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OBJECTIVES Current screening questions for pediatric tobacco smoke exposure are suboptimal. Factors influencing screening accuracy, particularly in the pediatric inpatient setting, are unknown. Our objective was to identify facilitators of and barriers to parental disclosure of smoke exposure when screened during their child’s hospitalization and strategies to promote accurate disclosure. METHODS This qualitative study was conducted with a convenience sample of parents of children admitted to the medical and surgical unit of a Midwest tertiary care children’s hospital. Eligible parents included those with documented disclosure of smoke exposure in the child’s electronic health record. A researcher trained in qualitative methods conducted semistructured, in-depth interviews with parents regarding their experiences with smoke exposure screening in the inpatient pediatric setting. Two researchers independently identified concepts directed at barriers, facilitators, and strategies for effective screening, which were compared and reconciled by a third researcher. RESULTS Facilitators of disclosing their child’s smoke exposure included the following: (1) the caregiver’s internal characteristic(s) promoting disclosure, (2) perceived relevance of the screening question to the child’s health, and (3) the questioner being viewed positively. Barriers included the following: (1) fear of negative consequences, (2) a vague question, (3) lack of knowledge, (4) guilt, and (5) unconducive environment and timing. The strategies parents suggested to improve screening for smoke exposure included the following: (1) communicate preemptively, (2) provide specific exposure examples, (3) improve questioner-caregiver rapport, and (4) improve screening environment and timing. CONCLUSIONS Parents identified various mechanisms to improve tobacco smoke exposure screening. The facilitators, barriers, and strategies provide opportunities to improve the inpatient pediatric screening process.

OBJECTIVES:The American Academy of Pediatrics recommends that all pediatricians screen for social determinants of health to identify families in need and connect them to available resources. We examined pediatric residents’ screening practices for social needs in different clinical settings and explored the influence of electronic health record (EHR) prompts on screening.METHODS:In this cross-sectional study, pediatric residents participated in a brief electronic survey assessing (1) screening practices for unmet social needs and (2) perceived barriers to and facilitators of routine screening in the inpatient and outpatient settings. The differences in screening by care setting were assessed by using Fisher’s exact test. Mixed-effects logistic regression was used to examine the association between EHR prompts and resident screening practices.RESULTS:Ninety-two pediatric residents (64% of the residency program) responded to the survey. Respondents reported significantly higher rates of social needs screening in the outpatient as compared with the inpatient setting (98% vs 37%; P < .001). Residents cited time constraints, lack of knowledge about available resources, and discomfort with screening questions as barriers to screening in both settings. Residents were more likely to screen for social needs when screening questions were embedded in the EHR (odds ratio = 9.6; 95% confidence interval: 6.7–13.9).CONCLUSIONS:Pediatric residents were more likely to screen for unmet social needs in the outpatient than in the inpatient setting despite reporting similar barriers to screening in both settings. EHR-based social needs screening templates could be used to increase rates of screening and reach additional families in need.

D.M. is a 5-year-old boy admitted to the pediatric hospital medicine (PHM) service overnight with 7 days of persistent fever. His examination and laboratory studies in the emergency department are unrevealing. The next morning on inpatient rounds, the resident team lists a broad differential diagnosis and suggests placing subspecialty consultations for the infectious diseases, rheumatology, and oncology services for testing and management recommendations. However, the attending PHM physician disagrees, stating: “Why don’t we start the workup ourselves and involve subspecialists later if needed? It may add confusion to have too many ‘cooks in the kitchen.’” She discusses the case with an equally-experienced colleague, who states, “That’s interesting. I usually consult subspecialties right away for a patient like this. We’ll get him out the door faster if everyone is on the same page from the start.” This difference in opinion may sound familiar because subspecialty consultation is among the most ubiquitous practices in PHM. Yet we know remarkably little about the impact of subspecialty consultation in the pediatric inpatient setting on patients, families, and the broader health system. Although emerging data have questioned the value of certain consultation practices for hospitalized adults, hospitalists caring for children face unique considerations, including different risk calculations for an inherently vulnerable population, the integral role of families in clinical decision-making, and distinct clinical conditions. In this article, we outline: (1) what is known regarding consultation practice variation; (2) scenarios in which consultations add value to inpatient care; (3) areas in which consultations may decrease health care value; and (4) an agenda for future research on this topic. Identifying practice variation across providers is a key first step in identifying low-value practices.1 Multiple studies of adult inpatients using Medicare administrative data revealed wide variation in consultation use across hospitals that persist after adjustment for patient …

