New ACGME pediatric guidelines

[oldbearprofessor]

The new proposed ACGME Program Requirements for Graduate Medical Education (GME) in Pediatrics have been published and are available for public comment (http://www.appd.org/home/PDF/ACGMEPediatricRequirements7_2011.pdf).

Any thoughts? I haven't gone through the details yet but will soon.

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[Valentine Mott]

As a future med-peds applicant, I am particularly interested how this will affect the requirements for med-peds training, though my points I'll make about the critical care training requirement just as much applies to categorical training.

Noticed that that under IV.A.6 "Curriculum Organization and Resident Experiences" that "overall structure must include" 2 units of pediatric critical care and 2 units of neonatal intensive care.

Currently, med-peds trainees have to do 3 months of NICU, and 1 month of PICU -- which doesn't make a whole lot of sense to me since a lot of those going into med-peds are drawn to transitional care. If this is what is reflected into the future requirements for med-peds training, it would seem to be beneficial for that population of trainees.

For the categoricals, these 2 mo PICU, 2 mo NICU requirements would seem to offer more a more balanced experience, too. As a neonatologist himself/herself, maybe OBP can chime in on this. Perhaps a pediatrician, generalist or subspecialist, needs that extra month of NICU training to grasp the nuances of baby care. Or perhaps the extra month of required PICU will encourage more to consider critical care.

 

[oldbearprofessor]

As a future med-peds applicant, I am particularly interested how this will affect the requirements for med-peds training, though my points I'll make about the critical care training requirement just as much applies to categorical training.

Noticed that that under IV.A.6 "Curriculum Organization and Resident Experiences" that "overall structure must include" 2 units of pediatric critical care and 2 units of neonatal intensive care.

Currently, med-peds trainees have to do 3 months of NICU, and 1 month of PICU -- which doesn't make a whole lot of sense to me since a lot of those going into med-peds are drawn to transitional care. If this is what is reflected into the future requirements for med-peds training, it would seem to be beneficial for that population of trainees.

For the categoricals, these 2 mo PICU, 2 mo NICU requirements would seem to offer more a more balanced experience, too. As a neonatologist himself/herself, maybe OBP can chime in on this. Perhaps a pediatrician, generalist or subspecialist, needs that extra month of NICU training to grasp the nuances of baby care. Or perhaps the extra month of required PICU will encourage more to consider critical care.

I'm a "him". I don't entirely understand the new guidelines on this. They talk about 2 months each of NICU and PICU and one month well baby as part of 10 in-patient mandatory months. But, they say you should have 16 total in-patient months with some verbiage I don't really understand about it. My question is whether this allows programs to mandate for themselves more NICU or PICU time if they want? Or is it only if an individual resident wants more time in these areas they can do it?

I'm not sure why med-peds would need an extra month of NICU - maybe that will be revised too by the med-peds folks?

The biggest issues will be those related to enhanced outpatient experiences and changes in rules related to procedures. I don't immediately understand why residents MUST be able to show that they can do a UVC but only learn the theory of intubations. When would a general pediatrician be caring for a baby and need to do an emergent UVC (not an intraosseous, but a UVC in the first days of life) and not intubate the baby first? I must be missing something here. Maybe they assume anesthesia will intubate and the pediatrician place the UVC. Not sure if this is sound reasoning.

 

[SurfingDoctor]

I don't immediately understand why residents MUST be able to show that they can do a UVC but only learn the theory of intubations. When would a general pediatrician be caring for a baby and need to do an emergent UVC (not an intraosseous, but a UVC in the first days of life) and not intubate the baby first? I must be missing something here.

I didn't read the guidelines but is that really true?! That's really funny/sad as even a kindergartener knows that A comes before C.

 

[oldbearprofessor]

Lines 518-547

must be able to competently perform procedures used by a pediatrician in general practice. This includes being able to describe the steps in the procedure, indications, contraindications, complications, pain management, post- procedure care, and interpretation of applicable results. Residents must demonstrate procedural competence by performing the following procedures:
525
IV.A.5.a).(1).(a) bag-mask ventilation; 526
527
IV.A.5.a).(1).(b) bladder catheterization; 528
529
IV.A.5.a).(1).(c) giving immunizations; 530
531
IV.A.5.a).(1).(d) incision and drainage of abscess; 532
533
IV.A.5.a).(1).(e) lumbar puncture; 534
535
IV.A.5.a).(1).(f) reduction of simple dislocation; 536
537
IV.A.5.a).(1).(g) simple laceration repair; 538
539
IV.A.5.a).(1).(h) simple removal of foreign body; 540
541
IV.A.5.a).(1).(i) temporary splinting of fracture; 542
543
IV.A.5.a).(1).(j) umbilical venous catheter placement; and, 544
545
IV.A.5.a).(1).(k) venipuncture. 546
547

and then lines 554 to 584

Medical Knowledge

Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological and social- behavioral sciences, as well as the application of this knowledge to patient care. Residents: must be competent in the understanding of the indications, contraindications, and complications for the following procedures:

