PEDIATRIC EMERGENCY MEDICINE

 

INTRODUCTION:Pediatric emergency medicine is that branch of medicine concerned with providing highly specialized acute health care to children of all ages and developmental level which includes triage, stabilization, diagnosis, treatment and appropriate follow-up care. The care will be provided in a compassionate fashion which will respect the individual and the family. Throughout this document the word family will include caregivers, legal guardians, and substitute decision makers. The pediatric emergency medicine specialist will provide acute and consultant care in a facility that is part of an emergency medical system for children. This individual will have a commitment to advancement of the field through education at the undergraduate and postgraduate level and through continuing education to physicians and allied health care professionals. The pediatric emergency specialist will be dedicated to advance the science of the field through primary and multidisciplinary research.

The purpose of this document is to provide program directors, surveyors and residents with an interpretation of the general standards of accreditation as they relate to the accreditation of programs in pediatric emergency medicine.

GOALS AND OBJECTIVES: There must be a clearly worded statement outlining the goals of the residency program and the educational objectives of the residents.

General Objectives

Residents must demonstrate the knowledge, skills and attitudes pertinent to pediatric emergency medicine.

The resident in pediatric emergency medicine will respect the rights of the individual and family and acknowledge the importance of age and development, gender, culture, and ethnicity.

Each program will develop rotation specific objectives which will be based on the objectives of training listed below.

Essential Roles and Key Competencies of the Pediatric Emergency Specialist

The objectives for the essential roles and key competencies are life-long learning objectives. During the pediatric emergency medicine residency program, residents will be introduced to these long term learning objectives.

  1. Medical Expert/Clinical Decision-Maker

1.1 General Requirements

The pediatric emergency medicine resident should demonstrate:

    1. diagnostic and therapeutic skills for ethical and effective patient care;
    2. the ability to access and apply relevant information to clinical practice;
    3. effective consultation services with respect to patient care, education and legal opinions.

1.2 Specific Requirements

The pediatric emergency medicine resident should demonstrate:

    1. an understanding of the basic sciences as applicable to pediatric emergency medicine;
    2. knowledge of the clinical features, diagnostic criteria, epidemiology, natural history, pathophysiology, complications and consequences of acute illness and injury;
    3. ability to perform diagnostic and therapeutic procedures as appropriate to the specialty, eg casting, suturing, cardioversion, intubation;
    4. knowledge of age and development related variables in acute care medicine as they apply to neonatal, pediatric, and adolescent patient care;
    5. the ability to perform a rapid relevant assessment and recognize a potentially serious problem;
    6. the ability to formulate a comprehensive management plan for patients;
    7. the ability to consider the medical, psychosocial, and familial considerations of the patients presentation;
    8. the ability to make rapid decisions in the uncontrolled environment of the emergency department;
    9. knowledge of the basic legal and ethical issues encountered in the practice of pediatric emergency medicine.
  1. Communicator

2.1 General Requirements

The pediatric emergency medicine resident should be able to:

    1. establish relationships with patients/families;
    2. listen effectively;
    3. obtain and synthesize relevant history from patients/families/communities;
    4. discuss appropriate information with patients/families and the health care team.

2.2 Specific Requirements

The pediatric emergency medicine resident should be able to:

    1. demonstrate consideration and compassion for patients and their families;
    2. gather in a timely efficient manner the data necessary for diagnosis and treatment, through history taking from patients and family, and all other relevant sources;
    3. rapidly establish trust and communicate decisions with patients and parents;
    4. provide accurate oral and written information appropriate to the situation to patients or families;
    5. communicate clearly and concisely with allied health professionals, paramedical personnel, and other physicians;
    6. show concern for the age and development, gender, disability, psychosocial, cultural, and economic implications of a patient's unique situation;
    7. demonstrate an appreciation of the family's perspective and concern for a child's health and its impact on the family;
    8. support and counsel a patient and the family.
  1. Collaborator

3.1 General Requirements

The pediatric emergency medicine resident should be able to:

    1. consult effectively with other physicians and health care professionals;
    2. contribute effectively to interdisciplinary team activities.

