Lafayette Medical Education Foundation, Inc.
PROGRAM EVALUATION
“Pediatric Asthma and Respiratory Assessment”
Lyticia Shea, MD, FAAP
Pediatric Hospitalist
Peyton Manning’s Children’s Hospital at St. Vincent
August 16, 2011
Franciscan St. Elizabeth Health Lafayette East
1F27
The Lafayette Medical Education Foundation and Purdue University respects and appreciates your opinions. To assist us
in evaluating the effectiveness of this activity and to make recommendations for future educational offerings, please take a
few minutes to complete this evaluation form.
To receive acknowledgement of participation for this activity, this form must be returned to the activity facilitator.
How well did this activity meet the
following learning objectives?
This learning objective did (or
will) increase/improve my:
OBJECTIVE 1 Recognize the risk factors that are
linked with the development of a severe asthma
attack or possible mortality
OBJECTIVE 2 Identify the normal respiratory rates
by age for pediatric patients with unique differences
in presentation of infants and adolescents with
respect to respiratory distress
OBJECTIVE 3 Articulate the sequential steps in
evaluating a pediatric patient of any age with
respiratory distress or asthma
OBJECTIVE 4 Recognize the three primary
medications and three alternative medications used
in Emergency Room to treat asthma and appropriate
dosages
OBJECTIVE 5 Name the other medications and
modalities used to treat a patient with severe asthma
in the inpatient and pediatric intensive care setting
Please Comment if any of
the above Objectives were
not met or had No Impact
High
Impact
Moderate
Impact
No
Impact
Not
Applicable
Knowledge
Competence
Performance
Patient Outcomes
Knowledge
Competence
Performance
Patient Outcomes
Knowledge
Competence
Performance
Patient Outcomes
Knowledge
Competence
Performance
Patient Outcomes
Knowledge
Competence
Performance
Patient Outcomes
Please answer the following questions by circling the appropriate rating:
5 = Outstanding 4 = Good 3 = Satisfactory 2 = Fair 1 = Poor
Effectiveness of the speaker – Dr. Lyticia Shea
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Knowledge of subject matter ..............................................................................................5
Effectiveness of delivery ....................................................................................................5
Responsiveness to questions ............................................................................................5
4
4
4
3
3
3
2
2
2
1
1
1
4
4
4
3
3
3
2
2
2
1
1
1
Is there anything you would like to communicate directly to the speaker?
Logistically
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
The physical environment/arrangement was conducive to learning ..................................5
There was sufficient time for questions and answers ........................................................5
The handout materials were useful ....................................................................................5
Impact of the Activity
Please indicate which of the following American Board of Medical Specialties/Institute of Medicine core
competencies were addressed by this educational activity (select all that apply):
Patient care or patient-centered care
Practice-based learning and improvement
Interpersonal and communication skills
Employ evidence-based practice
Interdisciplinary teams
Professionalism
Quality improvement
Medical knowledge
System-based practice
Utilize informatics
None of the above
The content of this activity matched my current (or potential) scope of practice.
No
Yes, please
explain:
Was this activity scientifically sound and free of commercial bias* or influence?
Yes
No, please
explain:
* Commercial bias is defined as a personal judgment in favor of a specific product or service of a commercial interest.
Full disclosure of all commercial relationships must be made in writing to the audience prior to the activity. Dr. Lyticia Shea has nothing to disclose. All
additional planning committee members, Lafayette Medical Education Foundation, Inc. staff and Purdue University College of Pharmacy staff have no
relationships to disclose
The educational activity has enhanced my professional effectiveness in treating patients.
Strongly Agree
Agree
Disagree
Strongly Disagree
Not Applicable
Strongly Disagree
Not Applicable
The educational activity will result in a change in my practice behavior.
Strongly Agree
Agree
Disagree
How will you change your practice as a result of participating in this activity (select all that apply)?
Create/revise protocols, policies, and/or procedures
This activity validated my current practice
Change the management and/or treatment of my patients
I will not make any changes to my practice
Other, please specify:
What new information did you learn during this activity?
Please indicate any barriers you perceive in implementing these changes.
Lack of experience
Lack of opportunity (patients)
Lack of resources (equipment)
Lack of administrative support
Lack of time to assess/counsel patients
Reimbursement/insurance issues
Lack of consensus of professional guidelines
Patient compliance issues
No barriers
Cost
Other
If you indicated any barriers, how will you address these barriers in order to implement changes in your knowledge,
competency, performance, and/or patients’ outcomes?
Comments to help improve this activity?
Recommendations for future CME topics.
REQUEST FOR CREDIT
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and return this form to the registration desk upon your departure. Please do not use abbreviations.
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