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Background Fatigue-related errors that occur during patient care impose a tremendous socioeconomic impact on the health care system. Blue-enriched light has been shown to promote alertness and attention. The present study tested whether blue-enriched light can help to reduce medical errors in a university hospital adult ICU. Methods In this interventional study, a blue-enriched white light emitting diode was used to enhance traditional fluorescent light at the nurse workstation and common areas in the ICU. Medical errors were identified retrospectively using an established two-step surveillance process. Suspected incidents of potential errors detected on nurse chart review were subsequently reviewed by two physicians blinded to lighting conditions, who made final classifications. Error rates were compared between the preintervention fluorescent and postintervention blue-enriched lighting conditions using Poisson regression. Results The study included a total of 1,073 ICU admissions, 522 under traditional and 551 under interventional lighting (age range 17–97 years, mean age ± standard deviation 58.5 ± 15.8). No difference was found in overall medical error rate (harmful and non-harmful) pre- vs. postintervention, 45.5 vs. 42.7 per 1,000 patient-days (rate ratio: 0.94, 95% confidence interval = 0.71–1.23, p = 0.64). Conclusion Interventional lighting did not have an effect on overall medical error rate. The study was likely underpowered to detect the 25% error reduction predicted. Future studies are required that are powered to assess more modest effects for lighting to reduce the risk of fatigue-related medical errors and errors of differing severity.

BACKGROUND: Pediatric Hospital Medicine (PHM) was approved as a subspecialty in 2016. Perspectives of pediatric and combined pediatric residents regarding barriers and facilitators to pursuing PHM fellowships have not previously been assessed. METHODS: A survey to explore residents’ perspectives on PHM fellowships, with questions regarding demographics, likelihood of pursuing PHM after fellowship introduction, and influencing factors was distributed to pediatric and combined pediatric residents via program directors. RESULTS: The survey was distributed to an estimated 2657 residents. A total of 855 (32.2%) residents completed the survey; 89% of respondents had at least considered a career in PHM, and 79.4% reported that the introduction of the PHM fellowship requirement for subspecialty certification made them less likely to pursue PHM. Intent to practice in a community setting or only temporarily practice PHM, Combined Internal Medicine and Pediatric trainee status, and high student loan burden were associated with decreased likelihood of pursuing PHM (P < .05). Most respondents reported that forfeited earnings during fellowship, family and student loan obligations, and perceived sufficiency of residency training discouraged them from pursuing PHM fellowship. Half of respondents valued additional training in medical education, quality improvement, hospital administration, research, and clinical medicine. CONCLUSIONS: Many survey respondents expressed interest in the opportunity to acquire new skills through PHM fellowship. However, the majority of respondents reported being less likely to pursue PHM after the introduction of fellowship requirement for board certification, citing financial and personal opportunity costs. Understanding factors that residents value and those that discourage residents from pursuing PHM fellowship training may help guide future iterations of fellowship design.

Background In 2011, the Accreditation Council for Graduate Medical Education (ACGME) instituted a 16-h limit on consecutive hours for first-year resident physicians. We sought to examine the effect of these work-hour regulations on physician safety. Methods All medical students matched to a US residency program from 2002 to 2007 and 2014 to 2017 were invited to participate in prospective cohort studies. Each month participants reported hours of work, extended duration shifts, and adverse safety outcomes, including motor vehicle crashes, percutaneous injuries, and attentional failures. The incidence of each outcome was compared before and after the 2011 ACGME work-hour limit. Hypotheses were tested using generalized linear models adjusted for potential confounders. Results Of all first-year resident physicians nationwide, 13% participated in the study, with 80,266 monthly reports completed by 15,276 first-year resident physicians. Following implementation of the 16-h 2011 ACGME work-hour limit, the mean number of extended duration (≥24-h) shifts per month decreased from 3.9 to 0.2. The risk of motor vehicle crash decreased 24% (relative risk [RR] 0.76; 0.67-0.85), percutaneous injury risk decreased more than 40% (relative risk 0.54; 0.48-0.61), and the rate of attentional failures was reduced 18% (incidence rate ratio [IRR] 0.82; 0.78-0.86). Extended duration shifts and prolonged weekly work hours were associated with an increased risk of adverse safety outcomes independent of cohort. Conclusions The 2011 ACGME work-hour limit was associated with meaningful improvements in physician safety and health. Surveillance is needed to monitor the ongoing impact of work hours on physician safety, health, and well-being.