IV.A.5.b).(1).(a) arterial line placement; 565
566
IV.A.5.b).(1).(b) arterial puncture; 567
568
IV.A.5.b).(1).(c) chest tube placement; 569
570
IV.A.5.b).(1).(d) circumcision; 571
572
IV.A.5.b).(1).(e) endotracheal intubation; 573
574
IV.A.5.b).(1).(f) peripheral intravenous catheter placement; 575
576
IV.A.5.b).(1).(g) thoracentesis; and, 577
578
IV.A.5.b).(1).(h) umbilical artery catheter placement. 579
580
IV.A.5.b).(2) When these procedures are important for a resident's post-581 residency position, residents should receive real and/or 582 simulated training

 

[SurfingDoctor]

Interesting.

Where are IOs on that list and IVs are secondary to UVCs? Venipuncture is great, but IVs/IOs are more useful for general emergencies. Venipuncture won't save a child's life. UVCs are of no value in general practice (except maybe for practices that cover deliveries, I don't know how common that is).

I think IV/IOs should be moved up to required and UVC down to knowledge, but that's just my feeling. The rest I agree with as far as required competency.

Thanks for saving me the time of looking through all that myself

 

[michigangirl]

Just to clarify-- venipuncture is IVs-- UVCs are a form of central line placement. I know that's what OP meant, but want to clarify for our young skywalkers. I agree-- there is not enough emphasis on peripheral IV placement and simple venous sticks for labs, etc. during residency. I can tell you our residents who rotate through the PICU during their 1 or 2 months rarely get to do a central line- it's a fellow level skill. They are more likely to do UVCs with the fellow in the NICU-- as it's helpful to have two persons-- the fellow who knows what they are doing and the resident who can put the UVC in the vein the fellow has isolated and will help guide to the right position. Other central lines, like IJ lines, subclavians, femorals, that involve seldinger technique, are, I believe a step more complex and really not a general pediatric skill thats needed unless you are going to be in a NICU or PICU environment. UVCs may be a skill to have if you regularly deal with neonates in the delivery room and occasionally get a critically one who you can't obtain IV access on. But then there's always the IO until you get them to a tertiary care center. So I leave that to OBP ;-)

 

[oldbearprofessor]

Just to clarify-- venipuncture is IVs-- UVCs are a form of central line placement. I know that's what OP meant, but want to clarify for our young skywalkers. I agree-- there is not enough emphasis on peripheral IV placement and simple venous sticks for labs, etc. during residency. I can tell you our residents who rotate through the PICU during their 1 or 2 months rarely get to do a central line- it's a fellow level skill. They are more likely to do UVCs with the fellow in the NICU-- as it's helpful to have two persons-- the fellow who knows what they are doing and the resident who can put the UVC in the vein the fellow has isolated and will help guide to the right position. Other central lines, like IJ lines, subclavians, femorals, that involve seldinger technique, are, I believe a step more complex and really not a general pediatric skill thats needed unless you are going to be in a NICU or PICU environment. UVCs may be a skill to have if you regularly deal with neonates in the delivery room and occasionally get a critically one who you can't obtain IV access on. But then there's always the IO until you get them to a tertiary care center. So I leave that to OBP ;-)

Unless I'm misunderstanding, the ACGME guidelines separates out venipuncture, the act of putting a needle in a vein for phlebotomy for lab tests in most cases, from peripheral IV insertion. The former is a skill that must be demonstrated, the latter is in the "watch a sim and explain it" category. I don't disagree that residents should be able to provably do a UVC. UVC's are trivial to at least put in the vein. The real skill is to be able to identify when it has gone into the right place by X-ray and how to handle its placement if it does not go in the right place. No, my concern is that UVC's are mandated and intubation is a "watch a sim and explain it" skill. I do not understand or agree with that decision.

We do not do IOs in the DR. We can always place a low UVC until better access can be obtained.

