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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.

Family caregivers use tools and technology to provide care for children with medical complexity (CMC) in the home. It is unclear what barriers families experience when using the tools and technology integral to the care and wellbeing of CMC. Our objective was to identify the barriers family caregivers experience in using tools and technology to provide care to CMC in the home. We used contextual inquiry to interview 30 caregivers in their homes and analyzed our data using a deductive content analysis informed by the patient work system (PWS) model and an inductive content analysis to identify emergent barriers. Through these combined analyses, we identified four categories of barriers families experienced using tools and technology to care for CMC: 1) Access and Cost; 2) Usability, which includes the subcategories Functionality, Tool design, Ease of use, and Reliability; 3) Short-term tool impact; and 4) Long-term tool impact. Our results point to the need for further interventions to reduce or mitigate tools and technology barriers to the in-home care for CMC.

Objective Elicit stakeholder perspectives on the anticipated benefits and challenges of sharing hospital physicians’ admission and daily progress notes with parents at the bedside during their child's hospitalization and identify strategies to aid implementation of inpatient note sharing. Methods Five semistructured focus groups were conducted with 34 stakeholders (8 parents, 8 nurses, 5 residents, 7 hospitalists, 6 administrators) at a tertiary children's hospital from October to November 2018 to identify anticipated benefits, challenges, and implementation strategies prior to sharing inpatient physicians’ notes. A facilitator guide elicited participants’ perspectives about the idea of sharing notes with parents during their child's hospitalization. Three researchers used content analysis to analyze qualitative data inductively. Results Anticipated benefits of sharing inpatient notes included: Reinforcement of information, improved parental knowledge and empowerment, enhanced parent communication and partnership with providers, and increased provider accountability and documentation quality. Expected challenges included: Increased provider workload, heightened parental confusion, distress or anxiety, impaired parent relationship with providers, and compromised note quality and purpose. Suggested implementation strategies included: Setting staff and parent expectations upfront, providing tools to support parent education, and limiting shared note content and family eligibility. Conclusions Stakeholders anticipated multiple benefits and drawbacks of sharing notes with parents during their child's hospital stay and made practical suggestions for ways to implement inpatient note sharing to promote these benefits and mitigate challenges. Findings will inform the design and implementation of an intervention to share notes using an inpatient portal and evaluation of its effect on child, parent, and healthcare team outcomes.

OBJECTIVES:Evaluate provider experiences with a bedside tablet inpatient portal application given to hospitalized patients and families across a children’s hospital.METHODS:In this cross-sectional study, English-speaking parents of children RESULTS:Of 1892 admissions given a tablet over 5 months, 1502 (79.4%) logged in to view their inpatient health record at least once during their hospital stay. No tablets were lost or stolen. Of 101 providers, 96 completed the survey (a response rate of 95%). They reported that patients and/or parents asked them questions about information they found, including laboratory results (45% of respondents), medications (13%), diagnoses (13%), and errors and/or mistakes in care (3%). Few perceived spending more time answering questions related to portal use (8%) or that it increased their workload (11%). In all, 92% of providers wanted patients and parents to continue to be able to use the portal.CONCLUSIONS:Almost 80% of hospitalized patients and parents given a tablet accessed real-time information from the inpatient health record. The portal facilitated communication about test results, diagnoses, and medications and providers overwhelmingly supported its ongoing use.

Preterm birth affects approximately 10% of U.S. births, with survival rates close to 95%. All health care providers, regardless of population or setting, are treating preterm birth survivors. The purpose of this manuscript is to present an umbrella review of the health outcomes of 2- to 12-year-old children who were born preterm. The current umbrella review consisted of 29 reviews, 14 meta-analyses, eight systematic reviews, and seven described as both meta-analysis and systematic review. Studies were grouped into six health outcome categories: neurodevelopmental, motor and/or cerebral palsy, pulmonary, mental and/or behavioral health, quality of life and/or leisure, and eczema. The analysis supports a resounding recommendation to recognize preterm birth, at all gestations, as a risk factor to health and educational outcomes. Increased attention to developmental screenings is critical, specifically recognition that children who are on the lower ranges of normal may benefit from therapies or interventions that support the attainment of future skills.

BACKGROUND: Enteral tubes are prevalent among children with medical complexity (CMC), and complications can lead to costly health care use. Our objective was to design and test the usability of a mobile application (app) to support family-delivered enteral tube care. METHODS: Human-centered design methods (affinity diagramming, persona development, and software development) were applied with family caregivers of CMC to develop a prototype. During 3 waves of usability testing with design refinement between waves, screen capture software collected user-app interactions and inductive content analysis of narrative feedback identified areas for design improvement. The National Aeronautics and Space Administration Task Load Index and the System Usability Scale quantified mental workload and ease of use. RESULTS: Design participants identified core app functions, including displaying care routines, reminders, tracking inventory and health data, caregiver communication, and troubleshooting. Usability testing participants were 80% non-Hispanic white, 28% lived in rural settings, and 20% had not completed high school. Median years providing enteral care was 2 (range 1–14). Design iterations improved app function, simplification, and user experience. The mean System Usability Scale score was 76, indicating above-average usability. National Aeronautics and Space Administration Task Load Index revealed low mental demand, frustration, and effort. All 14 participants reported that they would recommend the app, and that the app would help with organization, communication, and caregiver transitions. CONCLUSIONS: Using a human-centered codesign process, we created a highly usable mobile application to support enteral tube caregiving at home. Future work involves evaluating the feasibility of longitudinal use and effectiveness in improving self-efficacy and reduce device complications.

Objective This study examined family-reported ambulatory care quality and its association with emergency department and hospital utilization, and how these relationships differed across levels of medical complexity. Data sources The 2006-2013 Medical Expenditure Panel Survey (MEPS). Study design Secondary analysis of MEPS data. Variables fitting the National Quality Measures Clearinghouse clinical quality measures domain framework were selected. Exploratory factor analysis grouped ambulatory quality into 12 access, experience, or process measures. Weighted negative binomial regression stratified by health status identified associations between ambulatory quality and ED visits or hospitalizations. Data collection 41,497 children ≤18 years were included. The 5-item special health care needs (SHCN) screener categorized health status as complex, less complex, or no SHCN. Principal findings Weighted SHCN proportions were 1.6 Percent complex, 18.2 Percent less complex, and 80.0 Percent no SHCN. Mean ED visits were 130 and 335 visits/1000 children/year for no/ complex SHCN, respectively. Mean hospitalizations were 20 and 175 hospitalizations/1000 children/year for no/complex SHCN, respectively. ED visits were associated with 8 of 12 quality measures for no/less complex SHCN. For example, usually/always receiving needed care right away was associated with 22 Percent lower ED visit rate (95% CI 0.64-0.96). Hospitalizations were associated with 4 of 12 quality measures for less complex SHCN. In complex SHCN, associations between ambulatory quality and ED/hospital use were weak and inconsistent. Conclusions Ambulatory quality may best predict ED and hospital use for children with no or less complex SHCN. Whether and how ambulatory care predicts emergency and hospital care in complex SHCN remains an important question.