Key Points Question Are audit and feedback strategies and educational outreach associated with clinician perceptions of the feasibility, acceptability, appropriateness, and safety of continuous pulse oximetry use in children hospitalized with bronchiolitis who are not receiving supplemental oxygen (guideline-discordant use)? Findings In this 6-hospital single-group nonrandomized clinical trial, 847 nurses and physicians highly rated the feasibility, acceptability, and appropriateness of audit and feedback strategies and educational outreach. Guideline-discordant pulse oximetry use decreased from 53% to 23% during the intervention period. Meaning Educational outreach and audit and feedback strategies were feasible, acceptable, appropriate, and associated with a reduction in guideline-discordant continuous pulse oximetry use in children hospitalized with bronchiolitis who are not receiving supplemental oxygen., Importance National guidelines recommend against continuous pulse oximetry use for hospitalized children with bronchiolitis who are not receiving supplemental oxygen, yet guideline-discordant use remains high. Objectives To evaluate deimplementation outcomes of educational outreach and audit and feedback strategies aiming to reduce guideline-discordant continuous pulse oximetry use in children hospitalized with bronchiolitis who are not receiving supplemental oxygen. Design, Setting, and Participants A nonrandomized clinical single-group deimplementation trial was conducted in 14 non–intensive care units in 5 freestanding children’s hospitals and 1 community hospital from December 1, 2019, through March 14, 2020, among 847 nurses and physicians caring for hospitalized children with bronchiolitis who were not receiving supplemental oxygen. Interventions Educational outreach focused on communicating details of the existing guidelines and evidence. Audit and feedback strategies included 2 formats: (1) weekly aggregate data feedback to multidisciplinary teams with review of unit-level and hospital-level use of continuous pulse oximetry, and (2) real-time 1:1 feedback to clinicians when guideline-discordant continuous pulse oximetry use was discovered during in-person data audits. Main Outcomes and Measures Clinician ratings of acceptability, appropriateness, feasibility, and perceived safety were assessed using a questionnaire. Guideline-discordant continuous pulse oximetry use in hospitalized children was measured using direct observation of a convenience sample of patients with bronchiolitis who were not receiving supplemental oxygen. Results A total of 847 of 1193 eligible clinicians (695 women [82.1%]) responded to a Likert scale-based questionnaire (71% response rate). Most respondents rated the deimplementation strategies of education and audit and feedback as acceptable (education, 435 of 474 [92%]; audit and feedback, 615 of 664 [93%]), appropriate (education, 457 of 474 [96%]; audit and feedback, 622 of 664 [94%]), feasible (education, 424 of 474 [89%]; audit and feedback, 557 of 664 [84%]), and safe (803 of 847 [95%]). Sites collected 1051 audit observations (range, 47-403 per site) on 709 unique patient admissions (range, 31-251 per site) during a 3.5-month period of continuous pulse oximetry use in children with bronchiolitis not receiving supplemental oxygen, which were compared with 579 observations (range, 57-154 per site) from the same hospitals during the baseline 4-month period (prior season) to determine whether the strategies were associated with a reduction in use. Sites conducted 148 in-person educational outreach and aggregate data feedback sessions and provided real-time 1:1 feedback 171 of 236 times (72% of the time when guideline-discordant monitoring was identified). Adjusted for age, gestational age, time since weaning from supplemental oxygen, and other characteristics, guideline-discordant continuous pulse oximetry use decreased from 53% (95% CI, 49%-57%) to 23% (95% CI, 20%-25%) (P, This nonrandomized clinical trial evaluates deimplementation outcomes of educational outreach and audit and feedback strategies aiming to reduce guideline-discordant continuous pulse oximetry use in children hospitalized with bronchiolitis who are not receiving supplemental oxygen.

Objective The risk of medical errors increases upon transfer out of the intensive care unit (ICU). Discrepancies in the documented care plan between notes at the time of transfer may contribute to communication errors. We sought to determine the frequency of clinically meaningful discrepancies in the documented care plan for patients transferred from the pediatric ICU to the medical wards and identified risk factors. Materials and Methods Two physician reviewers independently compared the transfer note and handoff document of 50 randomly selected transfers. Clinically meaningful discrepancies in the care plan between these two documents were identified using a coding procedure adapted from healthcare failure mode and effects analysis. We assessed the influence of risk factors via multivariable regression. Results We identified 34 clinically meaningful discrepancies in 50 patient transfers. Fourteen transfers (28%) had ≥1 discrepancy, and ≥2 were present in 7 transfers (14%). The most common discrepancy categories were differences in situational awareness notifications and documented current therapy. Transfers with handoff document length in the top quartile had 10.6 (95% CI: 1.2–90.2) times more predicted discrepancies than transfers with handoff length in the bottom quartile. Patients receiving more medications in the 24 hours prior to transfer had higher discrepancy counts, with each additional medication increasing the predicted number of discrepancies by 17% (95% CI: 6%–29%). Conclusion Clinically meaningful discrepancies in the documented care plan pose legitimate safety concerns and are common at the time of transfer out of the ICU among complex patients.

Communication errors during transitions of care are a leading source of adverse events for hospitalized patients. This article provides an overview of the role of communication errors in adverse events, describes the complexities of communication for hospitalized patients, and provides evidence regarding the positive effects of applying high-reliability principles to transitions of care and culture of safety. Elements of effective handoffs and a detailed approach for successful implementation of a handoff program are provided. The role of handoff communication in medical education at all levels, as well as for the interprofessional team, is discussed.

OBJECTIVES: Previous studies have revealed racial/ethnic and socioeconomic disparities in quality of care and patient safety. However, these disparities have not been examined in a pediatric inpatient environment by using a measure of clinically confirmed adverse events (AEs). In this study, we do so using the Global Assessment of Pediatric Patient Safety (GAPPS) Trigger Tool. METHODS: GAPPS was applied to medical records of randomly selected pediatric patients discharged from 16 hospitals in the Pediatric Research in Inpatient Settings Network across 4 US regions from January 2007 to December 2012. Disparities in AEs for hospitalized children were identified on the basis of patient race/ethnicity (black, Latino, white, or other; N = 17 336 patient days) and insurance status (public, private, or self-pay/no insurance; N = 19 030 patient days). RESULTS: Compared with hospitalized non-Latino white children, hospitalized Latino children experienced higher rates of all AEs (Latino: 30.1 AEs per 1000 patient days versus white: 16.9 AEs per 1000 patient days; P ≤ .001), preventable AEs (Latino: 15.9 AEs per 1000 patient days versus white: 8.9 AEs per 1000 patient days; P = .002), and high-severity AEs (Latino: 12.6 AEs per 1000 patient days versus white: 7.7 AEs per 1000 patient days; P = .02). Compared with privately insured children, publicly insured children experienced higher rates of preventable AEs (public: 12.1 AEs per 1000 patient days versus private: 8.5 AEs per 1000 patient days; P = .02). No significant differences were observed among other groups. CONCLUSIONS: The GAPPS analysis revealed racial and/or ethnic and socioeconomic disparities in rates of AEs experienced by hospitalized children across a broad range of geographic and hospital settings. Further investigation may reveal underlying mechanisms of these disparities and could help hospitals reduce harm.

