October 27, 2007

NRP Fosters Collaborative Learning Among Pediatricians
The Future is Now at Technology Display
A Message From the AAP President
Pediatric Practice May be Outmoded, Expert Says

NRP Fosters Collaborative Learning Among Pediatricians

With 20 years of providing advanced teaching and learning aids in neonatal resuscitation, planners of AAP’s Neonatal Resuscitation Program (NRP) took stock Friday when they celebrated the program’s rich history and set a course for the future.

The daylong course examined the program’s great strides, where it is today and what lies ahead. Particular topics highlighted international initiatives, resuscitation with 100-percent oxygen versus room air in premature lambs and a randomized controlled trial of end-tidal CO2-guided resuscitation in an asphyxiated neonatal model. In concurrent sessions, speakers provided insights on the technology and methodology of simulation training.

A related session, “Using Medical Simulators to Improve the Management of Ill Patients,” will be presented twice on Tuesday. Session W428 will be presented from 10:00 am to 12:00 pm in Moscone Center Room 121 and session W469 will be presented from 4:00 to 6:00 pm in the same room.

A forerunner in neonatal simulation, Louis P. Halamek, MD, FAAP, program chair, has witnessed NRP’s successes since its inception in 1987. He developed and directs a center dedicated to the simulation of neonatal, pediatric and obstetric patients, the Center for Advanced Pediatric and Perinatal Education (CAPE) at Packard Children’s Hospital at Stanford, Palo Alto, Calif. “NRP has allowed us to train more than 2 million providers in the US, and we now have more than 26,000 instructors. Most importantly, NRP has provided a tremendous service to babies and their families in the US and around the world, as well as to the health care professionals whose responsibility it is to care for those babies,” said Dr Halamek, co-chair of the NRP Steering Committee.

Not a group to be “content with the status quo,” he added, the NRP Steering Committee continues to evolve, striving for newborn resuscitation based on the best evidence-based science available. With that in mind, NRP has incorporated an even higher degree of simulation-based training.

“We are moving toward a training methodology that focuses on instructors as facilitators versus instructors as teachers. We hope that NRP will become even more focused on the trainee rather than the instructor,” said Dr Halamek, associate professor of pediatrics in the Division of Neonatal and Developmental Medicine at Stanford.

Such a model involves a learning environment where trainees assume responsibility for the learning process through a series of highly realistic scenarios.

“When the trainees come into a training situation, they will be asked to demonstrate their cognitive, technical and behavioral skills as evidence that they possess the appropriate content knowledge, hands-on skills and ability to perform while working to resuscitate a newborn under realistic time pressure. We hope to get a much better assessment of their overall skill level by observing them perform in this kind of environment.”

According to Dr Halamek, the focus of simulation-based training is on the methodology, not the technology. In his workshop on how to write, run, tape and debrief scenarios, one group of participants created a birth scenario while a second group was sent outside the room. The second group was placed into the scenario created by the first group, with their actions recorded with a video camera. After the scenario was acted out, the group’s actions were evaluated in a debriefing.

While Dr Halamek concentrated on the methodology of NRP, Kimberly Yaeger, RN, MEd, shared the intricacies of a new, high-tech patient simulator. In 10 workstations, Yaeger ran participants through a hands-on simulation, which allowed for collaborative responses to her continually changing stream of scenarios.

“This methodology goes beyond simply engaging learners’ minds and actively engaging their bodies. The concept is to work hands-on as a team — just as they would in a real environment. We believe that this improves training,” said Yaeger, director of training and research at CAPE.

Yaeger provided interventions — some incorrect and some incorrect — so that each group could determine how the manikin should respond.

“I wanted them to begin thinking about how they could do this on fly,” she said. “When you have a student who does unpredictable things, how do you interpret their interventions in terms of what the manikin will display and the state of the manikin? That’s a crucial piece.

“This is about teaching, education, and a new methodology. Instructors need to become comfortable with the flexibility that simulation allows. This is very much hands-on, experiential learning where we need to meet the learner at their baseline, let them make mistakes, and learn from them.”

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The Future is Now at Technology Display

The latest developments in technology for pediatricians is on display in the exhibit hall at the Pediatric Office of the Future, but the display is really misnamed because all of the technology is available today.