 

[group_theory]

Just to clarify-- venipuncture is IVs-- UVCs are a form of central line placement. I know that's what OP meant, but want to clarify for our young skywalkers. I agree-- there is not enough emphasis on peripheral IV placement and simple venous sticks for labs, etc. during residency. I can tell you our residents who rotate through the PICU during their 1 or 2 months rarely get to do a central line- it's a fellow level skill. They are more likely to do UVCs with the fellow in the NICU-- as it's helpful to have two persons-- the fellow who knows what they are doing and the resident who can put the UVC in the vein the fellow has isolated and will help guide to the right position. Other central lines, like IJ lines, subclavians, femorals, that involve seldinger technique, are, I believe a step more complex and really not a general pediatric skill thats needed unless you are going to be in a NICU or PICU environment. UVCs may be a skill to have if you regularly deal with neonates in the delivery room and occasionally get a critically one who you can't obtain IV access on. But then there's always the IO until you get them to a tertiary care center. So I leave that to OBP ;-)

Your medicine and surgical colleagues are expected to know how to place central lines (not only to place, but be able to supervise others in placing lines). For pediatrician, it may be possible that a child in a hospital (that does not have a PICU) will need pressors (or if IV access cannot be obtain due to severe dehydration) while waiting for transport to a childrens hospital. Many of the smaller hospitals and pediatric floors are covered by outpatient pediatric groups. Having the knowledge and skills to place a central line may come in handy.

As for NICU rotations, it was my understanding the American Board of Pediatrics was the one (or maybe it was the RRC of Pediatrics) that insisted that Med-Peds do 3 months of NICU since it is a rotation that is uniquely "pediatrics" with no overlap with medicine. Many Med-Peds programs have complained in the past but have always been given the stiff arm about that requirement. Perhaps with the new RRC recommendations, it will change?

 

[michigangirl]

Your medicine and surgical colleagues are expected to know how to place central lines (not only to place, but be able to supervise others in placing lines). For pediatrician, it may be possible that a child in a hospital (that does not have a PICU) will need pressors (or if IV access cannot be obtain due to severe dehydration) while waiting for transport to a childrens hospital. Many of the smaller hospitals and pediatric floors are covered by outpatient pediatric groups. Having the knowledge and skills to place a central line may come in handy.

As for NICU rotations, it was my understanding the American Board of Pediatrics was the one (or maybe it was the RRC of Pediatrics) that insisted that Med-Peds do 3 months of NICU since it is a rotation that is uniquely "pediatrics" with no overlap with medicine. Many Med-Peds programs have complained in the past but have always been given the stiff arm about that requirement. Perhaps with the new RRC recommendations, it will change?

Central lines are a skill that requires practice to get good at and maintaining that skill-particularly in pediatrics. It's one thing to hit an adult size IJ/subclavian or femoral vein. I can tell you that in my last five years as part of a pediatric critical care transport team, I have never and will never recommend that a pediatrician place a central line in a child that I am going to go pick up. If the child needs pressors, run dopamine through a peripheral. If they are too dehydrated for a peripheral, place an IO. The amount of time it takes to PROPERLY place a central line, particularly in an awake child (virtually impossible) is not to be underestimated, especially in unskilled hands. And the risks are not small. IJ and subclavians? bring on the pneumothorax. The ONLY kids who show up in our PICU with central line access in place are big intubated kids (>10) who showed up in an adult ED where the ED physician placed one because they were in full arrest and there was nothing to lose. And the ED physician either does them often or has surgical colleagues to come do them. There is MUCH more to be lost by an inexperienced person putting in a central line than throwing in an IO (life threatening bleeding/infxn/pneumo vs. bone injury)

To be even more concrete-- If I, as the picu attending or fellow, go to pick up a sick kid by helicopter or ambulance from some hospital far away with no pediatric icu or specialty services and they need access-- I have NEVER put in a central line at the outside hospital-- I will either find an IV or put in an IO. My transport nurses who do critical care transports-- same thing. I just want to get back to the place that has the most resources.

Your comment about outpatient pediatric groups-- all the more reason for everyone to know how to place an IO-- how often do you think that outpatient pediatrician is going to use that skill? Definitely not enough to do it safely and well most of the time. ALSO, the gold standard for central line placement is with ultrasound guidance in this day and age. How many outpatient pediatricians want to become well versed in use of ultrasound to place central venous access? If there is a complication, and ultrasound wasn't used, medicolegally, another point to contend with.

Have I made my point clear?

IV, IO or bust. Central lines are not the answer unless in a fully skilled and practiced set of hands. Would you want the outpatient pediatrician putting a central line in YOU? I know they wouldn't want ME as your general pediatrician.

 

[group_theory]

I guess this all leads to the big question which the ACGME/RRC is trying to address - what are the skills and knowledge set that every pediatric residents graduating should have and know. You make the argument that placing central lines shouldn't be a requirement (very good arguments) - but what about UV lines, intubations, ABGs, A-lines, etc? How will you get experience placing IOs when they are rarely done (outside PALS courses)?

What skillset should every pediatrician (whether going into fellowship, outpatient primary care, or hospitalist) should have?

It appears, based on the list that OBP listed, that intubation isn't a necessary skillset, but airway management is (hence they list Bag-Mask Ventilation as a required skillset).

I was wondering why central line placement wasn't a requirement, but your arguments are convincing for not making it a requirement (and yes, I am well aware of complications and the use of ultrasound since I have placed quite a few lines myself (with supervision) in adults and kids with ultrasound).