Introduction Medical device-related complications often lead to emergency department (ED) visits and hospitalizations for children with medical complexity (CMC), and pediatric complex care programs may be one way to decrease unnecessary encounters. Methods A retrospective cohort study comparing ED and inpatient encounters due to device complications of 2 cohorts of CMC at a single children's hospital during 2014-2016; 99 enrolled in a complex care program and 244 in a propensity-matched comparison group. Structured chart reviews identified ED and inpatient encounters due to device complications. The outcome was a change in the frequency of these encounters from the year before to the year after enrollment in the hospital's complex care program. Program effects were estimated with weighted difference-in-differences (DiDs), comparing the change in mean encounter frequency for CMC enrolled in the program with change for propensity-matched children not enrolled in the program. Results Mean encounters related to device complications decreased for both groups. Complication-related ED encounters per year decreased from a weighted mean (SD) of 0.74 (0.85) to 0.30 (0.44) in enrolled children and 0.26 (0.89) to 0.12 (0.56) in comparison children, a DiD of 0.30 fewer [95% confidence interval (CI) -0.01 to 0.60]. The largest reductions in device complication ED visits were among those with enteral tubes [0.36 fewer (95% CI 0.04-0.68)]. Hospitalizations decreased over time, but DiDs were not significantly different between groups. Conclusions Acute care use from device complications decreased with time. Complex care program enrollment may be associated with more substantial reductions in device complication ED visits, and effects may be most pronounced for CMC with enteral tubes.

Inpatient care of pediatric trauma patients includes care transitions, including from emergency department (ED) to operating room (OR), OR to pediatric intensive care unit (PICU) and ED to PICU, which are important to patient safety and quality of care. Previous research identified work system barriers and facilitators in these transitions; the most common related to team cognition. We conducted interviews with 18 healthcare professionals to better understand how work system design influences team cognition barriers and facilitators. Using Systems Engineering Initiative for Patient Safety (SEIPS)-based process modeling, we identified when each barrier/facilitator occurred. The ED to OR transition had more barriers in transition preparation, while OR to PICU had more facilitators in the transition. Future research should explore solutions to support team cognition early in the ED to OR transition, such as designing a technology to be used by distributed teams.

Background High-flow nasal cannula (HFNC) is increasingly used to treat children hospitalized with bronchiolitis; however, the best practices for feeding during HFNC and the impact of feeding on time to discharge and adverse events are unknown. The study objective was to assess whether feeding exposure during HFNC was associated with time to discharge or feeding-related adverse events. Methods This retrospective cohort study included inpatients aged 1-24 months receiving HFNC for bronchiolitis at an academic children's hospital from January 1, 2015 to March 1, 2017. Feeding exposures during HFNC were categorized as fed or not fed. Among fed children, we further evaluated mixed (oral and tube) or exclusive oral feeding. The primary outcome was time to discharge after HFNC cessation. Secondary outcomes were aspiration, intubation after HFNC, and seven-day readmission. Results Of 123 children treated with HFNC, 45 (37 %) were never fed. A total of 78 children (63%) were fed; 50 (41%) were exclusively orally fed and 28 (23 %) had mixed feeding. Median (interquartile range) time to discharge after HFNC was 29.5 hours (23.5-47.9) and 39.8 hours (26.4-61.5) hours in the fed and not fed groups, respectively. In adjusted models, time to discharge was shorter with any feeding (hazard ratio [HR] 2.17; 95% CI: 1.34-3.50) and with exclusive oral feeding (HR 2.13; 95% CI: 1.31-3.45) compared with no feeding. Time to discharge from HFNC initiation was shorter for exclusive oral feeding versus not feeding (propensity weighted HR 1.97 [95% CI: 1.13-3.43]). Adverse events (one intubation, one aspiration pneumonia, one readmission) occurred in both groups. Limitations Assessment of feeding exposure did not account for quantity and duration. Discussion Children fed while receiving HFNC for bronchiolitis may have shorter time to discharge than those not fed. Feeding-related adverse events were rare regardless of the feeding method. Controlled prospective studies addressing residual confounding are needed to justify a change in the current practice.

Background: Prematurity affects 10% of American children. Despite excellent survival rates, children born preterm have potential long-term physical, psychological, neurodevelopmental, and behavioral impairments. Nurse practitioners are essential health care providers in primary and specialty settings. The specific aim was to examine select pediatric textbooks for content related to children born preterm. Method: Six textbooks published between 2012 and 2017 were selected and analyzed using summative content analysis to identify inclusion of content within newborn, toddler, school-age, and adolescent categories. Results: The newborn category earned the highest scores, ranging from 16 to 47 (mean = 32.4 ± 13.41, maximum possible = 92). All textbooks reviewed failed to adequately address topic categories for school-age and adolescent children born preterm. Conclusion: Pediatric textbooks fail to address the health and neurodevelopmental risks of children born preterm. Revisions to future textbooks and health care provider curriculum are needed to increased knowledge of this special population. [ J Nurs Educ. 2019;58(6):339–346.]

Pediatric trauma is one of the leading causes of morbidity and mortality in children in the USA. Every year, nearly 10 million children are evaluated in emergency departments (EDs) for traumatic injuries, resulting in 250,000 hospital admissions and, unfortunately, 10,000 deaths. Pediatric trauma care in hospitals is distributed across time and space and involves a large and fluid care team. Several clinical teams (including emergency medicine, surgery, anesthesiology, and pediatric critical care) converge to help support trauma care in the ED; this co-location in the ED can help to support communication, coordination and cooperation of team members. The most severe trauma cases often need surgery in the operating room (OR) and are admitted to the pediatric intensive care unit (PICU). Care transitions in pediatric trauma can result in loss of information or transfer of incorrect information, which can negatively affect the care a child will receive. In this study, we interviewed 18 clinicians and asked questions about communication and coordination during care transitions between the ED, operating room and PICU. After the interview was completed, clinicians completed a short questionnaire about patient safety during transitions. Results of our study show that, despite the fact that the many services and units involved in pediatric trauma cooperate well together during trauma cases, often important patient care information is lost when transitioning patients between units. To safely manage the transition of this fragile and complex population, we need to find ways to better manage the information flow during these transitions by, for instance, providing technological support for shared mental models.

BACKGROUND AND OBJECTIVES:Engaging with parents in care improves pediatric care quality and patient safety; however, parents of hospitalized children often lack the information necessary to effectively participate. To enhance engagement, some hospitals now provide parents with real-time online access to information from their child’s inpatient medical record during hospitalization. Whether these “inpatient portals” provide benefits for parents of hospitalized children is unknown. Our objectives were to identify why parents used an inpatient portal application on a tablet computer during their child’s hospitalization and identify their perspectives of ways to optimize the technology.METHODS:Semistructured in-person interviews were conducted with 14 parents who were given a tablet computer with a commercially available inpatient portal application for use throughout their child’s hospitalization. The portal included vital signs, diagnoses, medications, laboratory test results, patients’ schedule, messaging, education, and provider pictures and/or roles. Interviews were audio recorded and transcribed and continued until reaching thematic saturation. Three researchers used an inductive approach to identify emergent themes regarding why parents used the portal.RESULTS:Five themes emerged regarding parent motivations for accessing information within the portal: (1) monitoring progress, (2) feeling empowered and/or relying less on staff, (3) facilitating rounding communication and/or decision-making, (4) ensuring information accuracy and/or providing reassurance, and (5) aiding memory. Parents recommended that the hospital continue to offer the portal and expand it to allow parents to answer admission questions, provide feedback, and access doctors’ daily notes.CONCLUSIONS:Providing parents with real-time clinical information during their child’s hospitalization using an inpatient portal may enhance their ability to engage in caregiving tasks critical to ensuring inpatient care quality and safety.

