprehensive education. Conclusions While residents show proficiency in identifying severe IEI manifestations, gaps remain in recognizing subtle presentations and understanding management protocols. These findings emphasize the need for targeted educational interventions, including case-based learning and diagnostic frameworks, to improve early detection, appropriate management, and patient outcomes.

As point-of-care ultrasound (POCUS) evolves into a standard tool for the care of children, pediatric residency programs need to develop POCUS training programs. Few POCUS training resources exist for pediatric residents, and little is known about POCUS training in pediatric residencies. We aim to describe pediatric residency leadership perspectives regarding the value of POCUS and to elucidate the current state of POCUS training in pediatric residency programs. A group of pediatric educators and POCUS experts developed a novel survey followed by cognitive interviews to establish response-process validity. The survey was administered electronically to pediatric residency associate program directors between December 2019 and April 2020. Program characteristics, including region, setting, and size, were used to perform poststratification for analyses. We performed comparative analyses using program and respondent characteristics. We achieved a 30% (58 of 196) survey response rate. Although only a minority of respondents (26%) used POCUS in clinical practice, a majority (56%) indicated that all pediatric residents should be trained in POCUS. A majority of respondents also considered 8 of 10 POCUS applications important for pediatric residents. Only 37% of programs reported any POCUS training for residents, primarily informal bedside education. Most respondents (94%) cited a lack of qualified instructors as a barrier to POCUS training. Most pediatric residency programs do not provide residents with POCUS training despite its perceived value and importance. Numerous POCUS applications are considered important for pediatric residents to learn. Future curricular and faculty development efforts should address the lack of qualified POCUS instructors.