3.2 Specific Requirements

The pediatric emergency medicine resident should be able to:

    1. function effectively within the unique environment of the emergency department recognizing the unpredictable nature of patient presentations, and the demands of working with a multi-disciplinary team;
    2. understand and respect the unique role of each of the members of the emergency care team and demonstrate an ability to resolve differences in a professional and sensitive manner;
    3. assume team leadership or an effective participant role in the complex multidisciplinary environment of the emergency department;
    4. understand the unique interaction of the emergency department with every component of the hospital and its significant role in interacting with the external community;
    5. promote autonomy of patients and families and promote their involvement in decision making.
  1. Manager

4.1 General Requirements

The pediatric emergency medicine resident should be able to:

    1. allocate finite health care resources wisely;
    2. work effectively and efficiently in a health care organization.
    3. utilize information technology to optimize patient care, life-long learning and other activities;
    4. utilize personal resources effectively to balance patient care, learning needs, and outside activities.

4.2 Specific Requirements

The pediatric emergency medicine resident should:

    1. demonstrate the skills of efficient assessment, management and decision making in an environment of large patient volumes and rapidly changing priorities. This includes the skill to do multiple tasks simultaneously and change focus appropriately;
    2. know the principles of quality assurance including but not restricted to the role of audits, quality improvement reviews, risk management, incident reporting, and complaint management as pertinent to the emergency department;
    3. understand the basic principles of leadership, management and administration of hospitals and clinical programs;
    4. understand the role of the academic institutions and licensing bodies and their interaction with physicians;
    5. acknowledge, understand and work within the context of the economic restraints of the health care system;
    6. utilize resources effectively;
    7. recognize the importance of shared responsibility with the patient, family, other health care professionals, and community agencies.
  1. Health Advocate

5.1 General Requirements

The pediatric emergency medicine resident should be able to:

    1. identify the important determinants of health affecting patients;
    2. contribute effectively to improved health of patients and communities.

5.2 Specific Requirements

The pediatric emergency medicine resident should be able to:

    1. appreciate that the acute health care needs of children are distinct from adults;
    2. provide leadership in developing and maintaining national competency and equipment standards and practice guidelines for acute pediatric care;
    3. advocate for resources for emerging medical technology, and new acute care practices;
    4. assist patients and families to identify appropriate health and social resources in the community, including support groups;
    5. advocate on behalf of patients and families to access or utilize appropriate health care resources internal and external to the institution;
    6. understand the key roles of health promotion, and injury and illness prevention and incorporate them into practice;
    7. effectively communicate with media, regulatory and governmental agencies to inform and advocate for the acute and chronic care needs of children.
  1. Scholar

6.1 General Requirements

The pediatric emergency medicine resident should be able to:

    1. critically appraise sources of medical information;
    2. facilitate the learning of patients, housestaff/students and other health professionals;
    3. contribute to the development of new knowledge;
    4. develop, implement and monitor a personal continuing education strategy.

6.2 Specific Requirements

The pediatric emergency medicine resident should be able to:

    1. to apply critical appraisal skills to pediatric emergency medicine literature and basic research methodology;
    2. demonstrate basic research skills necessary to develop and evaluate research proposals;
    3. understand pediatric issues in research ethics, methodology, data acquisition, analysis, presentation and publication;
    4. teach effectively within multiple environments (individual, workshop and didactic settings) to diverse groups of learners;
    5. demonstrate proficiency at self assessment and a commitment to life-long self-directed learning and the application of new information technology and evidence based medicine.
  1. Professional

7.1 General Requirements

The pediatric emergency medicine resident should be able to:

    1. deliver the highest quality care with integrity, honesty and compassion;
    2. exhibit appropriate personal and interpersonal professional behaviours;
    3. practice medicine ethically consistent with the obligations of a physician.