Background Preterm birth, defined as birth before the completion of 37 weeks of gestation, is a multifactorial global epidemic with psychosocial, economic, and physical ramifications affecting the child, family, and community at large. Toxic stress-the results of exposure to adverse childhood experiences-results in changes to brain structure and function that negatively affects future health. Objectives The aim of this study was to apply the eco-bio-developmental (EBD) model of poverty and preterm birth to the cross-sectional data of the 2016 National Survey of Children's Health to evaluate the associations between poverty, toxic stress, and prematurity on neurodevelopmental and educational outcomes. Methods A subset of data representing children ages 6-11 years old (n = 15,010) from the 2016 National Survey of Children's Health was used for multivariate analysis of demographic variables and neurodevelopmental and educational outcome variables. Pearson's chi-square, logistic regression, and interaction effects explored the relationships between prematurity, toxic stress, and poverty. Results Children in this sample born preterm had a higher incidence of toxic stress, poverty, developmental delay, learning disability, intellectual disability, speech/language disorders, attention-deficit disorder (ADD)/attention-deficit/hyperactivity disorder (ADHD), autism, and special education/early intervention plans. The combination of poverty, toxic stress, and preterm birth significantly increased the risk of these conditions. After accounting for gender, insurance coverage, race, and parental education, children in the sample born preterm were more likely to experience developmental delay, intellectual disability, speech/language disorder, learning disability, and ADD/ADHD. Toxic stress increased the incidence of ADD/ADHD and autism in both the preterm and full-term samples. Discussion The negative effect of poverty and toxic stress on children born preterm, as depicted by the eco-bio-developmental model, is supported by this analysis. Healthcare providers are encouraged to address the tripartite vulnerability resulting from prematurity, poverty, and toxic stress.

While care transitions influence quality of care, less work studies transitions between hospital units. We studied care transitions from the operating room (OR) to pediatric and adult intensive critical care units (ICU) using Systems Engineering Initiative for Patient Safety (SEIPS)-based process modeling. We interviewed twenty-nine physicians (surgery, anesthesia, pediatric critical care) and nurses (OR, ICU) and administered the AHRQ Hospital Survey on Patient Safety Culture items about handoffs, care transitions and teamwork. Care transitions are complex, spatio-temporal processes and involve work during the transition (i.e., handoff and transport) and preparation and follow up activities (i.e., articulation work). Physicians defined the transition as starting earlier and ending later than nurses. Clinicians in the OR to adult ICU transition without a team handoff reported significantly less information loss and better cooperation, despite positive interview data. A team handoff and supporting articulation work should increase awareness, improving quality and safety of care transitions.

OBJECTIVES:Physicians increasingly share ambulatory visit notes with patients to meet new federal requirements, and evidence suggests patient experiences improve without overburdening physicians. Whether sharing inpatient notes with parents of hospitalized children yields similar outcomes is unknown. In this pilot study, we evaluated parent and physician perceptions of sharing notes with parents during hospitalization.METHODS:Parents of children aged RESULTS:In all, 25 parents and their children’s discharging attending and intern physicians participated. Parents agreed that the information in notes was useful and helped them remember their child’s care plan (100%), prepare for rounds (96%), and feel in control (91%). Although many physicians (34%) expressed concern that notes would confuse parents, no parent reported that notes were confusing. Some physicians perceived that they spent more time writing and/or editing notes (28%) or that their job was more difficult (15%). Satisfaction with sharing was highest among parents (100%), followed by attendings (81%) and interns (35%).CONCLUSIONS:Parents all valued having access to physicians’ notes during their child’s hospital stay; however, some physicians remained concerned about the potential negative consequences of sharing. Comparative effectiveness studies are needed to evaluate the effect of note sharing on outcomes for hospitalized children, families, and staff.

Aim This integrative review synthesized research on the healthcare inequities experienced by adults with developmental disability in the United States and discussed implications for nursing education. Background Individuals with developmental disability are living longer with chronic comorbidities and experience healthcare inequities. Method Application of inclusion criteria to database and ancestry searches resulted in 26 articles that were assessed for quality and analyzed thematically. Results Three categories of inequity were identified: knowledge deficits, communication challenges and poor quality of care. Knowledge deficits and communication challenges can lead to frustration, errors and unmet needs. Poor quality of care encompasses the decreased availability and access to services, limited health promotion participation and higher rates of hospitalizations and complications for adults with developmental disability. Conclusion Healthcare inequities may be reduced by targeting patient and provider knowledge. Inclusion of developmental disability content and clinical experiences in nursing education may improve care and reduce inequities for this underserved population.

OBJECTIVES: Progress notes communicate providers’ assessments of patients’ diagnoses, progress, and treatment plans; however, providers perceive that note quality has degraded since the introduction of electronic health records. In this study, we aimed to (1) develop a tool to evaluate progress note assessments and plans with high interrater reliability and (2) assess whether a bundled intervention was associated with improved intern note quality without delaying note file time. METHODS: An 8-member stakeholder team developed a 19-item progress note assessment and plan evaluation (PNAPE) tool and bundled intervention consisting of a new note template and intern training curriculum. Interrater reliability was evaluated by calculating the intraclass correlation coefficient. Blinded assessors then used PNAPE to evaluate assessment and plan quality in pre- and postintervention notes (fall 2017 and 2018). RESULTS: PNAPE revealed high internal interrater reliability between assessors (intraclass correlation coefficient = 0.86; 95% confidence interval: 0.66–0.95). Total median PNAPE score increased from 13 (interquartile range [IQR]: 12–15) to 15 (IQR: 14–17; P = .008), and median file time decreased from 4:30 pm (IQR: 2:33 pm–6:20 pm) to 1:13 pm (IQR: 12:05 pm–3:59 pm; P < .001) in pre- and postintervention notes. In the postintervention period, a higher proportion of assessments and plans indicated the primary problem requiring ongoing hospitalization and progress of this problem (P = .0016 and P < .001, respectively). CONCLUSIONS: The PNAPE tool revealed high reliability between assessors, and the bundled intervention may be associated with improved intern note assessment and plan quality without delaying file time. Future studies are needed to evaluate whether these improvements can be sustained throughout residency and reproduced in future intern cohorts and other inpatient settings.

OBJECTIVES: Children with medical complexity (CMC) are commonly assisted by medical devices, which family caregivers are responsible for managing and troubleshooting in the home. Optimizing device use by maximizing the benefits and minimizing the complications is a critical goal for CMC but is relatively unexplored. In this study, we sought to identify and describe workarounds families have developed to optimize medical device use for their needs. METHODS: We conducted 30 contextual inquiry interviews with families of CMC in homes. Interviews were recorded, transcribed, and analyzed for barriers and workarounds specific to medical device usage through a directed content analysis. We used observation notes and photographs to confirm and elaborate on interview findings. RESULTS: We identified 4 barriers to using medical devices in the home: (1) the quantity and type of devices allotted do not meet family needs, (2) the device is not designed to be used in locations families require, (3) device use is physically or organizationally disruptive to the home, and (4) the device is not designed to fit the user. We also identified 11 categories of workarounds to the barriers. CONCLUSIONS: Families face many barriers in using medical devices to care for CMC. Our findings offer rich narrative and photographic data revealing the ways in which caregivers work around these barriers. Future researchers should explore the downstream effects of these ubiquitous, necessary workarounds on CMC outcomes toward developing interventions that optimize device use for families.