Background Miscommunication during patient transfers is a leading cause of medical errors. Inpatient standardization of handoff communication has been associated with reduced medical errors, but less is known about best practices for handoffs from referring providers to the emergency department (ED). The study aims were to identify (1) stakeholder perceptions of current handoff processes and (2) key handoff elements and strategies to optimize patient care on transfer. Methods A mixed-methods needs assessment study was conducted at a tertiary care children's hospital with a communication center that receives verbal handoff via telephone from referring providers and provides written summary to the ED. ED, primary care providers, and communication center staff were surveyed to understand perceptions of handoff processes and ideal handoff elements. Focus groups were conducted to refine concepts. Descriptive statistics, chi-square analysis, and qualitative content analysis were used to analyze responses. Results The survey response rate was 129/152 providers (85%). Forty-two percent of respondents described the quality of the handoff process as "very good" or "excellent"; 43% reported miscommunication occurring "sometimes" or "frequently." Within the I-PASS framework—Illness severity, Patient summary, Action list, Situation awareness and contingency planning, and Synthesis by receiver—respondents identified 10 key elements to obtain through a receiver-driven process to optimize care on transfer. Free-text responses revealed a perceived need to standardize communication. Conclusion A minority of providers perceived handoff quality between outpatient practices and the ED as "very good" or "excellent"; almost half perceived regular miscommunication. A receiver-driven process is a novel approach that may help ensure standardized communication of key handoff elements in this context.

Background The COVID-19 pandemic resulted in disruptions to medical school training and the transition to residency for new post-graduate year 1 resident-physicians (PGY1s). Therefore, the aim of this study was to understand the perspectives of United States PGY1s regarding the impact of the pandemic on these experiences. Our secondary aims were to understand how desire to practice medicine was impacted by the pandemic and whether PGY1s felt that they were able to meaningfully contribute to the COVID-19 response as students. Method We conducted a national, cross-sectional study of PGY1s who had recently graduated from medical school in 2020. A survey was distributed to PGY1s from across specialties, in programs distributed throughout the United States. It included questions about medical school training during the pandemic, impact on graduation timing and transition to internship, concerns about caring for patients with COVID-19, desire to practice medicine, and ability to meaningfully contribute to the pandemic. Findings are presented using descriptive statistics and univariate logistic regression models. Results 1980 PGY1s consented to participate, 1463 completed the survey (74%), and 713 met criteria for this analysis. 77% of PGY1s reported that the pandemic adversely affected their connection with their medical school communities, and 58% reported that the pandemic impeded their preparation for intern year. 4% of PGY1s reported graduating medical school and practicing as an intern earlier than their expected graduation date. While the majority of PGY1s did not have a change in desire to practice medicine, PGY1s with concerns regarding personal health or medical conditions (OR 4.92 [95% CI 3.20–7.55] p p p Conclusions The COVID pandemic disrupted the social connectedness and educational experiences of a majority of PGY1 residents in a sample of trainees in United States training programs. Those with health concerns and children had particularly challenging experiences. As the current and subsequent classes of PGY1s affected by COVID-19 proceed in their training, ongoing attention should be focused on their training needs, competencies, and well-being.

OBJECTIVES: Extended-duration work rosters (EDWRs) with shifts of 24+ hours impair performance compared with rapid cycling work rosters (RCWRs) that limit shifts to 16 hours in postgraduate year (PGY) 1 resident-physicians. We examined the impact of a RCWR on PGY 2 and PGY 3 resident-physicians. METHODS: Data from 294 resident-physicians were analyzed from a multicenter clinical trial of 6 US PICUs. Resident-physicians worked 4-week EDWRs with shifts of 24+ hours every third or fourth shift, or an RCWR in which most shifts were ≤16 consecutive hours. Participants completed a daily sleep and work log and the 10-minute Psychomotor Vigilance Task and Karolinska Sleepiness Scale 2 to 5 times per shift approximately once per week as operational demands allowed. RESULTS: Overall, the mean (± SE) number of attentional failures was significantly higher (P =.01) on the EDWR (6.8 ± 1.0) compared with RCWR (2.9 ± 0.7). Reaction time and subjective alertness were also significantly higher, by ∼18% and ∼9%, respectively (both P CONCLUSIONS: Performance impairment due to EDWR is improved by limiting shift duration. These data and their correlation with SME rates highlight the impairment of neurobehavioral performance due to extended-duration shifts and have important implications for patient safety.

The accuracy of pulse oximetry monitor orders for identifying infants with bronchiolitis who are being continuously monitored is unknown. In this 56-hospital repeated cross-sectional study, investigators used direct bedside observation to determine continuous pulse oximetry monitor use and then assessed if an active continuous monitoring order was present in the electronic health record. Investigators completed 3,612 observations of infants aged 8 weeks to 23 months hospitalized with bronchiolitis and on room air. Most monitored infants did not have an active monitoring order (sensitivity 49% [95% CI, 41-57]). The positive predictive value of a monitoring order was 77% (95% CI, 72-82), and the negative predictive value was 69% (95% CI, 61-77). Teams intending to measure continuous pulse oximetry use should understand the limitations of using electronic health record orders as a stand-alone measure.