It is with great pleasure that we present the August 2020 issue of Hospital Pediatrics dedicated to the care of children with medical complexity, also known as complex care. The past decade has been characterized by an increasingly detailed understanding of the impact of children with medical complexity on the inpatient setting. Children with complex chronic conditions account for ∼10% of US pediatric hospital admissions, ∼25% of pediatric hospital days, and ∼40% of pediatric hospital charges.1 Children with complex chronic conditions are increasing in prevalence over time as well as complexity.2 Children with complex chronic conditions experience wide …

OBJECTIVES: To assess pediatric providers’ attitudes and barriers to initiating a contraceptive method in the inpatient setting. METHODS: Pediatric attending physicians and trainees from 5 academic institutions were surveyed about contraceptive prescribing practices, attitudes, and potential barriers to initiating contraception in the inpatient setting. RESULTS: In 2016, 271 pediatric providers (34.0% were attending physicians, 18.1% fellows, and 47.9% residents) completed the survey; the response rate was 19.2%. Most participants practiced in both inpatient and outpatient settings (95.7% and 85.0%, respectively). More providers felt confident screening for sexual activity among young adults as compared with adolescents (71.9% vs 65.6%). The same was true for discussing contraceptive options (44.0% vs 38.8%, respectively). Inpatient providers reported seeing adolescents and young adults privately, discussing confidentiality, and asking about sex less than half of the time. More than 80% of providers agreed that it would be appropriate to initiate a contraceptive method for inpatients; 35.8% had done so, and 85.2% indicated that having additional consultation would increase initiation of a contraceptive method in the hospital (88.1% felt similarly for long-active reversible contraception methods). General barriers to initiating contraception included insufficient training, insufficient exposure to adolescents and young adults to maintain skills, and lack of time. Barriers specific to the inpatient setting included concerns about follow-up, confidentiality, and interference with the treatment plan. CONCLUSIONS: Initiation of a contraceptive method in the inpatient setting is acceptable to providers. In our findings, it is suggested that strategies are needed to enhance provision of these services by addressing confidentiality concerns and educating providers.

OBJECTIVES:The goal of this study was to examine preferences for shared decision-making (SDM) in parents of acutely ill versus chronically ill children in the inpatient setting. Additionally, we explored the effect of parental perception of illness severity and uncertainty in illness on decision-making preference.METHODS:In this cross-sectional study, we surveyed parents of children admitted to pediatric inpatient units at an academic, tertiary-care hospital. Surveys were administered in person and used validated tools to assess SDM preferences and uncertainty in illness. Descriptive statistics evaluated associations stratified by acute versus chronic illness, and multivariable analyses were performed.RESULTS:Of the 200 parents who participated, the majority were women (78%), Hispanic (81.5%), English speaking (73%), between 30 and 39 years old (37.5%), and had an education achievement of less than a college degree (77%). The mean age of hospitalized children was 8.1 years, and half reported a chronic illness. Most parents preferred an active (43%) or collaborative (40%) role in SDM. There was no association with SDM preference by demographics, number of previous hospitalizations, perception of illness severity, or uncertainty. However, parents of chronically ill children significantly preferred a passive role in SDM when they perceived a high level of uncertainty in illness.CONCLUSIONS:Most parents of hospitalized children prefer to take an active or collaborative role in SDM. However, parents of chronically ill children who perceive high levels of uncertainty surrounding their children’s illness prefer a passive role, thus illustrating the complexity in decision-making among this parent population.