Preterm birthrates, coupled with excellent preterm birth survival rates, guarantee that every health care provider, regardless of specialty, is caring for patients who were born preterm. Patients and families may not share a preterm birth history however, eliciting this information is important for mitigating potential risk. Long-term health outcomes research supports health implications associated with preterm birth throughout the life course. Through an in-depth review of literature and validation from health care experts in pediatric and adult care, recommendations for primary care providers were developed. The aim was to enhance the identification of those born prematurely, empower health care providers to employ familiar screening strategies, and advocate for mitigations strategies with anticipatory guidance and health promotion. These recommendations advocate a paradigm shift toward proactive intervention, rather than the reactive practice of waiting for children to fail to meet specific milestones or begin to show comorbid tendencies.

OBJECTIVES: Children with medical complexity (CMC) are commonly assisted by medical devices to support essential body functions, although complications may lead to preventable emergency department (ED) and hospital use. Our objective was to identify predictors of device-complicated ED visits and hospitalizations. METHODS: This single-center retrospective cohort study included patients referred to a Pediatric Complex Care Program between April 1, 2014, and April 30, 2016, assisted by at least 1 medical device. Hospitalizations and ED visits in the year before enrollment were rated for likelihood for being due to device complications. Interrater reliability among 3 independent reviewers was assessed. Bivariate followed by multivariate logistic regression clustered by patient helped us identify associations between demographic, clinical, and device characteristics associated with device-complicated ED or hospital encounters. RESULTS: Interrater reliability was high (κ = 0.92). Among 98 CMC, device-complicated encounters represented 17% of 258 hospitalizations and 31% of 228 ED visits. Complications of 3 devices (central venous catheters, enteral tubes, and tracheostomy tubes) accounted for 13% of overall hospitalizations and 28% of overall ED visits. Central venous catheter presence (adjusted odds ratio [aOR] 3.2 [95% confidence interval (CI) 1.1–9.5]) was associated with device-complicated ED visits. Gastrojejunostomy/jejunostomy tube presence (aOR 3.3 [95% CI 1.5–7.5]) or tracheostomies with (aOR 8.1 [95% CI 2.3–28.5]) or without (aOR 4.5 [95% CI 1.7–7.5]) ventilator use was associated with device-complicated hospitalizations. Clinical variables were poor predictors of device-complicated encounters. CONCLUSIONS: Device-complicated ED visits and hospitalizations comprised a substantial proportion of total hospital and ED use. Developing interventions to prevent device complications may be a promising strategy to reduce overall CMC use.

Hospital-based care of pediatric trauma patients includes transitions between units that are critical for quality of care and patient safety. Using a macroergonomics approach, we identify work system barriers and facilitators in care transitions. We interviewed eighteen healthcare professionals involved in transitions from emergency department (ED) to operating room (OR), OR to pediatric intensive care unit (PICU) and ED to PICU. We applied the Systems Engineering Initiative for Patient Safety (SEIPS) process modeling method and identified nine dimensions of barriers and facilitators - anticipation, ED decision making, interacting with family, physical environment, role ambiguity, staffing/resources, team cognition, technology and characteristic of trauma care. For example, handoffs involving all healthcare professionals in the OR to PICU transition created a shared understanding of the patient, but sometimes included distractions. Understanding barriers and facilitators can guide future improvements, e.g., designing a team display to support team cognition of healthcare professionals in the care transitions.

Trauma is the leading cause of disability and death in children and young adults in the US. While much is known about the medical aspects of inpatient pediatric trauma care, not much is known about the processes and roles involved in in-hospital care. Using human factors engineering (HFE) methods, we combine interview, archival document and trauma registry data to describe how intra-hospital care transitions affect process and team complexity. Specifically, we identify the 53 roles directly involved in patient care in each hospital unit and describe the 3324 total transitions between hospital units and the 69 unique pathways, from arrival to discharge, experienced by pediatric trauma patients. We continue the argument to shift from eliminating complexity to coping with it and propose supporting three levels of awareness to enhance the resilience and adaptation necessary for patient safety in health care, i.e. safety in complex systems. We discuss three levels of awareness (individual, team and organizational) and describe challenges and potential sociotechnical solutions for each. For example, one challenge to individual awareness is high time pressure. A potential solution is clinical decision support of information perception, integration and decision making. A challenge to team awareness is inadequate "non-technical" skills, e.g., leadership, communication, role clarity; simulation or another form of training could improve these. The complex, distributed nature of this process is a challenge to organizational awareness; a potential solution is to develop awareness of the process and the roles and interdependencies within it, by using process modeling or simulation.

Preterm birth is a significant public health issue, with children born prematurely experiencing educational and health difficulties throughout childhood. The aim of the descriptive secondary data analysis was to compare health implications and educational experiences in children born prematurely compared with children born at term.The 2011/2012 National Survey of Children's Health data set was explored using separate chi-square tests of homogeneity to investigate differences in the occurrence of chronic health conditions and educationally relevant outcomes: individualized family services plan/individualized education plan (IFSP/IEP), and grade repetition between children born prematurely compared with those born at term.The six most frequently occurring chronic health conditions that disproportionally affected children born prematurely include the following: attention deficit disorder/attention deficit hyperactive disorder (odds ratio [OR], 1.59), anxiety (OR, 1.63), asthma (OR, 1.7), learning disability (OR, 2.07), speech problems (OR, 2.27), and developmental delay (OR, 3.17). Preterm birth negatively affects the educational experience of CBP as measured by increased report of IFSP/IEP and repeated grades across all age categories.All health care providers have an important role in preventing preterm birth and in supporting the children and families affected by preterm birth. Appreciation of the incidence and prevalence of the health conditions and educational difficulties associated with preterm birth is essential for facilitating access to appropriate resources. Beyond patient interactions, these modifiable yet additive factors should inform health policy and planning.

The preterm birth rate in the United States is 10%, with 8% being born between 36 and 32 weeks of gestation, and the remaining 2% born less than 31 weeks of gestation. The global preterm birth rate varies from 5% to 18%, with varying survival rates. These percentages signify a population of people that will receive health care across the life course without ever being asked about a preterm birth history. With a steady rise in the survival rate of preterm infants being discharged home from the neonatal intensive care unit, with limited referrals for neonatal or developmental follow up, it is essential adult care providers ask the right questions and identify risk factors for this vulnerable population. This review describes the recently published, evidence-based recommendations for addressing preterm history across the life course. A robust review of the literature has demonstrated that the long-term sequelae of being born preterm can adversely affect health and quality of life. The following will offer preterm birth history recommendations based on assessment and diagnosis, prevention and management and referral and treatment. The goal of the recommendations is to create awareness among adult health providers in acknowledging a past medical history of preterm birth and providing appropriate preventive care, therefore shifting the paradigm of care from reactive intervention to proactive care.

