Pediatric Urgent Care Rotation: Educational Goals and Objectives
Nehal Bhandari MD, Terri Coco MD, Theresa Guins MD, Cheryl Jackson MD, Leah Kaye MD, Emily Montgomery MD, Barbora Nelson DO, Amy Pattishall MD, Pareen Shah MD, Muhammad Waseem MD, Eric Weinberg MD
The following educational goals and objectives were developed through a collaboration between the Society for Pediatric Urgent Care (SPUC) and the Education Work Group of the American Academy of Pediatrics (AAP) Provisional Section on Urgent Care Medicine to assist both residents and educators in establishing rotations in the urgent care setting.
The rotation in Pediatric Urgent Care is an opportunity for a resident in pediatrics, family medicine or internal medicine/pediatrics to explore the emerging field of Pediatric Urgent Care Medicine, which spans the scope between lower acuity visits similar to a primary care setting and high acuity illnesses and injuries requiring care in an emergency department. The rotation provides a useful knowledge base and skill set for residents interested in urgent care, emergency medicine, outpatient primary care or hospital-based medicine. Pediatric Urgent Care practitioners are called upon to render expert care to patients with a wide range of pathology, often without the on-site availability of consultants. They must therefore have a broad knowledge base and be comfortable functioning independently, yet understand the limitations of their practice.
Settings:
Private urgent care centers
Hospital-affiliated outpatient urgent care centers
Emergency department based urgent care
Other potential learning opportunities: EMT/Transport team exposure, scheduled conferences, resident-led didactics, staff meetings/presentations, radiology review, simulation sessions, skills workshops, communication skills training
Suggested Methods of Evaluation: Evaluation of documentation for accuracy, clarity, timeliness, quality of care; direct observation of patient care; direct observation of procedure performance
Patient care
Goals:
- Resident will better understand the unique flow and process of an urgent care/fast track pod
- Resident will develop and implement appropriate management plans for patients and become proficient at basic bedside procedures
- Resident will provide patient care that is compassionate, appropriate and effective for the treatment of ill and injured patients in the urgent care setting as well as for the promotion of health
- Resident will gain experience in managing ill and injured patients of all levels of acuity that present to a pediatric urgent care setting
- Resident will learn to prioritize and simultaneously care for multiple patients
- Resident will master obtaining focused history and physical exam for common acute, non-emergent pediatric complaints
- Resident will understand the scope of practice of your urgent care setting, including who needs emergent or urgent referral to a hospital or higher acuity setting
- Resident will recognize the importance of the patient experience and its impact on overall patient care
Objectives:
- Describe the ESI system or triage system utilized and how patients are assigned level of care
- Identify and stabilize critically ill/injured patients who require a higher level of care
- Describe the initial emergency management of seizures
- Describe the initial emergency management of severe respiratory distress (upper and lower respiratory)
- Describe the initial emergency management of shock
- Describe the initial emergency management of head, C-spine, thoracic, extremity, and abdominopelvic trauma
- Appropriately document patient encounter, including documentation of pertinent positive and negative findings on history and exam
- Demonstrate improvement in efficiency (patients per hour) over the course of the rotation
- Determine appropriate disposition for patients, including need for follow-up care
- Relay discharge instructions to parents and patients in appropriate language, including explanation of problem, instructions on how to take care of the problem and when to return, and expectations for improvement
- Demonstrate ability to interpret radiographs, especially common fractures and chest radiographs
- Demonstrate ability to perform the following procedures:
- Cerumen removal
- Foreign body removal (orofacial and simple subcutaneous)
- Splinting (simple without bone manipulation)
- Reduction of nursemaid’s elbow
- Simple incision and drainage
- Fluorescein application/wood’s lamp evaluation
- Pelvic examinations
- Laceration repair
- Visual acuity exam
- Nasal suctioning techniques
- Airway management: BVM ventilation, ET intubation, supraglottic devices
- LP (where applicable)
- Nerve blocks
- Procedural sedation
- Simple dislocation and fracture reduction
- IV placement
- Lab draw
- Burn/wound debridement
- Nail trephination
- Demonstrate effective asthma teaching including aerochamber (and mask when applicable) usage
- Utilize appropriate diagnostic studies and formulate treatment plans for pediatric acute care diagnoses, taking into account possible resource limitations and cost-effective care
- Demonstrate age appropriate strategies to develop rapport with patients
- Demonstrate ability to screen and appropriately triage a patient with suicidality
- Assess state of hydration—recognize exam findings of dehydration, explain how to use oral rehydration therapy for mild/moderate dehydration
- Elicit or observe an appropriate history surrounding an ingestion (type, route, amount, timing) and demonstrate knowledge about the use of the poison control center
- Recognize when intentional injury or non-accidental trauma ought to be considered in a patient’s differential
Medical Knowledge
Goals:
- Resident will gain a better understanding of the evaluation, diagnosis and management of common pediatric illness and injury in the urgent care setting