I am curious about not requiring ABGs though (I agree that a-line placement should not be an require skillset). Do you think this is a skillset that is important for every pediatric resident to know?

 

[michigangirl]

"We do not do IOs in the DR. We can always place a low UVC until better access can be obtained."- OBP, when I was speaking of doing IO's in the DR, I only meant in community hospitals without NICUs or NICU level expertise, as a last resort while they wait for you to come pick up the kid. But of course a UVC is much preferred here if you know how to place one.

With regard to the practice it takes to put in an IO-- if you are up to date with PALs, that's sufficient. It's not rocket science to memorize the major sites for placement, and then you just screw it into the bone and secure it. You can practice at home with an IO needle and chicken bones. And now with the EZ IO, its even more simple.

I agree-- ABGs (and VBGs, which goes back to my venous stick point) should be a necessary skill set. If I, as the accepting referral center, ask for an ABG on a kid to figure out how to help you, then you should be able to do it. Agreed that arterial lines go in the same category as central lines-- rarely useful in the pre-icu setting.

Bag mask ventilation-- for sure. Intubation-- not an absolute necessity-- almost every hospital has an anesthesiologist on call who can intubate someone over the age of 2, or an ED physician. Intubation is another skill set that gets rusty without practice, and where a lot of things can go wrong when inducing a sick child who actually needs sedation to do it (unlike a newly born in the DR). But I do think it is a skill that one should demonstrate competence in before graduation. In fact, I think all pediatricians should do a 2 week rotation on pediatric anesthesia to get this experience. But I can dream ;-) That's the anesthesiologist in me...

 

[KidDr]

I'm a new PEM attending (just finished fellowship last month). I have done about 15 central lines over the past 7 years (since I started residency), all of them supervised. I could probably put in a central line if I had to, but I can tell you that I have a hard time thinking of a situation in which I will place one in the future.

Our goal in the ED (for sick pediatric patients) is quick access. CVLs, in most pediatric patients, are not quick. And like Michigangirl pointed out, the potential complications are not minor. I made it my goal throughout residency and fellowship to place as many PIVs as I could, including as many "difficult" PIVs as possible (EJs, scalp veins, upper arm/brachial veins, feet veins, etc). As a result, I estimate I've placed at least 200 PIVs and I feel very competent in this skill. If I or the nurses can't get a PIV, and the kid is sick enough to need urgent access, they get an IO for temporary access (and then they can get a CVL placed in the PICU later).

I always encourage residents and especially PEM fellows to focus on becoming competent at placing PIVs. I think it is a skill that has unfortunately been neglected for the average trainee (and it doesn't seem like many programs focus on residents gaining this skill either, which is unfortunate--and it seems like it's only going to get worse with the new guidelines).

 

[SurfingDoctor]

I think people are getting confused about what the ACGME requires for a general pediatric residency and what is expected of a refering doctor from an outside facility who hopefully has EM training.

I think the goal fo pediatric residency should be to train the future physician how to handle general pediatric care. Most of this should be preventive, ie what you can do to prevent sending kiddos to ERs and subspecialist. Should a pediatrician be able to manage moderate-persistent asthma? Yep. Should a pediatric be able to straight cath a well appearing 2 year old female with a febrile UTI? Absolutely. Should a pediatrician be able to get blood for a CBC or ESR in an FUO scenario, or monitoring of TFTs? Yep. Should a pediatrician now how to use a BMV or CPR or IO or IV? Sure. ABGs, CVLs, intubations, not necessary. I would say that even an ABG would be useless in a general practice (not to mention the cost of maintaining of the blood gas analyzer). If a patient is really that sick, getting an ABG and waiting for the results is only wasting time when the kid needs to get somewhere else with the real resources.

I can't speak for michigangirl's experiences, but our transport team almost never transports from a general clinic. Outside facilities are usually community ECs with nursing and other personal that can get IV, blood, etc. Usually outside ECs have no problem getting labs and doing procedures, its the management they have issues with. But then again, most graduating pediatric residents aren't going to find themselves working in community ECs as there first job, nor should they. They will either become subspecialists and will have time to develop procedural skills, or be a general practioner whose job should be able to know skills required for outpatient/follow up diagnostics or non-procedural A->B->C.

I think the work hours reduction are a far greater hinderance to graduating residents skill set then procedures could ever be.

 

[michigangirl]

"But then again, most graduating pediatric residents aren't going to find themselves working in community ECs as there first job, nor should they. "

I'm glad you said this-- because-- I can't tell you how MANY peds residents in my experience take "a year off" after graduation and work in a community ER as the attending so that they can decide what they want to do with their life. It happens a lot more than you think. Which is precisely why we need to train folks with these skills. Lots of non-peds ER fellowship trained folks attending in peds ERs- this is why they need to know how to get an art gas.