Patient portals, web-based personal health records linked to electronic health records (EHRs), provide patients access to their healthcare information and facilitate communication with providers. Growing evidence supports portal use in ambulatory settings; however, only recently have portals been used with hospitalized patients. Our objective was to review the literature evaluating the design, use, and impact of inpatient portals, which are patient portals designed to give hospitalized patients and caregivers inpatient EHR clinical information for the purpose of engaging them in hospital care. Literature was reviewed from 2006 to 2017 in PubMed, Web of Science, CINALPlus, Cochrane, and Scopus to identify English language studies evaluating patient portals, engagement, and inpatient care. Data were analyzed considering the following 3 themes: inpatient portal design, use and usability, and impact. Of 731 studies, 17 were included, 9 of which were published after 2015. Most studies were qualitative with small samples focusing on inpatient portal design; 1 nonrandomized trial was identified. Studies described hospitalized patients' and caregivers' information needs and design recommendations. Most patient and caregiver participants in included studies were interested in using an inpatient portal, used it when offered, and found it easy to use and/or useful. Evidence supporting the role of inpatient portals in improving patient and caregiver engagement, knowledge, communication, and care quality and safety is limited. Included studies indicated providers had concerns about using inpatient portals; however, the extent to which these concerns have been realized remains unclear. Inpatient portal research is emerging. Further investigation is needed to optimally design inpatient portals to maximize potential benefits for hospitalized patients and caregivers while minimizing unintended consequences for healthcare teams.

Background and purpose Few nurse practitioner (NP) programs include an after-hours/on-call component in their clinical preparation of NP students. This role is expected in many primary and specialty care practices, and is one that students feel unprepared to competently navigate. Methods Utilizing simulated callers as patients or parents, NP students participated in a simulated after-hours/on-call experience that included receiving the call, managing the patient, and submitting documentation of the encounter. Students completed pre- and postparticipation evaluations, and were evaluated by the simulated patient callers and faculty using standardized evaluation tools. Conclusions NP students rated the experience as an educationally valuable experience despite feeling anxious and nervous about the experience. Several essential skills were identified including critical thinking, clear communication, self-confidence, and access to resources. After participation NP students were more receptive to an NP position with an on-call component. Implications for practice Inclusion of a simulated on-call experience is a feasible component of NP education and should be added to the NP curriculum.

Introduction Prematurity affects a significant portion (10–12%) of children in the Unites States, with potential for physical, psychological, neurodevelopmental, and behavioral impairments continuing long past the neonatal period. The specific aim of this research was to evaluate pediatric primary and specialty care providers' knowledge and understanding of neurodevelopmental outcomes of children born prematurely. Methods Pediatric nurse practitioner (PNP) members of the National Association of Pediatric Nurse Practitioners participated in an online survey using the 33-item Premature Birth Knowledge Scale (PB-KS) to assess their knowledge of current neurodevelopmental outcomes of children born prematurely. Results Neither years of practice as a registered nurse nor as a PNP predicted performance on the PB-KS. The mean score on the PB-KS in the PNP sample was 17.8 (possible score = 0–33), with a mean accuracy of 53.9%. Higher scores on the PB-KS were correlated with higher perceived level of preparation to care for children born prematurely. Discussion To our knowledge, this is the first study to use the PB-KS with pediatric primary and specialty providers. PNPs are uniquely situated to educate and support families facing the long-term consequences of premature birth; to do so they must maintain accurate understanding of current outcomes.

Young people with chronic disease are asked to remember the things needed for self-management, such as refilling prescriptions, taking medicines and going to healthcare appointments, during a time when schedules are busy and demanding. School providers can play a critical role in supporting adolescents with chronic disease, from the assessment of symptoms to encouraging adherence to communicating between families and primary care or specialty healthcare providers. In this chapter, we will briefly describe the use of electronic health record systems and online patient portal technologies to promote the health of populations and individuals with chronic disease. We will then introduce a case of an adolescent with type 1 diabetes to illustrate how apps and wearable technology may be used to support disease self-management. We will also outline potential opportunities for digital health technology to adapt to better fulfill these functions and provide tips for healthcare and school providers.

BACKGROUND AND PURPOSE In recent decades, increased neonatal survival has enabled research of long-term outcomes of those born preterm. The purpose of this article is to present the findings of an umbrella review, an examination of published systematic reviews and meta-analyses, to examine the outcomes of adolescents and adults born preterm. METHODS The research was guided by the Joanna Briggs Institute methodology for umbrella reviews. A systematic search of PubMed, CINAHL, and PsycINFO databases with the search years 2010 through September 2018 yielded 16 reviews for inclusion. CONCLUSIONS The 16 reviews included in this umbrella review represent five clinical outcomes: neurodevelopmental (3 reviews), mental/behavioral health (5 reviews), cardiovascular (4 reviews), pulmonary (3 reviews), and life experience outcomes (4 reviews). One review included data for multiple clinical outcomes. This umbrella review highlights the adolescent and adult risks related to cognitive scores, executive function, anxiety, depression, attention-deficit hyperactivity disorder, long-term effects on systolic blood pressure, low-density lipoproteins and cholesterol levels, pulmonary symptoms, including asthma, pulmonary function, radiographic changes in the lungs, sports and leisure participation, and educational attainment and employment. IMPLICATIONS FOR PRACTICE There is a preponderance of evidence that supports targeted screening for a history of preterm birth by all health care providers. This screening should facilitate the promotion of healthy lifestyles and improving psychosocial and neurodevelopmental difficulties through early and continued support services. Curricular and practice standards are advocated to support this change.

Background Patient portals are intended to engage patients and enhance patient-centered care. Recent studies suggest that the information within portals could provide benefits to patients and their caregivers during hospitalization; however, few studies have examined nurse and staff expectations of portals when used in the hospital setting. Objective This article examines inpatient nurse and support staff expectations of a commercially available inpatient portal prior to its hospital-wide implementation. Methods In this cross-sectional study, nurses and support staff were surveyed 1 month prior to the implementation of an inpatient portal for patients. Items included respondent characteristics, satisfaction with online inpatient portal training, expectations of the effects of portal use on patients, caregivers, and staff, overall acceptance, and barriers to its implementation. Results Of 881 respondents, 73.0% were staff nurses, 18.4% nurse assistants, 4.3% unit coordinators, and 1.2% nurse managers. Respondents were generally satisfied with the portal information they received from online training. A majority liked the portal to some extent prior to its use (66.7%); however, they noted multiple implementation barriers, including: tablets would get lost/damaged (66.2% of respondents), patients and/or caregivers would have too many questions (48.5%), and staff would have problems integrating it into their workflow (44.7%). Respondents working on medical units had higher expectations (p Conclusion Overall, nurse and support staff had high expectations of the effects of inpatient portal use prior to its hospital-wide implementation. They thought it would benefit patients and/or their caregivers; however, they also perceived several barriers to its implementation. These results will be used in conjunction with patient and caregiver perspectives to inform future efforts to evaluate and improve upon inpatient portal implementation and dissemination across health systems.

BACKGROUND AND OBJECTIVES: Hospital discharge requires multidisciplinary coordination. Insufficient coordination impacts patient flow, resource use, and postdischarge outcomes. Our objectives were to (1) implement a prospective, multidisciplinary discharge timing designation in the electronic health record (EHR) and (2) evaluate its association with discharge timing. METHODS: This quality-improvement study evaluated the implementation of confirmed discharge time (CDT), an EHR designation representing specific discharge timing developed jointly by a patient’s family and the health care team. CDT was intended to support task management and coordination of multidisciplinary discharge processes and could be entered and viewed by all team members. Four plan-do-study-act improvement phases were studied: (1) baseline, (2) provider education, (3) provider feedback, and (4) EHR modification. Statistical process control charts tracked CDT use and the proportion of discharges before noon. Length of stay was used as a balancing measure. RESULTS: During the study period from April 2013 through March 2017, 20 133 pediatric discharges occurred, with similar demographics observed throughout all phases. Mean CDT use increased from 0% to 62%, with special cause variations being detected after the provider education and EHR modification phases. Over the course of the study, the proportion of discharges before noon increased by 6.2 percentage points, from 19.9% to 26.1%, whereas length of stay decreased from 47 (interquartile range: 25–95) to 43 (interquartile range: 24–88) hours (both P CONCLUSIONS: The implementation of a prospective, multidisciplinary EHR discharge time designation was associated with more before-noon discharges. Next steps include replicating results in other settings and determining populations that are most responsive to discharge coordination efforts.

