Discharge Education Curriculum for Residents Rotating on an Inpatient Pediatric Ward

Adult literature has demonstrated that patient preferences and understanding of discharge instructions can impact success of discharge and even predict return ER visits. There is very little data in pediatric literature describing what information should be discussed with families when providing discharge instructions, and most pediatric residents do not receive formal education on the topic. This curriculum is designed as a brief educational intervention that can improve residents’ comfort and skills in providing discharge education to families. The materials include both how to present the curriculum and tools to assess resident knowledge, behaviors and attitudes regarding discharge education as well as an objective checklist to evaluate their skills. The curriculum is designed to be presented in small group, open discussion format while residents are rotating on the inpatient pediatric ward months. This curriculum has been taught to pediatric interns, family medicine residents and psychiatry residents rotating on the inpatient pediatric wards at two large, free-standing children’s hospitals and demonstrated reproducible, statistically significant improvement in resident comfort and performance in providing discharge education. When evaluating the curriculum, resident free text comments included “it made me think of considerations I hadn’t previously thought of” and “this has made me make an effort to be present, rather than just give written instructions for the nurse to go over. The curriculum is significant because it is a brief educational intervention that can have an impact on trainee comfort and skills as well as patient care. Although not well demonstrated in pediatric literature, adult literature has shown that a patients’ preparedness for discharge can predict the risk of a return ER visit, making this an important topic to address in pediatric inpatient medicine, as improvement in the quality of discharge counseling likely impacts patient safety and overall understanding and adherence to the outpatient treatment plan. There were slight variations in the way the curriculum was executed at each institution, yet both had favorable results, demonstrating the flexibility of the curriculum and the potential for interdisciplinary collaboration in the shared goal of improving the patient experience and safety at the time of discharge. In addition, it allows for objective observation of a trainee providing direct patient care. Providing thorough discharge counseling to a family should address all 6 ACGME core competencies, and this curriculum provides for an additional way to evaluate performance. AAMC MedEdPORTAL publication ID 10079. Link to origina

Case report: Cystic fibrosis with kwashiorkor: A rare presentation in the era of universal newborn screening

BackgroundUniversal newborn screening changed the way medical providers think about the presentation of cystic fibrosis (CF). Before implementation of universal screening, it was common for children with CF to present with failure to thrive, nutritional deficiencies, and recurrent infections. Now, nearly all cases of CF are diagnosed by newborn screening shortly after birth before significant symptoms develop. Therefore, providers often do not consider this illness in the setting of a normal newborn screen. Newborn screening significantly decreases the risk of complications in early childhood, yet definitive testing should be pursued if a patient with negative newborn screening presents with symptoms consistent with CF, including severe failure to thrive, metabolic alkalosis due to significant salt losses, or recurrent respiratory infections.Case presentationWe present a case of a 6-month-old infant male with kwashiorkor, severe edema, multiple vitamin deficiencies, hematemesis secondary to coagulopathy, and diffuse erythematous rash, all secondary to severe pancreatic insufficiency. His first newborn screen had an immunoreactive trypsinogen (IRT) value below the state cut-off value, so additional testing was not performed, and his growth trajectory appeared reassuring. He was ultimately diagnosed with CF by genetic testing and confirmatory sweat chloride testing, in the setting of his parents being known CF carriers and his severe presentation being clinically consistent with CF. Acutely, management with supplemental albumin, furosemide, potassium, and vitamin K was initiated to correct the presenting hypoalbuminemia, edema, and coagulopathy. Later, pancreatic enzyme supplementation and additional vitamins and minerals were added to manage ongoing deficiencies from pancreatic insufficiency. With appropriate treatment, his vitamin deficiencies and edema resolved, and his growth improved.ConclusionDue to universal newborn screening, symptomatic presentation of CF is rare and presentation with kwashiorkor is extremely rare in resource-rich communities. The diagnosis of CF was delayed in our patient because of a normal newborn screen and falsely reassuring growth, which after diagnosis was determined to be secondary to severe edematous malnutrition. This case highlights that newborn screening is a useful but imperfect tool. Clinicians should continue to have suspicion for CF in the right clinical context, even in the setting of normal newborn screen results