581 - Faculty Decision Making in Ad-hoc Entrustment of Pediatric Critical Care Fellows: A National Case-Based Survey

Poster Number: 581
Publication Number: 581.117

Rachel S. Poeppelman, University of Minnesota Masonic Children's Hospital, Edina, MN, United States; Ashley Siems, Johns Hopkins All Children's Hospital, St. Petersburg, FL, United States; Melissa Moore-Clingenpeel, Nationwide Children's Hospital, Richmond, IN, United States; Priti Jani, University of Chicago, Comer Children's Hospital, Chicago, IL, United States; Diana L. Mitchell, Advocate Children's Hospital Park Ridge, La Grange Highlands, IL, United States; Claire Stewart, Nationwide Children's Hospital, Columbus, OH, United States

Background: Ad-hoc entrustment decisions about the degree of supervision necessary for a trainee to complete patient care tasks are critical- too much supervision creates physicians ill prepared for independent practice, while inadequate supervision results in patient harm.
Previous work demonstrates significant variability and potential bias in ad-hoc entrustment decisions. Traits that influence ad-hoc entrustment decisions have been described in numerous qualitative works, but the relationship between these traits and the relative contribution of each to entrustment decisions is not fully described.

Objective: To characterize how ad-hoc entrustment decisions are made for pediatric critical care (PCCM) fellows through faculty ratings of clinical vignettes and investigate how acuity, relationship, training level and task interact to influence ad-hoc entrustment decisions.

Design/Methods: A survey containing 16 vignettes which varied by 4 traits (acuity, relationship, training level and task) was distributed to US faculty of pediatric critical care fellowships. Faculty respondents determined an entrustment level for each case and provided demographic data. Univariate and multivariable mixed effects logistic regression was used to evaluate which traits, faculty demographics or practice contexts were associated with “high entrustment”. A p-value of < 0.05 was considered significant.

Results: 178 respondents completed the survey. Response rate could not be calculated based on the distribution method. Acuity, relationship and task all significantly influenced the entrustment level selected. “Direct supervision” was the most frequently selected entrustment level for the majority of the vignettes. There was no interaction between the traits and no relationship between faculty or institutional demographics and the entrustment level selected.Conclusion(s): As has been found in summative entrustment for Pediatrics, Internal Medicine and Surgery trainees, PCCM fellows were often rated at or below the “direct supervision” level of ad hoc entrustment, including in 24% of vignettes for fellows in the final year of training. This may relate to declining opportunities to practice procedures, a culture of low trust propensity among the specialty and/or variation in the interpretation of entrustment-supervision scales.
Respondent and Institutional Characteristics
Univariate Association Between Respondent Characteristics and Entrustment