7.2 Specific Requirements

The pediatric emergency medicine resident should be able to:

    1. understand and incorporate into practice the professional, legal, and ethical codes relevant to pediatric emergency practice. The CMA guidelines of ethical interactions with industry (especially the pharmaceutical industry) should be followed;
    2. demonstrate knowledge of medical ethics pertinent to the practice of pediatric emergency medicine including but not limited to: best interest, autonomy, beneficence, confidentiality, and conflict of interest;
    3. recognize the specific issues of informed consent of children;
    4. recognize the specific issues of child protection;
    5. recognize the specific issues of public health infection issues, and death notification;
    6. demonstrate a proficiency at self assessment in regard to one's personal and professional performance and establish a pattern of ongoing professional development;
    7. recognize the limitations of one's competence and appropriately consult with other professionals;
    8. identify appropriate strategies to identify and deal with substandard care or unprofessional behaviour;
    9. recognize the importance of a balanced lifestyle on one's own health and the ability to provide optimum patient.

CONTENT AND ORGANIZATION OF THE RESIDENCY PROGRAM:

There must be an organized program of rotations and other educational experiences, both mandatory and elective, designed to provide each resident with the opportunity to fulfill the educational requirements and achieve competence in the specialty.

The following are the minimum educational requirements in pediatric emergency medicine. Additional experience may be required by the program director.

  1. Prerequisites

Pediatrics or emergency medicine training which must be completed prior to entry into the pediatric emergency medicine program.

  1. Program requirements

            Pediatric emergency medicine.

For satisfactory completion of the requirements in pediatric emergency medicine a resident must:

    1. have attained certification in pediatrics or emergency medicine;
    2. have successfully completed program in pediatric emergency medicine in accredited program;
    3. have completed or significantly participated in a scholarly project related to any aspects (research, educational, or creative professional activity) in the subspecialty of pediatric emergency medicine. Ideally, this project would lead to a presentation or publication which would permit peer review in a setting outside the resident's own centre. This may include research protocol development, development of an educational curriculum for a specific course or group, or presentation of continuous quality improvement activities or protocol development.

RESOURCES:There must be sufficient resources including teaching faculty, the number and variety of patients, physical and technical resources, as well as the supporting facilities and services necessary to provide the opportunity for all residents in the program to achieve the educational objectives in pediatric emergency medicine.

  1. Teaching Faculty

There must be a sufficient nucleus of pediatric emergency medicine teaching staff who have experience and knowledge of the care of acute pediatric illness and injuries to provide adequate supervision of residents and to ensure the educational and research quality of the program. At least two of the faculty (one of which must include the program director) must have completed formal training in pediatric emergency medicine, or have pediatric medical emergency experience for >5 years with an 80% commitment to pediatric emergency medicine. The Pediatric Emergency Faculty must have an active role in curriculum development as well as the supervision, education, and evaluation of the residents.

There must be sufficient number of qualified teaching staff to provide adequate instruction and supervision for residents in the subspecialty areas related to pediatric emergency medicine.

  1. Number and Variety of Patients

The core emergency department facility must meet the following criteria:

    1. At least 15,000 pediatric visits per year
    2. Tertiary care institution with pediatric intensive care facilities
    3. Located in a hospital fully affiliated with a university
    4. All levels of triage categories must be fully represented
    5. Patient diagnostic categories must include the full spectrum of medical, surgical, psychiatric, and psychosocial problems characteristic of pediatric emergency department setting
    6. 24 hour attending staff supervision
    7. Must be associated with an Emergency Medicine Services system

Service requirements should not interfere with the educational objectives of the training program but should be sufficient to guarantee adequate exposure to and comfort with, the majority of situations that arise in the course of working in a pediatric emergency department. During an emergency rotation the clinical component should be a minimum of 36 hours per week divided amongst days, evening, and nights.