Adolescents with severe eating disorders require hospitalization for medical stabilization. Supervision best practices for these patients are not established. This study sought to evaluate the cost and feasibility of centralized video monitoring (CVM) supervision on a general pediatric unit of an academic quaternary care center. This was a retrospective cohort study of nursing assistant (NA) versus CVM supervision for girls 12-18 years old admitted for medical stabilization of an eating disorder between September 2013 and March 2017. There were 37 consecutive admissions (NA = 23 and CVM = 14). NA median supervision cost was more expensive than CVM ($4,104/admission vs $1,166/admission, P < .001). Length of stay and days to weight gain were not statistically different. There were no occurances of family refusal of CVM, conversion from CVM to NA, technological failure, or unplanned discontinuation. Video monitoring was feasible and associated with lower supervision costs than one-to-one NA supervision. Larger samples in multiple centers are needed to confirm the safety, acceptability, and efficacy of CVM.

Background Inpatient portals are online patient portals linked to electronic health records that provide hospitalized patients and caregivers secure access to real-time clinical information and tools to enhance their communication with providers and hospital experience. Objective The main objective of this commentary was to provide a perspective that inpatient portals are innovative tools poised to engage patients and caregivers during hospitalization and, thus, enhance patient-centered care. Results Inpatient portals are desired by patients and caregivers and may contribute to improved recognition of their inpatient care team, knowledge of their treatment plan and overall inpatient experience. A sociotechnical systems approach is recommended to mitigate potential unintended consequences of inpatient portal use and support effective portal design, implementation and evaluation. Conclusions This article highlights the potential of using inpatient portals to engage hospitalized patients and caregivers and proposes next steps to evaluate this emerging technology.

Introduction Preterm birth remains a significant public health issue, with children born prematurely experiencing health and educational difficulties throughout childhood. The specific aim of this study was to evaluate the educational implications of actual or potential health risks of premature birth for children in middle childhood compared with children of the same age who were born at term. Methods This descriptive study is a secondary analysis of the 2011/2012 National Survey of Children's Health, specifically an 8- to 11-year-old subset, comparing children identified as being born premature and those born at term. Educational and health outcome variables were explored. Results Preterm birth negatively affects the educational experience of children born prematurely. Logistic modeling provides insight into predicting risk. Discussion Collaboration between primary care providers, educators, and families is recommended to improve care coordination and address educational need of children born premature.

Purpose The specific aim of this study was to evaluate the health sequelae of preterm birth on children 8 to 11 years of age as compared to same age children born at term; selected variables include special health care needs, chronic conditions, and caregiver perception of health. Design/Methods A secondary data analysis was conducted to evaluate the health outcomes of children 8 to 11 years of age who were born prematurely compared to a sample of children born at term. The 2011/2012 National Survey of Children's Health (NSCH) is a nationally representative telephone interview survey of parents/caregivers of children 0 to 17 years of age. Preterm birth was determined by parent report of birth more than 3 weeks early. Results Utilizing the Children with Special Health Care Needs (CSHCN) Screener, 35% of children born prematurely, compared to 24% of children born at term were identified as having a special health care need. The 5 most prevalent conditions were the same in both groups of 8 to 11 year old children and in the larger total sample of children 2 to 17 years of age. However 82% of children born prematurely were described by parents as having excellent or very good health. Conclusions Premature birth places children at increased risk for conditions that impede the crucial activities of childhood (education, psychosocial development and play). These conditions may require both medications and increased health care services. Implications for Practice Understanding the relationship between preterm birth and ongoing health risks has the potential to inform the health care providers' ability to provide care that maximizes the potential of children born prematurely. Health care providers need to be cognizant of this risk, utilizing early screening and encouraging intervention and family supports.

Objective To describe physician perceptions of the potential goals, characteristics, and content of the electronic problem list (PL) in pediatric trauma. Methods We conducted 12 semistructured interviews with physicians involved in the pediatric trauma care process, including residents, fellows, and attendings from four services: emergency medicine, surgery, anesthesia, and pediatric critical care. Using qualitative content analysis, we identified PL goals, characteristics, and patient-related information from these interviews and the hospital's PL etiquette document of guideline. Results We identified five goals of the PL (to document the patient's problems, to make sense of the patient's problems, to make decisions about the care plan, to know who is involved in the patient's care, and to communicate with others), seven characteristics of the PL (completeness, efficiency, accessibility, multiple users, organized, created before arrival, and representing uncertainty), and 22 patient-related information elements (e.g., injuries, vitals). Physicians' suggested criteria for a PL varied across services with respect to goals, characteristics, and patient-related information. Conclusion Physicians involved in pediatric trauma care described the electronic PL as ideally more than a list of a patient's medical diagnoses and injuries. The information elements mentioned are typically found in other parts of the patient's electronic record besides the PL, such as past medical history and labs. Future work is needed to evaluate the optimal design of the PL so that users with emergent cases, such as pediatric trauma, have access to key information related to the patient's immediate problems.

IMPORTANCE: Clinical guidelines recommend that children with pleural empyema be treated with chest tube insertion and intrapleural fibrinolytics. The addition of dornase alfa (DNase) has been reported to improve outcomes in adults but remains unproven in children. OBJECTIVE: To determine if intrapleural tissue plasminogen activator (tPA) and DNase is more effective than tPA and placebo at reducing hospital length of stay in children with pleural empyema. DESIGN, SETTING, AND PARTICIPANTS: This multicenter, parallel-group, placebo-controlled, superiority randomized clinical trial included children diagnosed as having pleural empyema requiring drainage aged 6 months to 18 years treated at 6 tertiary Canadian children’s hospitals. A total of 379 children were assessed for eligibility; 281 were excluded and 98 were randomized. One child was excluded after randomization for not meeting the inclusion criteria. Data were collected from March 4, 2013, to December 13, 2017. INTERVENTIONS: Participants underwent chest tube insertion and 3 daily administrations of intrapleural tPA, 4 mg, followed by DNase, 5 mg (intervention group), or 5 mL of normal saline (placebo; control group). Participants, families, clinical staff, and members of the study team were blinded to allocation. MAIN OUTCOMES AND MEASURES: The primary outcome was hospital length of stay from chest tube insertion to discharge. Secondary outcomes included time to meeting discharge criteria, time to chest tube removal, mean fever duration, additional pleural drainage procedures, hospital readmissions, and total health care cost. RESULTS: Of the 97 analyzed children with pleural empyema, 52 (54%) were male, and the mean (SD) age was 5.1 (3.6) years. A total of 49 children were randomized to tPA and DNase and 48 were randomized to tPA and placebo. Treatment with tPA and DNase was not associated with decreased hospital length of stay compared with tPA and placebo (mean [SD] length of stay, 9.0 [4.9] vs 9.1 [5.3] days; mean difference, −0.1 days; 95% CI, −2.0 to 2.1; P = .96). Similarly, no significant differences were observed for any of the secondary outcomes. Of the 14 adverse events in the tPA and DNase group, 6 (43%) were serious; of the 21 adverse events in the tPA and placebo group, 8 (38%) were serious. There were no deaths. CONCLUSIONS AND RELEVANCE: The addition of DNase to intrapleural tPA for children with pleural empyema had no effect on hospital length of stay or other outcomes compared with tPA with placebo. Clinical practice guidelines should continue to support the use of chest tube insertion and intrapleural fibrinolytics alone as first-line treatment for pediatric empyema. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01717742