OBJECTIVES: Protecting confidentiality for hospitalized adolescents can be challenging and may interfere with optimal adolescent-friendly care. The goal of this study was to explore physician trainees’ experience with adolescent confidentiality at an academic children’s hospital. METHODS: A total of 175 trainees were invited to complete an online survey about knowledge, attitudes, and experiences with confidential adolescent concerns in the inpatient setting. A total of 133 (76%) responded: 78% female; 65% pediatric or family medicine residents; and 35% medical students. RESULTS: In the past year, 56 (42%) of 133 trainees cared for a hospitalized adolescent whose confidentiality had been breached. Barriers to ensuring confidentiality included: patient/family not knowledgeable about minor consent law (50%); trainees not knowledgeable about minor consent law (47%); and hospital discharge summary requiring parental signature (47%). On patient- and family-centered rounds (PFCR), respondents reported that minor adolescents (aged CONCLUSIONS: Breaches in confidentiality for hospitalized adolescents are a common trainee experience. On PFCR, adolescents are less likely to have confidential time with the medical team than young adults. In trainees’ experience, hospital systems such as PFCR and discharge procedures pose inherent challenges to confidentiality for minor adolescent patients, as do lack of knowledge of minor consent laws by both clinicians and families.

OBJECTIVES:Childhood obesity is rarely identified in hospitalized pediatric patients despite the high prevalence of obesity and potential for associated morbidity. The purpose of this study was to identify specific patient characteristics associated with the documentation of obesity and related weight management recommendations in the inpatient setting.METHODS:Retrospective chart review was conducted on all pediatric patients ages 2 to 18 years old and discharged between January 1, 2012, and December 31, 2014, to determine the following: (1) if obesity was noted in the clinical documentation of those with a BMI ≥95th percentile; and (2) if those with documented obesity had evidence of an obesity-specific management plan. Using χ2 and multivariable logistic regression, we determined patient characteristics associated with the documentation of obesity and presence of a management plan.RESULTS:Only 26% (214 of 809) of inpatients with obesity had documentation of weight status. The odds of obesity documentation were higher in patients with comorbid cholelithiasis, severe obesity, and older age. Of those with obesity documentation, 23% (49 of 214) had an obesity management plan. Comorbid sleep apnea and admission to a surgical service with a pediatric hospital medicine consult were significantly associated with the presence of an obesity management plan.CONCLUSIONS:Increased efforts are necessary to improve obesity diagnosis and management in younger children who have not yet developed comorbidities. Additionally, the role of pediatric hospitalists as consultants for surgical patients should be further explored as a tool for addressing obesity during inpatient hospitalization.

Objective: To determine the time to detection (TTD) of positive results on blood, urine, and cerebrospinal fluid (CSF) cultures taken during the evaluation for serious bacterial infection (SBI) in otherwise healthy infants aged 0 to 90 days. Methods: This study was a retrospective chart review of infants aged 0 to 90 days with positive blood, urine, or CSF cultures drawn during evaluation for SBI in the emergency department or inpatient setting. The TTD of positive culture results, reason for testing, and age of the infant were recorded. Results: A total of 283 charts were reviewed related to 307 positive culture results. Of the 101 positive results on blood culture, 38% were true pathogens with a mean TTD of 13.3 hours; 97% were identified in ≤36 hours. Blood cultures with TTD ≥36 hours were 7.8 times more likely to be contaminants compared with those with TTD Conclusions: In certain clinical situations, the inpatient observation period for infants under evaluation for SBI may be decreased to 36 hours.