  1. Clinical Services Specific to Pediatric Emergency Medicine

The pediatric emergency medicine service must be an organized dedicated formal teaching unit for pediatric emergency medicine with a defined person in charge to whom the resident is responsible. There must be a link between the pediatric emergency department and pediatric inpatient and outpatient services to allow adequate patient access and follow-up.

The clinical service must have adequate space for administration, teaching, and research. There must be access to a major medical library at the hospital or the University. Appropriate on-call space should be available where indicated by the nature of the rotations.

Pre-hospital Care: The training must be associated with a pre-hospital care program. This program must be able to adequately expose the resident to the clinical and administrative issues relating to pre-hospital care and teach the issues directly related to pre-hospital care for children.

  1. Supporting Services — Clinical, Diagnostic, Technical

Resources: Consultative services must be readily available from all major specialties            including cardiology, diagnostic radiology, neurosurgery, orthopedics, pediatric anesthesia, pediatric general surgery, pediatric intensive care, plastic surgery, psychiatry and toxicology. The resources needed would be the same as those needed to identify the emergency department as a level I Pediatric Trauma Centre.

ACADEMIC AND SCHOLARLY ASPECTS OF THE PROGRAM

The academic and scholarly aspects of the program must be commensurate with the concept of a university postgraduate education. The quality of scholarship in the program will in part, be demonstrated by a spirit of enquiry during clinical discussions, rounds, and conferences. Scholarship implies an in-depth understanding of basic mechanisms of normal and abnormal states and the application of current knowledge to practice.

  1. Organized Scholarly Activities

There must be regularly scheduled conference time that encourages an interactive adult learning approach as well as the establishment of life-long self-learning skills for the resident. The conferences can take the form of didactic lectures, journal clubs/critical appraisal of the literature, seminars, mortality and morbidity reviews, quality assurance rounds, general subject reviews, computer search and problem solving.

  1. Education in Teaching

Residents must be an active part of the teaching process and should receive teaching and formal feedback in this area. They should be responsible for preparation of audiovisual, written material, and educational models appropriate for the teaching sessions. They should be given guidance and practical experience in small group workshop sessions, one on one teaching with different levels of trainees, large group didactic sessions and teaching to para-medical and non-medical audiences.

  1. Conferences

Residents should attend a minimum of at least one national or international academic pediatric emergency medicine conference per year. Residents should be strongly encouraged to present at these conferences if the opportunity arises.

  1. Research

The pediatric emergency medicine program must be associated with an active pediatric emergency medicine research program as part of the academic teaching environment. There must be adequate resources available for mentoring of research activities and an atmosphere of encouragement. Adequate space, equipment, and computer services for data analysis and statistical consultation must be available to both the faculty and the residents.

There must be a formalized program to teach research methodology, biostatistics, and epidemiology offered through courses, workshops or seminars.

EVALUATION OF RESIDENT PERFORMANCE:

There must be mechanisms in place to ensure the systematic collection and interpretation of evaluation data on each resident enrolled in the program.

As there is not summative evaluation at a national level, it is particularly important that the evaluation of residents in the program be rigorous and well documented. Programs must have a comprehensive assessment plan including assessment criteria and methods, based on the objectives of the program.

There must be a process of evaluation in place which is documented, signed, dated and received in timely fashion. Evaluations may be done using the following tools.

Assessments of the performance of individual residents in the program are to be kept on file in the office of the postgraduate dean for review at the time of on-site surveys.

For each resident deemed by the program director to have completed the program, an "Attestation of Program Completion" form on university letterhead must be filed. These forms will be sent to the program for each resident shown on the Annual Report to have completed the required program.