None of the technology is dated, but medical practices are increasingly incorporating technology that makes you say “Wow … that’s amazing.” And much of it can be seen at the Pediatric Office of the Future (POF) booth, no. 1505.

The display, though, does not just focus on the wow factor. It paints a realistic portrait of how technology can improve the workflow of the typical pediatric practice using electronic medical records (EMR) while improving the treatment of patients. The interactive exhibit is sponsored by Microsoft.

Some of the more dynamic features include demonstrations of Telemedicine in a Box tools for remote examinations of patients and a facial biometric scan that improves the security of electronic records by scanning thousands of points of a user’s face, according to Alice Loveys, MD, FAAP, a member of the AAP Council on Clinical Information Technology (COCIT). With the scan, if the user walks away from the computer and out of the room, he is automatically logged out from the computer.

Lewis C. Wasserman, MD, FAAP, a member of COCIT, said, “Pediatricians have a great thirst for knowing how the technology can be used right now. The purpose of Office of the Future is to give them a hands-on sense of what is available.” The POF is set up to show how information can be entered electronically and placed into a workflow that will improve patient care by reducing errors and generating comprehensive reports.

The workflow goes through five areas: The Reception Desk, where attendees can see how their medical history is updated; The Nurses Station, where height, weight and blood pressure is checked and risk factors calculated; The Exam Room, which includes demonstrations of diagnostic tools, how physicians are reminded if patients need shots, how they can order lab work or prescriptions on a PDA and how the biometric scan works; The Doctor’s Area, where physicians can see how to remotely connect to office computer systems, and how to dictate notes to let the computer do the transcription; The Central Area, where whiteboards display information about what is going on in the office and PDAs are used to check references or send emails.

At least three members of the COCIT will be at the booth at all times to meet with attendees and answer questions.

“Most of what we are focusing on is about improving care by reducing errors, making EMR more convenient and providing more information if needed,” Dr Wasserman said.

Faculty members will lead tours that will visit the exhibits of EMR vendors so attendees can compare the features of each vendor’s offerings. Much of this information is also available in an Academy clinical report, “Special Requirements of Electronic Health Record Systems in Pediatrics.”

The tours will be presented:
• Saturday: 12:30 pm, 1:45 pm and 3:00 pm
• Sunday: 11:15 am, 12:30 pm, 1:45 pm, 3:45 pm and 5:45 pm
• Monday: 11:15 am, 12:30 pm and 1:45 pm
Tours are limited to 10 participants, and attendees must make a reservation at the booth’s reception desk.

Live telemedicine demonstrations are scheduled for:
• Saturday: 1:00 pm, 2:15 pm and 3:30 pm
• Sunday: 11:45 am, 1:00 pm, 2:15 pm, 4:15 pm and 5:15 pm
• Monday: 11:45 am, 1:00 pm and 2:15 pm

The demonstrations will feature Telemedicine in a Box, according to Gregg M. Alexander, DO, a member of COCIT, who said, “It’s so high-end, it’s amazing. It’s a suitcase with a monitor and a computer.”

Inside the suitcase is an otocscope, opthalmascope, dermascope and general viewing scope that all fit on one head so a health care professional, such as an EMT, can transmit information to a physician for a diagnosis.

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A Message From the AAP President

Dear Colleagues:

Welcome to San Francisco and to the American Academy of Pediatrics’ 2007 National Conference and Exhibition (NCE)! I’m so glad you’ve joined us in this spectacular city for what promises to be an equally spectacular CME experience.

We’ll be officially opening the conference at 7:55 am this morning with the Presidential Plenary in the San Francisco Marriott’s Yerba Buena Ballroom. In addition to my Presidential Address and the presentation of the AAP Education and National Children’s Art Contest awards, James J. Heckman, Nobel Laureate economist and our keynote speaker, will address the importance of investing in disadvantaged children. Professor Heckman is an extraordinary advocate for children, and I know you’ll want to be there to hear firsthand what he has to say about this topic that’s so important to all of us.

Following the opening plenary, you’ll be able to select from a diverse offering of educational sessions designed to accommodate your CME needs and learning style. You will also want to build in time to explore our technical exhibits — the largest showcase of innovative pediatric products and services anywhere. From cutting-edge pediatric advances to networking opportunities to the always popular special events and tours, the 2007 AAP NCE truly does have something for everyone.