About 9.2 million children visit the emergency department (ED) in the US annually because of trauma and 20% experience a missed injury. Upon arriving to the hospital, physicians evaluate the child and make the ED disposition decision of whether to admit, operate or discharge. The objective of this study is to report the challenges mentioned by healthcare professionals about ED disposition decision making. We conducted 11 interviews with 12 healthcare professionals and identified 2 challenges of ED disposition decision making. The first challenge was timing of the decision; e.g., an ED nurse explained that a quick decision by physicians is important for providing timely patient care to critically ill children. The second challenge was leadership and team organization; e.g., the OR nurse and surgery resident both mentioned the need to know who to listen to so that they can understand what to do. Analyzing these challenges to ED disposition decision making can help to identify sociotechnical solutions for enhancing team situation awareness.

Pediatric trauma is one of the leading causes of morbidity and mortality in children in the USA. Several clinical teams converge to support trauma care in the Emergency Department (ED); the most severe trauma cases often need surgery in the operating room (OR) and/or are admitted to the pediatric intensive care unit (PICU). These care transitions can result in loss of information or transfer of incorrect information, We interviewed 18 clinicians about communication and coordination during care transitions between the ED, OR and PICU. Clinicians completed a short questionnaire about patient safety during transitions. Results show that, although many services and units involved in pediatric trauma work well together, important patient care information may be lost in the transitions. To safely manage transitions of this fragile, unstable, complex population, we need to better manage the information flow during these transitions.

Objective To evaluate ambulatory-care sensitive (ACS) hospitalizations for children with noncomplex chronic diseases (NC-CD) and children with medical complexity (CMC), and identify associations with ambulatory care characteristics. Although ACS hospitalizations are potentially preventable in general populations, the specific ambulatory care predictors and influence of medical complexity on them is poorly understood. Study design Retrospective cohort study of NC-CD and CMC hospitalizations at a children's hospital during 2007-2014, excluding labor/delivery and children over 21 years. Pediatric medical complexity algorithm identified NC-CD or CMC. ACS hospitalizations were identified using Agency for Healthcare Research and Quality indicator definitions. Demographic and ambulatory care characteristics were compared between ACS and non-ACS hospitalizations with logistic regression clustered by patient. Measures of ambulatory care during 2 years before admission were explored with 20% random sample of general pediatrics discharges. Results Among 4035 children with NC-CD, 14.6% of 4926 hospitalizations were ACS hospitalizations. Among 5084 CMC, 5.3% of 14 390 discharges were ACS hospitalizations. Among NC-CD discharges, ACS hospitalizations were more likely with no prior-year outpatient visits (OR 1.4, 95% CI 1.1-1.7) and less likely with timely well checks (OR 0.8, 95% CI 0.6-0.9) and phone encounters in the month before admission (OR 0.5, 95% CI 0.2-1.0). Among CMC discharges, the only association observed was with provider continuity (OR 0.3, 95% CI 0.1- 1.0). Conclusions Provider continuity may be associated with fewer CMC ACS hospitalizations, however, measures of ambulatory care were more consistently associated with ACS hospitalizations for NC-CD. CMC may need more precise ACS hospitalization definitions.

To evaluate trends in procedures used to treat children hospitalized in the US with empyema during a period that included the release of guidelines endorsing chest tube placement as an acceptable first-line alternative to video-assisted thoracoscopic surgery.We used National Inpatient Samples to describe empyema-related discharges of children ages 0-17 years during 2008-2014. We evaluated trends using inverse variance weighted linear regression and characterized treatment failure using multivariable logistic regression to identify factors associated with having more than 1 procedure.Empyema-related discharges declined from 3 in 100 000 children to 2 in 100 000 during 2008-2014 (P = .04, linear trend). There was no significant change in the proportion of discharges having 1 procedure (66.1% to 64.1%) or in the proportion having 2 or more procedures (22.1% to 21.6%). The proportion coded for video-assisted thoracoscopic surgery as the only procedure declined (41.4% to 36.2%; P = .03), and the proportions coded for 1 chest tube (14.6% to 20.9%; P = .04) and 2 chest tube procedures (0.9% to 3.5%; P .01) both increased. The median length of stay for empyema-related discharges remained unchanged (9.3 days to 9.8 days; P = .053). Having more than 1 procedure was associated with continuous mechanical ventilation (adjusted OR, 2.7; 95% CI, 1.8-4.1) but not with age, sex, payer, chronic conditions, transfer admission, hospital size, or census region.The use of video-assisted thoracoscopic surgery to treat children in the US hospitalized with empyema seems to be decreasing without associated increases in length of stay or need for additional drainage procedures.

Participatory ergonomics (PE) can promote the application of human factors and ergonomics (HFE) principles to healthcare system redesign. This study applied a PE approach to redesigning the family-centered rounds (FCR) process to improve family engagement. Various FCR stakeholders (e.g., patients and families, physicians, nurses, hospital management) were involved in different stages of the PE process. HFE principles were integrated in both the content (e.g., shared mental model, usability, workload consideration, systems approach) and process (e.g., top management commitment, stakeholder participation, communication and feedback, learning and training, project management) of FCR redesign. We describe activities of the PE process (e.g., formation and meetings of the redesign team, data collection activities, intervention development, intervention implementation) and present data on PE process evaluation. To demonstrate the value of PE-based FCR redesign, future research should document its impact on FCR process measures (e.g., family engagement, round efficiency) and patient outcome measures (e.g., patient satisfaction).

Approximately 43% of children in the United States (32 million) are currently living with at least 1 of 20 common chronic childhood illnesses. The most common chronic childhood illnesses are asthma, cystic fibrosis, diabetes, obesity, malnutrition, developmental disabilities, cerebral palsy, consequences of low birthweight, and mental illness. For all chronically ill pediatric populations, the outcome of health-related quality of life (HRQOL) is particularly important because many of these children have not and will not be cured, and will continue to manage their chronic illness into adulthood. Advances in biomedical science and technology continue to improve efficacy of treatments and care for chronically ill children, adolescents, and their families, which highlight the importance measurement of HRQOL as a treatment and health status outcome. The construct of HRQOL is subjective, multidimensional, dynamic, and unique to each individual. It includes aspects of physical, psychological, social function, and goal attainment. Outcomes of HRQOL now include the financial implications for these children and their families, as well as financial and organizational consequences for healthcare planning and delivery of services.This article reviews the importance of HRQOL as a health outcome for chronically ill children. A historical overview and synthesis of the conceptualization and measurement of HRQOL for the chronically ill pediatric population is provided. Current research investigations that have measured health outcomes using individual scales tailored to children's specific symptoms health outcomes, such as PROMIS®-Patient Reported Outcomes Measurement Information System-are reviewed. The clinical applications of HRQOL outcomes research include facilitation of patient-healthcare provider communication, improved patient satisfaction, identification of hidden morbidities, a positive impact on clinical decision making, and improvement of patient outcomes over time.