SPECIALTY REQUIREMENTS:

  1. Certification in General Surgery.
  2. Approved residency training including training in pediatric general surgery, of which one year must be in a senior residency position:

Senior residency is defined as a year in which the trainee is regularly entrusted with responsibility for pre-operative, operative, and post-operative care, including the most difficult problems in pediatric general surgery, and neonatal surgery. The senior resident shall be in charge of a pediatric general surgical unit. No other resident shall intervene between the senior resident and the attending staff surgeon.

Training should incorporate the principle of graded increasing responsibility. The term "approved" throughout this section means "approved by the candidate's program director and Credentials Committee."

Medical Expert/Clinical Decision-Maker

SECONDARY KNOWLEDGE OBJECTIVES

Emergency Care of Croup and Epiglottiditis

  1. Cardiac Surgery
    • Patent ductus arteriosus (PDA), coarctation, arch anomalies, vascular ring / sling (esp. as related to pediatric general surgical complications)
    • systemic/pulmonary shunts, pericardiectomy, pulmonary artery banding
    • atrial septal defect (ASD), ventricular septal defect (VSD), septum primum
    • tetralogy of Fallot, transposition of great vessels (TOGV), arterio-venous (A-V) canal, hypoplastic left heart
    • cardiac transplantation
  2. Vascular Conditions
    • management of vascular injuries
    • methods of arterial reconstruction
    • management of renal vascular hypertension related to arterial disorders (stenosis, fibromuscular dysplasia, abdominal coarctation)
    • angiographic and Doppler imaging: indications and techniques
    • A-V fistulas for dialysis
  3. Urology
    • kidney: ureteropelvic junction (UPJ) obstruction, duplex systems, renal transplantation
    • ureter: vesicoureteral reflux (principles of therapy and correction), megaureter, ectopic ureter, ureterocele, ureteral duplication and associated problems, ureteroureterostomy
    • stones: kidney (open vs. endourologic therapy), ureteral, bladder including metabolic aspects
    • bladder: diverticulum, neurogenic bladder, bladder neck obstruction, bladder augmentation
    • urethra: hypospadias, epispadias, urethral valves (anterior and posterior)
    • urinary diversion: indications and techniques (vesicostomy, nephrostomy, ureterostomy, colonic conduit, continent diversions)
    • endoscopy of the urinary tract, urodynamics, evaluation of hematuria
    • peritoneal dialysis and hemodialysis access
  4. Plastic Surgery
    • head and neck: contractures, facial anomalies, wounds
    • skin: frostbite, soft tissue injury, wound healing, wound management
    • hand: infection, lacerations (recognition of nerve and tendon injury)
    • burns: recognition and management of burn wound infection (including wound biopsy techniques); burn wound excision; use of skin substitutes; burn rehabilitation, (including psychological effects and recovery)
    • techniques: skin grafting, microsurgery, use of flaps and Z-plasty
  5. Orthopedics
    • traumatic: pulled elbow, major long bone injury (femur, humerus, supracondylar fracture, Volkman's ischemic contracture, ankle, wrist injury, knee injury and dislocation, compartment syndrome
    • congenital: hip dislocation, club foot
    • acquired: osteochondritis dissecans, slipped capital femoral epiphysis
    • scoliosis: idiopathic, hemivertebrae
    • tumours (osteogenic sarcoma, Ewing's tumour): concepts of limb salvage, chemotherapy, (management of pulmonary metastases = primary objective)
  6. Neurosurgery
    • spina bifida, tethered cord
    • V-P (ventriculoperitoneal) shunt complications
    • midline dermoid lesions

SECONDARY SKILLS OBJECTIVES

Experience is recommended in the following areas:

  1. Other thoracic surgery
    • laryngotracheoplasty
    • tracheobronchial reconstruction
    • bronchoscopy for tracheo-bronchial foreign bodies.

PROGRAMS (WITH TRAINING REQUIREMENTS):

Diplomas(Dip):

Six months of approved residency training.

Doctor of Medicine(M.D):

Eighteen months of approved residency training.

Doctor of Philosophy(Ph.D):

Forty eight months(four years)of approved residency training.