Also, I want to take this opportunity to thank you for allowing me the privilege of serving as AAP President. This past year has been one of remarkable progress in shaping the public debate on the future of children in the United States, and it has been a tremendous honor to represent you and the children we serve. Thank you!

Enjoy the conference,

Jay E. Berkelhamer, MD, FAAP
President
American Academy of Pediatrics

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Pediatric Practice May be Outmoded, Expert Says

Saying that “the death of any child is a tragedy and the death of any child from preventable causes is always unjust,” Paul Wise, MD, MPH, FAAP, urged pediatricians attending Friday’s Pediatrics for the 21st Century Symposium to rethink pediatric practice in light of rapid changes that are taking place in the epidemiology of childhood disease and the impact of those changes on everyday practice.

“Modern pediatrics has been characterized by remarkable expansion in clinical capability,” said Dr Wise, the Richard E. Behrman Professor of Child Health and Society, and director of the Center for Policy Outcomes and Prevention at Stanford University School of Medicine.

“The development of a host of new vaccines, highly effective antibiotics, medications for learning and psychiatric disorders, and advances in intensive care and pediatric surgery have all served to profoundly enhance the capacity to provide pediatric services over the past 50 years,” he began.

However, he expressed some concern about the future of pediatric practice.

“Inherent in this record of remarkable success are the seeds of obsolescence from transforming the threats to child health so dramatically that the traditional practice of pediatrics itself becomes increasingly outmoded,” he said.

Dr Wise pointed to a dramatic reduction in acute childhood diseases, and in particular infectious diseases such as pneumoccocal disease, and a steady rise in chronic conditions as major trends in child health care.

“We’ve seen an evaporation of much of the traditional acute infectious disease in this country. At the same time, we’ve seen a slow but steady rise in the prevalence of serious chronic conditions,” he said. “Kids with genetic and neuro-developmental problems, many of whom would have died 20 or 30 years ago, are now surviving and going on to live happy lives, integrating into school, family, and community life.”

He added that rates of asthma have gone up, as has the prevalence of autism. Another chronic problem, obesity, has become far more prevalent among children in America. As a result, hospitals are taking care of more chronic childhood diseases than acute diseases.

“These days, the likelihood that a well child is going to get seriously ill, wind up hospitalized and go on to die is extremely small, much smaller than it’s ever been,” Dr Wise said. “The name of the game more than ever before is serious chronic illness.”

“We are now increasingly expected in pediatrics to confront what I would call precursor conditions to adult-onset disease. Obesity is really a precursor condition,” he said. “It sets kids up for a lifetime of enhanced risk for a series of adult-onset diseases.”

One impact of these trends on pediatric practice is an increased need for ongoing chronic disease management for children. Another impact is the emergence of new well-child care structures, such as retail-based pediatric clinics that represent a challenge to traditional pediatric theory and practice, Dr Wise said.

Other impacts on practice include the growth of the specialty of hospitalists to address the increased complexity of hospital care to treat chronic diseases and the possibility that pediatricians will be less able to take care of chronically ill children in the hospital.

“Kids can be in an outpatient setting, wind up in an ER, go to the ICU, back to the ward and back into primary care practice within 36 hours. So the distinction between outpatient, inpatient and ED care is becoming increasingly blurred. That will put pressure on pediatric practices and hospitals to be far more nimble in their ability to confront complex problems,” Dr Wise.

“The last is what I think is the most troubling. Pediatric practice is increasingly being forced to treat higher and higher volumes of pediatric patients to maintain incomes at the same time that the epidemiology of childhood disease is suggesting that the real action for serious morbidity and mortality is in treating kids with serious chronic illness,” he said.

Dr Wise noted that some pediatricians are turning away children with serious chronic illnesses because they cannot take care of them. “Something is fundamentally wrong with pediatric practice if that is going to happen,” he added.

Dr Wise urged a rethinking of pediatric training, saying, “Such that the trainees spend more and more time in community settings learning how to structure pediatric practices to provide high-quality clinical care for that group of chronically ill kids who need it most.”

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