OBJECTIVES:Many parents report needing to watch over their child’s hospital care to prevent mistakes. In this study, we assessed whether needing to watch over care predicts parent performance of recommended safety behaviors to reduce medication errors and health care–associated infections.METHODS:At admission, we surveyed 170 parents about their need to watch over care, demographics, and hospitalization factors. At discharge, parents were surveyed about medication awareness and hand hygiene behaviors. Logistic regression was used to examine how parents’ need to watch over care predicted each behavior, adjusting for demographics and hospitalization factors.RESULTS:Thirty-eight percent of parents reported needing to watch over care. Most parents (77%) reported frequently or very frequently asking providers for drug names or doses. Fewer parents asked to check drug or infusion accuracy (29%) or to show or read aloud medication labels (21%). Few parents reminded providers to clean hands (4%), but most stated they would be comfortable asking (82%) and likely to speak up if a provider did not (78%). After adjustment, parents needing to watch over care were significantly more likely to ask providers to check drug or infusion accuracy (adjusted odds ratio = 4.59, 95% confidence interval 2.14–9.94) and for drug name or dose (adjusted odds ratio = 3.04, 95% confidence interval 1.25–7.39).CONCLUSIONS:Parents who report the need to watch over care are more likely to perform behaviors specific to safe medication use (but not hand hygiene) compared with those not reporting this need. Opportunities exist to engage parents as safety partners by leveraging their need to watch over care toward system-level safety initiatives.

Multiple reports from the Institute of Medicine and the National Academy of Engineering, (IOM 2001; Reid et al., 2005; Kaplan et al., 2013) have called for the use of human factors engineering (HFE) and systems engineering principles and methods/tools to improve health care delivery. Yet, the integration of engineers into health care settings and the education of clinicians and other health care professionals on human factors and systems engineering principles and methods/tools remain in its infancy. A recent editorial by Xiao and Fairbanks (2011), discusses a small, but growing presence of professionals who are “bilingual” in both human factors and medicine. Indeed, Carayon (2011) identified human factors as an innovation that will require diffusion into healthcare through the use of HFE methods and tools, increasing the health care professional knowledge of HFE, and the hiring HFEs in healthcare organizations. To achieve the goal of integration, there will be many “models” of healthcare – human factors collaborations, from experts working together from their different ‘silos’ to true bilingualism. SEIPS, the Systems Engineering Initiative for Patient Safety (Carayon et al., 2006), aims to integrate human factors and systems engineering with healthcare disciplines. Our panel of SEIPS-affiliated engineers and healthcare professionals represents many different types of collaborations across this spectrum and their work spans multiple healthcare settings and disciplines, including: ambulatory primary care, inpatient pediatrics, community pharmacy, and oncology.

A human factors approach to healthcare system redesign emphasizes the involvement of multiple stakeholders in the process. This study identifies work system factors facilitating and hindering the collaboration of multiple stakeholders in a healthcare system redesign project. We interviewed 10 stakeholders participating in the redesign of the family-centered rounds process in a pediatric hospital, and conducted qualitative content analysis of the interview transcripts using the work system model of Smith and Carayon-Sainfort (1989). Various facilitators and barriers to stakeholder collaboration in healthcare system redesign were identified, such as personal characteristics, team characteristics, organizational structure and culture. Results of this study can be used to improve the process used to redesign healthcare work systems and processes that involve multiple stakeholders.

PURPOSE To determine the extent to which alterations in health-related quality of life (HRQOL) and special healthcare needs are experienced by children born prematurely, compared to those born at term. STUDY DESIGN AND METHODS A descriptive comparative design was utilized. A total of 96 children (preterm N = 47, term N = 49) completed the PedsQL 4.0 Generic Core Scales 8- to 12-year-old self-report version. Parents of both groups of children completed the PedsQL 4.0 Generic Core Scales parent-proxy version, the Children with Special Health Care Needs (CSHCN) Screener, and a demographic data form. RESULTS Special healthcare needs were experienced by more than one half of the premature children evaluated. Mean HRQOL scores were significantly different between the children born prematurely and their peers born at term. Parents of both groups reported higher HRQOL scores than their children self-reported. CLINICAL NURSING IMPLICATIONS Given the sustained high rate of premature birth, understanding of current health status of children born prematurely is critical for maternal-child nurses. Advocacy and coordination of care are important to improve the healthcare provided to families of children born prematurely. Future nursing research should incorporate assessment of special healthcare needs and HRQOL of children.

Background Because patients are at the frontline of care where safety climate is closely tied to safety events, understanding patient perceptions of safety climate is crucial. We sought to develop and evaluate a parent-reported version of the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture and to relate parent-reported responses to parental need to watch over their child's care to ensure mistakes are not made. Methods Parents (n=172) were surveyed about perceptions of hospital safety climate (14 items representing four domains—overall perceptions of safety, openness of staff and parent communication, and handoffs and transitions) and perceived need to watch over their child's care. Confirmatory factor analysis (CFA) was used to validate safety climate domain measures. Logistic regression was used to relate need to watch over care to safety climate domains. Results CFA indices suggested good model fit for safety climate domains. Thirty-nine per cent of parents agreed or strongly agreed they needed to watch over care. In adjusted models, need to watch over care was significantly related to overall perceptions of safety (OR 0.20, 95% CI 0.11 to 0.37) and to handoffs and transitions (0.25, 0.14 to 0.46), but not to openness of staff (0.67, 0.40 to 1.12) or parent (0.83, 0.48 to 1.45) communication. Conclusions Findings suggest parents can provide valuable data on specific safety climate domains. Opportunities exist to improve our safety climate's impact on parent burden to watch over their child's care, such as targeting overall perceptions of safety as well as handoffs and transitions.

A growing body of literature suggests that patient- and family-centered care can improve patient outcomes1–5 as well as patient, family, and provider satisfaction.6–10 Engaging patients and families as a way to improve the quality and safety of care has been widely endorsed by leading healthcare organizations,11–13 including the Institute of Medicine.14 In the pediatric inpatient setting, family-centered rounds (FCR), defined as bedside rounds in which the “patient and family share in the control of the management plan as well as in the evaluation of the process itself,”15 potentially provide a consistent venue for family engagement and are recommended by the American Academy of Pediatrics as standard practice.13 According to a recent study by Mittal et al.,16 FCR are the most common type of rounds practiced among pediatric hospitalists surveyed in the United States and Canada. Despite this widespread shift from rounding in a conference room to the bedside with patients and families, there exist only a few studies that provide specific recommendations on conducting FCR.15,17,18 This research has been limited, primarily focusing how rounds are conducted, and further investigation is needed to identify the impact of other processes and elements within the hospital work system that may also affect family engagement during rounds. The objectives of this study were to: 1) identify strategies to enhance family engagement during FCR drawing from the viewpoints of the various stakeholders on rounds, and 2) characterize these strategies into known elements of hospital work systems and rounding processes using a recognized human factors engineering approach, The Systems Engineering Initiative for Patient Safety (SEIPS) model.19 According to the SEIPS model, barriers and facilitators to family engagement during FCR are likely embedded in the design of the hospital work systems and rounding process; therefore, we hypothesized that strategies that influence engagement will target all work system and process elements. This work is part of a larger study in which, after prioritization of this group of strategies based on feasibility and sustainability, a bundle of best practices for conducting FCR will be developed, implemented, and evaluated.