Importance Children of parents expressing limited comfort with English (LCE) or limited English proficiency may be at increased risk of adverse events (harms due to medical care). No prior studies have examined, in a multicenter fashion, the association between language comfort or language proficiency and systematically, actively collected adverse events that include family safety reporting. Objective To examine the association between parent LCE and adverse events in a cohort of hospitalized children. Design, setting, and participants This multicenter prospective cohort study was conducted from December 2014 to January 2017, concurrent with data collection from the Patient and Family Centered I-PASS Study, a clinician-family communication and patient safety intervention study. The study included 1666 Arabic-, Chinese-, English-, and Spanish-speaking parents of general pediatric and subspecialty patients 17 years and younger in the pediatric units of 7 North American hospitals. Data were analyzed from January 2018 to May 2020. Exposures Language-comfort data were collected through parent self-reporting. LCE was defined as reporting any language besides English as the language in which parents were most comfortable speaking to physicians or nurses. Main outcomes and measures The primary outcome was adverse events; the secondary outcome was preventable adverse events. Adverse events were collected using a systematic 2-step methodology. First, clinician abstractors reviewed patient medical records, solicited clinician reports, hospital incident reports, and family safety interviews. Then, review and consensus classification were completed by physician pairs. To examine the association of LCE with adverse events, a multivariable logistic regression was conducted with random intercepts to adjust for clustering by site. Results Of 1666 parents providing language-comfort data, 1341 (80.5%) were female, and the mean (SD) age of parents was 35.4 (10.0) years. A total of 147 parents (8.8%) expressed LCE, most of whom (105 [71.4%]) preferred Spanish. Children of parents who expressed LCE had higher odds of having 1 or more adverse events compared with children whose parents expressed comfort with English (26 of 147 [17.7%] vs 146 of 1519 [9.6%]; adjusted odds ratio, 2.1; 95% CI, 1.2-3.7), after adjustment for parent race and education, complex chronic conditions, length of stay, site, and the intervention period. Similarly, children whose parents expressed LCE were more likely to experience 1 or more preventable adverse events (adjusted odds ratio, 2.3; 95% CI, 1.2-4.2). Conclusions and relevance Hospitalized children of parents expressing LCE were twice as likely to experience harms due to medical care. Targeted strategies are needed to improve communication and safety for this vulnerable group of children.

Objectives Residents are often assigned online learning materials as part of blended learning models, superimposed on other patient care and learning demands. Data that describe the time patterns of when residents interact with online learning materials during the ICU rotation are lacking. We describe resident engagement with assigned online curricula related to time of day and ICU clinical schedules, using website activity data. Design Prospective cohort study examining curriculum completion data and cross-referencing timestamps for pre- and posttest attempts with resident schedules to determine the hours that they accessed the curriculum and whether or not they were scheduled for clinical duty. Residents at each site were cohorted based on two differing clinical schedules-extended duration (>24 hr) versus shorter (maximum 16 hr) shifts. Setting Two large academic children's hospitals. Subjects Pediatric residents rotating in the PICU from July 2013 to June 2017. Interventions None. Measurements and main results One-hundred and fifty-seven pediatric residents participated in the study. The majority of residents (106/157; 68%) completed the curriculum, with no statistically significant association between overall curriculum completion and schedule cohort at either site. Residents made more test attempts at nighttime between 6 PM and 6 AM (1,824/2,828; 64%) regardless of whether they were scheduled for clinical duty. Approximately two thirds of test attempts (1,785/2,828; 63%) occurred when residents were not scheduled to work, regardless of time of day. Forty-two percent of all test attempts (1,199/2,828) occurred between 6 PM and 6 AM while off-duty, with 12% (342/2,828) occurring between midnight and 6 AM. Conclusions Residents rotating in the ICU completed online learning materials mainly during nighttime and off-duty hours, including usage between midnight and 6 AM while off-duty. Increasing nighttime and off-duty workload may have implications for educational design and trainee wellness, particularly during busy, acute clinical rotations, and warrants further examination.

BACKGROUND: The effects on patient safety of eliminating extended-duration work shifts for resident physicians remain controversial. METHODS: We conducted a multicenter, cluster-randomized, crossover trial comparing two schedules for pediatric resident physicians during their intensive care unit (ICU) rotations: extended-duration work schedules that included shifts of 24 hours or more (control schedules) and schedules that eliminated extended shifts and cycled resident physicians through day and night shifts of 16 hours or less (intervention schedules). The primary outcome was serious medical errors made by resident physicians, assessed by intensive surveillance, including direct observation and chart review. RESULTS: The characteristics of ICU patients during the two work schedules were similar, but resident physician workload, described as the mean (±SD) number of ICU patients per resident physician, was higher during the intervention schedules than during the control schedules (8.8±2.8 vs. 6.7±2.2). Resident physicians made more serious errors during the intervention schedules than during the control schedules (97.1 vs. 79.0 per 1000 patient-days; relative risk, 1.53; 95% confidence interval [CI], 1.37 to 1.72; P

Introduction The I-PASS Handoff Program is a comprehensive handoff curriculum that has been shown to decrease rates of medical errors and adverse events during patient handoffs. Frontline providers are the key individuals participating in handoffs of patient care. It is important they receive robust handoff training. Methods The I-PASS Mentored Implementation Handoff Curriculum frontline provider training materials were created as part of the original I-PASS Study and adapted for the Society of Hospital Medicine (SHM) I-PASS Mentored Implementation Program. The adapted materials embrace a flipped classroom approach with an emphasis on adult learning theory principles. The training includes an overview of I-PASS handoff techniques, TeamSTEPPS team communication strategies, verbal handoff simulation scenarios, and a printed handoff document exercise. Results As part of the SHM I-PASS Mentored Implementation Program, 2,735 frontline providers were trained at 32 study sites (16 adult and 16 pediatric) across North America. At the end of their training, 1,762 frontline providers completed the workshop evaluation form (64% response rate). After receiving the training, over 90% agreed/strongly agreed that they were able to distinguish a good- from a poor-quality handoff, articulate the elements of the I-PASS mnemonic, construct a high-quality patient summary, advocate for an appropriate environment for handoffs, and participate in handoff simulations. Universally, the training provided them with knowledge and skills relevant to their patient care activities. Discussion The I-PASS frontline training materials were rated highly by those trained and are an integral part of a successful I-PASS Handoff Program implementation.