Objective:Many studies have evaluated BMI screening, communication, and follow-up recommendations in the outpatient setting. However, few studies have examined parental attitudes toward using the inpatient setting as a time to screen and counsel families regarding their child’s BMI. We sought to study parental attitudes about overweight and obesity screening in the inpatient setting.Methods:Parents (N = 101) of children aged 2 to 18 years admitted to a general pediatric hospital or surgical service were queried regarding their attitudes about screening and counseling for overweight and obesity. Children’s age, gender, height, weight, and diagnosis codes were extracted from electronic medical records and billing databases. BMI was calculated, plotted, and categorized according to standard Centers for Disease Control and Prevention growth charts and expert recommendation.Results:Fourteen percent of children in the study were overweight, and 17% were obese. Parents of overweight and obese children underestimated their child’s weight status 68% of the time. The majority believed admitted children should always have their BMI calculated. Almost all parents (90%) indicated that their inpatient physician should inform them if their child were overweight or obese and that primary care providers should be informed of the results of BMI screening.Conclusions:Parents of children admitted to the hospital believed their children should have their BMI screened. If their child was overweight or obese, parents believed they should be informed, and counseling should be initiated. These findings support using the inpatient time to screen and communicate BMI.

Over the past decade, there has been a steady increase in the medical complexity of patients on the pediatric inpatient service while at the same time, there are few data to show that families are satisfied with communication of complex issues. Family care conferences are defined as an opportunity outside of rounds to meet and discuss treatment decisions and options. They offer a potential pathway for psychosocial support and facilitated communication. The lack of consensus about the structure of these conferences impedes our ability to research patient, family, and provider outcomes related to communication. The goal of the present article was to describe a structure for family care conferences in the pediatric inpatient setting with a literature-based description of each phase of the conference. The theoretical framework for the structure is that patient and family engagement can improve communication and ultimately health care quality. This proposed model offers guidance to providers and researchers whose goal is to improve communication on the inpatient service.

In the last decade, in an effort to improve family-centered care, pediatric hospitalists have incorporated family-centered bedside rounds into the inpatient setting. By involving patients and families in decision-making during rounds, we have given a new twist to the old concept of bedside rounds and called it family-centered rounds (FCRs). In 2007, Muething et al1 developed the first FCR model for improvement and described the role of FCRs in enhancing family-centered care, trainee education, and reducing discharge timeliness. Since then, many hospitalists programs have incorporated FCRs into their daily rounds, and by 2010, >44% of pediatric hospitalists reported conducting FCRs.2 Sisterhen et al3 defined FCRs as a model that involves planned, purposeful interaction that requires the permission of patients and families and the cooperation of physicians, nurses, and ancillary staff. Although the last decade was spent in establishing FCRs and identifying the attendees’ perceptions of FCRs and their impact on patient care, a recent study by Sharma et al4 in the current issue of Hospital Pediatrics has taken FCRs to the next level by better operationalizing FCRs and setting the stage for future …

Objective: The goal of this study was to measure the costs and difficulty in placing peripheral intravenous (IV) catheters in hospitalized children; measures of resource utilization. We measured the costs and difficulty in placing peripheral intravenous (IV) catheters in hospitalized children. This common procedure has implications for the utilization of hospital resources. Methods: This was a prospective, large-scale observational study in 2 southeastern US pediatric teaching hospitals evaluating 592 children needing peripheral IV catheters in the inpatient setting. The median age was 2.25 years with an age range of 2 days to 18 years. Costs were estimated by using directly measured staff time and national salary data. Analyses included costs according to patient characteristics (age, weight, dehydration, and difficulty of stick attempts), and nurse characteristics (experience in years and anticipated difficulty). Results: The median cost of the pediatric IV insertions was $41, and 60% of the placements were obtained with the first nurse. Seventy-two percent of the children had a successful IV insertion in 1 to 2 attempts and accounted for 53% of total costs. However, the 28% of children who required ≥3 IV attempts had a cost range of $69 to more than $125, and they consumed 43% of the total IV costs. This subset was often Conclusions: The insertion of peripheral IV catheters in an inpatient setting can be time intensive and requires significant skill. Our study suggests that resource utilization may improve when nurses and personnel proficient in starting peripheral IV catheters are used when the initial nurse has failed to obtain IV access. This systems improvement should result in shortened time to administration of parenteral therapies, positively improving outcomes and lessening length of stay, as well as improving patient/family satisfaction due to reduced perceptions of pain.