- Resident will develop differential diagnoses that include common conditions as well as rare but potentially serious conditions
Objectives:
- Describe the pathophysiology, initial stabilization, evidence-based approach to management and potential complications for the following complaints and conditions commonly seen in pediatric urgent care:
| COMPLAINTS Ear pain Eye pain/eye discharge Fever Rhinorrhea/cough Sore throat Vomiting/diarrhea Musculoskeletal injuries Limp Nose bleed Vaginal discharge Dysuria Rash, including infestations Headache Difficulty breathing Abdominal pain Chest pain Dizziness Fussiness/irritability Neck swelling |
DIAGNOSES Acute sinusitis Strep pharyngitis Skin infection (e.g. cellulitis, abscesses) Stomatitis, Hand Foot and Mouth Nursemaid’s elbow Conjunctivitis/stye Asthma Minor head injury Dental trauma UTI STIs Retained foreign bodies Otitis media Otitis externa Allergic rhinitis Bronchiolitis Pneumonia URI Croup Influenza/Influenza like illness Constipation Allergic reactions, urticaria, anaphylaxis |
- Compare and contrast the presentation of illness and injuries based on age (neonate, infant, toddler, school aged child, adolescent, adult)
- Identify possible signs of physical and sexual assault and neglect that require further investigation/reporting
- Understand some of the basic legal issues encountered in the pediatric urgent care setting
- Explain the natural course of common pediatric diseases and how this affects anticipatory guidance, supportive care, follow-up, and return precautions
Practice Based Learning and Improvement
Goals:
- Resident will recognize deficient areas and improve knowledge and skills related to patient care and procedures in the urgent care setting
- Resident will investigate and evaluate patient care practices through appraisal of the literature and appropriate clinical guidelines, and assimilate this information to make appropriate patient management decisions
Objectives:
- Seek and incorporate feedback from faculty and staff on self-identified knowledge gaps
- Demonstrate ability to locate up-to-date clinical guidelines and to perform literature searches and use consultants when necessary to answer clinical questions
- Utilize available rotation resources (learning modules, grand rounds, lectures, case discussions/case reviews, simulation sessions, procedure workshops, etc.) to improve patient care and procedural competency
Systems-Based Practice
Goals:
- Resident will practice quality health care that is cost-effective
- Resident will improve efficiency and workflow in the acute care clinical setting
- Resident will recognize the scope of practice of the urgent care setting and indications for transfer to higher level of care
- Resident will learn to be an effective team member, working and communicating effectively with nurses, support staff and patients
Objectives:
- Demonstrate cost-effective patient care and appropriate resource allocation
- Advocate for quality patient care and assist patients in dealing with system complexities, including financial barriers
- Understand the interconnection between pediatric urgent care and the medical home and the importance of communication with the primary care provider to ensure continuity of care
- Collaborate with other health care providers, including appropriate transport systems, to facilitate efficient transfer from one care environment to another
- Utilize appropriate referral and consultation practices when needed
- Understand laws and limitations of adolescent confidentiality
Interpersonal Communication
Goals:
- Resident will develop skills to communicate effectively with patients, parents, and members of the urgent care healthcare team
Objectives:
- Introduce yourself in patient rooms and explain your role in healthcare team
- Communicate effectively and courteously with patients and parents, taking into consideration age/developmental level, language/cultural barriers, and privacy issues
- Demonstrate active listening skills, including appropriate non-verbal behavior
- Effectively communicate and collaborate with the health care team, including physicians, advanced practice providers, nurses, respiratory therapists, techs, and non-clinical support staff
- Formulate a synopsis and clinical question to effectively communicate with subspecialist consultants via phone
- Accurately record findings and assessments in the medical record in a timely manner
Professionalism
Goals:
- Resident will appreciate the different needs of patients from all socioeconomic backgrounds and provide medical care with the highest degree of professionalism
Objectives:
- Act in the best interest of and advocate for patients and families
- Exhibit a caring and respectful demeanor at all times
- Show a positive attitude
- Maintain patient/family confidentiality
- Demonstrate respect for cultural diversity of patients, families and other members of the health care team
- Dress and present yourself professionally
- Arrive on time, prepared for work. Be willing to care for patients throughout entire shift and beyond as needed. Ensure appropriate sign out at end of shift
- Complete medical records in an accurate and timely fashion
- Use professional language appropriate to health literacy of the patient and their family, taking into account language preference
- Notify appropriate supervisor immediately if there are personal or other problems that prevent you from carrying out professional duties
- Ensure adequate rest during time off to be prepared for work duties. Ensure adequate rest prior to driving home if one is too fatigued to drive safely
- Demonstrate understanding of your clinical limitations
- Demonstrate adherence to ethical and medico-legal principles in the consent and transfer of patients (e.g., emergency consent, AMA, EMTALA when appropriate)
- Recognize the psychosocial needs of patients and their families