Objective Continuous pulse oximetry monitoring (cSpO2) in children with bronchiolitis does not improve clinical outcomes and has been associated with increased resource use and alarm fatigue. It is critical to understand the factors that contribute to cSpO2 overuse in order to reduce overuse and its associated harms. Methods This multicenter qualitative study took place in the context of the Eliminating Monitor Overuse (EMO) SpO2 study, a cross-sectional study to establish rates of cSpO2 in bronchiolitis. We conducted semistructured interviews, informed by the Consolidated Framework for Implementation Research, with a purposive sample of stakeholders at sites with high and low cSpO2 use rates to identify barriers and facilitators to addressing cSpO2 overuse. Interviews were audio recorded and transcribed. Analyses were conducted using an integrated approach. Results Participants (n = 56) included EMO study site principal investigators (n = 12), hospital administrators (n = 8), physicians (n = 15), nurses (n = 12), and respiratory therapists (n = 9) from 12 hospitals. Results suggest that leadership buy-in, clear authoritative guidelines for SpO2 use incorporated into electronic order sets, regular education about cSpO2 in bronchiolitis, and visual reminders may be needed to reduce cSpO2 utilization. Parental perceptions and individual clinician comfort affect cSpO2 practice. Conclusion We identified barriers and facilitators to deimplementation of cSpO2 for stable patients with bronchiolitis across children's hospitals with high- and low-cSpO2 use. Based on these data, future deimplementation efforts should focus on clear protocols for cSpO2, EHR changes, and education for hospital staff on bronchiolitis features and rationale for reducing cSpO2.

Importance US national guidelines discourage the use of continuous pulse oximetry monitoring in hospitalized children with bronchiolitis who do not require supplemental oxygen. Objective Measure continuous pulse oximetry use in children with bronchiolitis. Design, Setting, and Participants A multicenter cross-sectional study was performed in pediatric wards in 56 US and Canadian hospitals in the Pediatric Research in Inpatient Settings Network from December 1, 2018, through March 31, 2019. Participants included a convenience sample of patients aged 8 weeks through 23 months with bronchiolitis who were not receiving active supplemental oxygen administration. Patients with extreme prematurity, cyanotic congenital heart disease, pulmonary hypertension, home respiratory support, neuromuscular disease, immunodeficiency, or cancer were excluded. Exposures Hospitalization with bronchiolitis without active supplemental oxygen administration. Main Outcomes and Measures The primary outcome, receipt of continuous pulse oximetry, was measured using direct observation. Continuous pulse oximetry use percentages were risk standardized using the following variables: nighttime (11pm to 7am), age combined with preterm birth, time after weaning from supplemental oxygen or flow, apnea or cyanosis during the present illness, neurologic impairment, and presence of an enteral feeding tube. Results The sample included 3612 patient observations in 33 freestanding children's hospitals, 14 children's hospitals within hospitals, and 9 community hospitals. In the sample, 59% were male, 56% were white, and 15% were black; 48% were aged 8 weeks through 5 months, 28% were aged 6 through 11 months, 16% were aged 12 through 17 months, and 9% were aged 18 through 23 months. The overall continuous pulse oximetry monitoring use percentage in these patients, none of whom were receiving any supplemental oxygen or nasal cannula flow, was 46% (95% CI, 40%-53%). Hospital-level unadjusted continuous pulse oximetry use ranged from 2% to 92%. After risk standardization, use ranged from 6% to 82%. Intraclass correlation coefficient suggested that 27% (95% CI, 19%-36%) of observed variation was attributable to unmeasured hospital-level factors. Conclusions and Relevance In a convenience sample of children hospitalized with bronchiolitis who were not receiving active supplemental oxygen administration, monitoring with continuous pulse oximetry was frequent and varied widely among hospitals. Because of the apparent absence of a guideline- or evidence-based indication for continuous monitoring in this population, this practice may represent overuse.

Continuous pulse oximetry monitoring in stable patients with bronchiolitis is discouraged by national guidelines in order to reduce overuse, yet wide practice variation exists among hospitals. Understanding the association between monitoring overuse and hospital unit-level factors may identify areas for improvement. Conducted at 25 sites from the Pediatric Research in Inpatient Settings (PRIS) Network’s Eliminating Monitoring Overuse (EMO) study, this substudy used data from 2,366 in-person observations of pulse oximetry use in patients with bronchiolitis to determine whether hospital unit-level factors were associated with variation in pulse oximetry use for patients in whom continuous monitoring is not indicated. Hospital units were classified by bronchiolitis admission burden. Monitoring rates were analyzed in a mixed-effects model that accounted for variation in baseline monitoring rates among hospitals and adjusted for covariates significantly associated with continuous pulse oximetry monitoring use in the primary study’s analysis. Low burden units (

The parents of a child recently hospitalized for 3 days for bronchiolitis receive the bill in the mail for their child’s hospital stay. They are stunned by the total amount of the bill. They notice that the hospital room charge accounts for nearly three-fourths of the billed amount. The bill provides no information about the room charge. The parents wonder, “What is this charge? What goes into it? Why is it so expensive?” They are grateful that the bill is covered almost fully by their child’s health insurance. In the current issue of Pediatrics , Synhorst et al1 assessed variation across children’s hospitals in the cost of care for pediatric patients hospitalized with asthma, bronchiolitis, and other common pediatric illnesses. Patients’ hospital rooms accounted for the majority of total hospital costs, whereas nonroom costs (eg, medications, laboratory testing) contributed much less. The authors concluded that initiatives to improve the quality of hospital care for common pediatric illnesses have limited opportunity to meaningfully reduce costs without addressing hospital room costs. Synhorst et al1 highlight the difficulty of conducting research on hospital cost of care using administrative data that provide little information about the biggest expense on the bill: the patient’s room. Although Synhorst et al1 suggest that room costs broadly include overhead and staffing expenses, there are neither established definitions nor … Address correspondence to Jay Berry, MD, MPH, Department of Medicine, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02130. E-mail: jay.berry{at}childrens.harvard.edu

Depression and burnout are highly prevalent among residents, but little is known about modifiable personality variables, such as resilience and stress from uncertainty, that may predispose to these conditions. Residents are routinely faced with uncertainty when making medical decisions.To determine how stress from uncertainty is related to resilience among pediatric residents and whether these attributes are associated with depression and burnout.We surveyed 86 residents in pediatric residency programs from 4 urban freestanding children's hospitals in North America in 2015. Stress from uncertainty was measured with the use of the Physicians' Reaction to Uncertainty Scale, resilience with the use of the 14-item Resilience Scale, depression with the use of the Harvard National Depression Screening Scale; and burnout with the use of single-item measures of emotional exhaustion and depersonalization from the Maslach Burnout Inventory.Fifty out of 86 residents responded to the survey (58.1%). Higher levels of stress from uncertainty correlated with lower resilience (r = -0.60; P .001). Five residents (10%) met depression criteria and 15 residents (31%) met burnout criteria. Depressed residents had higher mean levels of stress due to uncertainty (51.6 ± 9.1 vs 38.7 ± 6.7; P .001) and lower mean levels of resilience (56.6 ± 10.7 vs 85.4 ± 8.0; P .001) compared with residents who were not depressed. Burned out residents also had higher mean levels of stress due to uncertainty (44.0 ± 8.5 vs 38.3 ± 7.1; P = .02) and lower mean levels of resilience (76.7 ± 14.8 vs 85.0 ± 9.77; P = .02) compared with residents who were not burned out.We found high levels of stress from uncertainty, and low levels of resilience were strongly correlated with depression and burnout. Efforts to enhance tolerance of uncertainty and resilience among residents may provide opportunities to mitigate resident depression and burnout.

Background: Pediatric Hospital Medicine (PHM) fellowship programs must train leaders to address local and systemic health care challenges. It is unknown how leadership development education is currently incorporated into PHM fellowship and which topics should be included in future training. Objective: To identify fellowship directors’ perspectives on which leadership development topics are currently taught to PHM fellows and which topics should be required education during PHM fellowship training. Methods: …

PURPOSE: To determine whether higher rates of medical errors were associated with positive screenings for depression or burnout among resident physicians. METHOD: The authors conducted a prospective cohort study from 2011–2013 in seven pediatric academic medical centers in the United States and Canada. Resident physicians were screened for burnout and depression using the Maslach Burnout Inventory – Human Services Survey (MBI-HSS) and Harvard Department of Psychiatry/National Depression Screening Day Scale (HANDS). A two-step surveillance methodology, involving a research nurse and two physician reviewers, was used to measure and categorize errors. Bivariate and mixed-effects regression models were used to evaluate the relationship between burnout, depression, and rates of harmful, nonharmful, and total errors. RESULTS: A total of 388/537 (72%) resident physicians completed the MBI-HSS and HANDS surveys. Seventy-six (20%) and 178 (46%) resident physicians screened positive for depression and burnout, respectively. Screening positive for depression was associated with a 3.0-fold higher rate of harmful errors (incidence rate ratio = 2.99 [95% CI 1.40–6.36], P = .005). However, there was no statistically significant association between depression and total or nonharmful errors or between burnout and harmful, nonharmful, or total errors. CONCLUSIONS: Resident physicians with a positive depression screen were three times more likely than those who screened negative to make harmful errors. This association suggests resident physician mental health could be an important component of patient safety. If further research confirms resident physician depression increases the risk of harmful errors, it will become imperative to determine what interventions might mitigate this risk.

Background Deimplementation, the systematic elimination of low-value practices, has emerged as an important focus within implementation science. Bronchiolitis is the leading cause of infant hospitalization. Among stable inpatients with bronchiolitis who do not require supplemental oxygen, continuous pulse oximetry monitoring is recognized as an overused, low-value practice in pediatric hospital medicine. There is strong scientific evidence and practice guideline support for limiting pulse oximetry monitoring of stable children with bronchiolitis who do not require supplemental oxygen, yet the practice remains common. This study aims to (1) characterize the extent of this overuse in hospitals located in the USA and Canada, (2) identify barriers and facilitators of successful deimplementation of continuous pulse oximetry monitoring in bronchiolitis, and (3) develop consensus strategies for large-scale deimplementation. In addition to identifying feasible strategies for deimplementation, this study will test the feasibility of data collection approaches to be employed in a large-scale deimplementation trial. Methods This multicenter study will be performed in approximately 38 hospitals in the Pediatric Research in Inpatient Settings Network. In Aim 1, we will determine the rate of overuse within each hospital by performing repeated cross-sectional observational sampling of continuous pulse oximetry monitoring of stable bronchiolitis patients age 8 weeks through 23 months who do not require supplemental oxygen. In Aim 2, we will use the Consolidated Framework for Implementation Research (CFIR) as a framework for semi-structured interviews with key stakeholders (physician, nurse, respiratory therapist, administrator, and parent) at the highest- and lowest-overuse hospitals to understand barriers and facilitators of continuous pulse oximetry monitoring deimplementation. In Aim 3, we will use a theory-based causal model to match the identified barriers and facilitators to potential strategies for deimplementation. Candidate strategies will be discussed with a panel of stakeholders from hospitals with high rates of overuse to assess feasibility and acceptability. A questionnaire ranking strategies based on feasibility, acceptability, and impact will be administered to a broader group of stakeholders to arrive at consensus about promising strategies for large-scale deimplementation to be tested in a subsequent trial. Discussion Effective strategies for deimplementing continuous pulse oximetry monitoring of stable patients with bronchiolitis have not been well characterized. The findings of this study will provide further understanding of factors that facilitate deimplementation in pediatric hospital settings and provide pilot and feasibility data to inform a trial of large-scale deimplementation of this overused practice. Trial registration Not applicable. This study does not meet the World Health Organization definition of a clinical trial. Electronic supplementary material The online version of this article (10.1186/s40814-019-0453-2) contains supplementary material, which is available to authorized users.

Introduction: While the Accreditation Council for Graduate Medical Education limited first year resident-physicians to 16 consecutive work hours from 2011 to 2017, resident-physicians in their second year or higher were permitted to work up to 28 h consecutively. This paper describes the Randomized Order Safety Trial Evaluating Resident-physician Schedules (ROSTERS) study, a clustered-randomized crossover clinical trial designed to evaluate the effectiveness of eliminating traditional shifts of 24 h or longer for second year or higher resident-physicians in pediatric intensive care units (PICUs). Methods: ROSTERS was a multi-center non-blinded trial in 6 PICUs at US academic medical centers. The primary aim was to compare patient safety between the extended duration work roster (EDWR), which included shifts �24 h, and a rapidly cycling work roster (RCWR), where shifts were limited to a maximum of 16 h. Information on potential medical errors was gathered and used for classification by centrally trained physician reviewers who were blinded to the study arm. Secondary aims were to assess the relationship of the study arm to resident-physician sleep duration, work hours and neurobehavioral performance. Results: The study involved 6577 patients with a total of 38,821 patient days (n = 18,749 EDWR, n = 20,072 RCWR). There were 413 resident-physician rotations included in the study (n = 203 EDWR, n = 210 RCWR). Resident-physician questionnaire data were over 95% complete. Conclusions: Results from data collected in the ROSTERS study will be evaluated for the impact of resident-physician schedule roster on patient safety outcomes in PICUs, and will allow for examination of a number of secondary outcome measures. ClinicalTrials.gov Identifier: NCT02134847 © 2019 Elsevier Inc.

Introduction Communication failures during shift-to-shift handoffs of patient care have been identified as a leading cause of adverse events in health care institutions. The I-PASS Handoff Program is a comprehensive handoff program that has been shown to decrease rates of medical errors and adverse events. As part of the spread and adaptation of this program, a comprehensive implementation guide was created to assist individuals in the implementation process. Methods The I-PASS Mentored Implementation Guide grew out of materials created for the original I-PASS Study, Society of Hospital Medicine (SHM) mentored implementation programs, and the experience of members of the I-PASS Study Group. The guide provides a comprehensive framework of all elements required to implement the large-scale I-PASS Handoff Program and contains detailed information on generating institutional support, training activities, a campaign, measuring impact, and sustaining the program. Results Thirty-two sites across North America utilized the guide as part of the SHM program. The guide served as a main reference for 477 hours of mentoring phone calls between site leads and their mentors. Postprogram surveys from wave 2 sites revealed that 85% (N = 34) of respondents felt the quality of the guide was very good/excellent. Site leads noted that they referenced the guide most often during the early part of the program and that they referenced the sections on the curriculum and handoff observations most often. Discussion The I-PASS Mentored Implementation Guide is an essential resource for those looking to implement the large-scale I-PASS Handoff Program at their institution.

Study ObjectivesWe compared resident physician work hours and sleep in a multicenter clustered-randomized crossover clinical trial that randomized resident physicians to an Extended Duration Work Roster (EDWR) with extended-duration (≥24 hr) shifts or a Rapidly Cycling Work Roster (RCWR), in which scheduled shift lengths were limited to 16 or fewer consecutive hours.MethodsThree hundred two resident physicians were enrolled and completed 370 1 month pediatric intensive care unit rotations in six US academic medical centers. Sleep was objectively estimated with wrist-worn actigraphs. Work hours and subjective sleep data were collected via daily electronic diary.ResultsResident physicians worked fewer total hours per week during the RCWR compared with the EDWR (61.9 ± 4.8 versus 68.4 ± 7.4, respectively; p < 0.0001). During the RCWR, 73% of work hours occurred within shifts of ≤16 consecutive hours. In contrast, during the EDWR, 38% of work hours occurred on shifts of ≤16 consecutive hours. Resident physicians obtained significantly more sleep per week on the RCWR (52.9 ± 6.0 hr) compared with the EDWR (49.1 ± 5.8 hr, p < 0.0001). The percentage of 24 hr intervals with less than 4 hr of actigraphically measured sleep was 9% on the RCWR and 25% on the EDWR (p < 0.0001).ConclusionsRCWRs were effective in reducing weekly work hours and the occurrence of >16 consecutive hour shifts, and improving sleep duration of resident physicians. Although inclusion of the six operational healthcare sites increases the generalizability of these findings, there was heterogeneity in schedule implementation. Additional research is needed to optimize scheduling practices allowing for sufficient sleep prior to all work shifts.Clinical Trial: Multicenter Clinical Trial of Limiting Resident Work Hours on ICU Patient Safety (ROSTERS), https://clinicaltrials.gov/ct2/show/NCT02134847

Objective To determine whether medical errors, family experience, and communication processes improved after implementation of an intervention to standardize the structure of healthcare provider-family communication on family centered rounds. Design Prospective, multicenter before and after intervention study. Setting Pediatric inpatient units in seven North American hospitals, 17 December 2014 to 3 January 2017. Participants All patients admitted to study units (3106 admissions, 13171 patient days); 2148 parents or caregivers, 435 nurses, 203 medical students, and 586 residents. Intervention Families, nurses, and physicians coproduced an intervention to standardize healthcare provider-family communication on ward rounds (“family centered rounds”), which included structured, high reliability communication on bedside rounds emphasizing health literacy, family engagement, and bidirectional communication; structured, written real-time summaries of rounds; a formal training programme for healthcare providers; and strategies to support teamwork, implementation, and process improvement. Main outcome measures Medical errors (primary outcome), including harmful errors (preventable adverse events) and non-harmful errors, modeled using Poisson regression and generalized estimating equations clustered by site; family experience; and communication processes (eg, family engagement on rounds). Errors were measured via an established systematic surveillance methodology including family safety reporting. Results The overall rate of medical errors (per 1000 patient days) was unchanged (41.2 (95% confidence interval 31.2 to 54.5) pre-intervention v 35.8 (26.9 to 47.7) post-intervention, P=0.21), but harmful errors (preventable adverse events) decreased by 37.9% (20.7 (15.3 to 28.1) v 12.9 (8.9 to 18.6), P=0.01) post-intervention. Non-preventable adverse events also decreased (12.6 (8.9 to 17.9) v 5.2 (3.1 to 8.8), P=0.003). Top box (eg, “excellent”) ratings for six of 25 components of family reported experience improved; none worsened. Family centered rounds occurred more frequently (72.2% (53.5% to 85.4%) v 82.8% (64.9% to 92.6%), P=0.02). Family engagement 55.6% (32.9% to 76.2%) v 66.7% (43.0% to 84.1%), P=0.04) and nurse engagement (20.4% (7.0% to 46.6%) v 35.5% (17.0% to 59.6%), P=0.03) on rounds improved. Families expressing concerns at the start of rounds (18.2% (5.6% to 45.3%) v 37.7% (17.6% to 63.3%), P=0.03) and reading back plans (4.7% (0.7% to 25.2%) v 26.5% (12.7% to 7.3%), P=0.02) increased. Trainee teaching and the duration of rounds did not change significantly. Conclusions Although overall errors were unchanged, harmful medical errors decreased and family experience and communication processes improved after implementation of a structured communication intervention for family centered rounds coproduced by families, nurses, and physicians. Family centered care processes may improve safety and quality of care without negatively impacting teaching or duration of rounds. Trial registration ClinicalTrials.gov NCT02320175 .

1) To develop validity evidence for the use of the Verbal Handoff Assessment Tool (VHAT) and examine the reliability of VHAT scores, and 2) to determine whether implementation of a resident handoff bundle (RHB) was associated with improved verbal patient handoffs among pediatric resident physicians.In a pre-post design, prospectively audio recorded verbal patient handoffs conducted at Boston Children's Hospital before and after implementation of the RHB were rated using the VHAT, which was developed for this study (primary outcome). Using generalizability theory, we evaluated the reliability of VHAT scores.Overall, VHAT scores increased after RHB implementation (mean 142 vs 191, possible score 0-500; P .0001). When accounting for clustering according to resident physician, hospital unit, unit census, and patient complexity, implementation of the RHB was associated with a 63-point increase in VHAT score. Using generalizability theory, we determined that a resident's mean VHAT score on the basis of a handoff of 15 patients assessed by a single observer was sufficiently reliable for relative ranking decisions (ie, norm-based; generalizability coefficient, 0.81), whereas a VHAT score on the basis of a handoff of 21 patients would be sufficiently reliable for high-stakes, standard-based decisions (Phi, 0.80).Verbal handoffs improved after implementation of a RHB, although gains were variable across the 2 clinical units. The VHAT shows promise as an assessment tool for resident handoff skills. If used for competency or entrustment decisions, a resident's mean VHAT score should be on the basis of observation of verbal handoff of ≥21 patients.

BACKGROUND AND OBJECTIVE:Communication breakdowns between members of the health care team compromise patient safety and experience. Communication breakdowns with parents, an important but often overlooked part of the health care team, are understudied. Parents may play a particularly important role in nighttime care given decreased staffing and inadequate transitions of care at night. We studied communication breakdowns evidenced by lack of shared understanding between parents and night-team residents about the reason for admission and care plan.METHODS:We conducted a prospective cohort study of parents (n = 286) and night-team senior residents (n = 34) from May 1, 2013 to October 31, 2013. Parents and residents rated communication and described patients’ reason for admission, overall plan, and overnight plan. Two physician investigators independently reviewed (κ = 0.63) resident-parent dyads, assigned subsequently dichotomized 4-point overall agreement scores, and rated plan complexity. Using clustered logistic regression, we evaluated relationships among demographics, plan complexity, and shared understanding. We also examined resident and parent perceptions of shared understanding.RESULTS:We analyzed data from 257 parent-resident dyads. Among these, 45.1% were rated as lacking shared understanding (agreement score = 1 or 2). In multivariate analysis, higher plan complexity (P < .001) and length of stay (P = .002) were associated with lack of shared understanding; lower parental education was a borderline predictor (P = .05). When surveyed, parents and residents reported that they shared an understanding with one another about care plans in 86.0% and 73.1% of cases, respectively.CONCLUSIONS:Parents and night-team residents frequently lack shared understanding. Family-centered care initiatives to improve parent-provider communication and shared understanding may help empower parents as partners in safe and high-quality nighttime care.

Physicians are among the few professionals who are expected to work extended duty shifts of 24 hours or more, often with little opportunity for rest. The physiological factors regulating sleepiness, including circadian rhythms, sleep homeostasis, and sleep inertia, are pushed to their limits when meeting the demands of training programmes and patient care. Sleep-deprived physicians experience reduced clinical performance and vigilance, putting patients at risk. Tired physicians are more likely to make both cognitive errors (e.g. diagnostic reasoning) and technical errors (e.g. surgical complications). Over recent decades, regulations have promulgated that limit physician hours in Europe and the United States. Studies of their impact have generally shown improvements in patient and physician outcomes, though have also revealed concerns about education and training which must also be addressed. As medicine evolves to meet our 24-hour on-demand society, physicians and patients will need to embrace new approaches to high-quality and safe care delivery.

BACKGROUND: Patient safety concerns over the past 2 decades have prompted widespread efforts to reduce adverse events (AEs). It is unclear whether these efforts have resulted in reductions in hospital-wide AE rates. We used a validated safety surveillance tool, the Global Assessment of Pediatric Patient Safety, to measure temporal trends (2007–2012) in AE rates among hospitalized children. METHODS: We conducted a retrospective surveillance study of randomly selected pediatric inpatient records from 16 teaching and nonteaching hospitals. We constructed Poisson regression models with hospital random intercepts, controlling for patient age, sex, insurance, and chronic conditions, to estimate changes in AE rates over time. RESULTS: Examining 3790 records, reviewers identified 414 AEs (19.1 AEs per 1000 patient days; 95% confidence interval [CI] 17.2–20.9) and 210 preventable AEs (9.5 AEs per 1000 patient days; 95% CI 8.2–10.8). On average, teaching hospitals had higher AE rates than nonteaching hospitals (26.2 [95% CI 23.7–29.0] vs 5.1 [95% CI 3.7–7.1] AEs per 1000 patient days, P < .001). Chronically ill children had higher AE rates than patients without chronic conditions (33.9 [95% CI 24.5–47.0] vs 14.0 [95% CI 11.8–16.5] AEs per 1000 patient days, P < .001). Multivariate analyses revealed no significant changes in AE rates over time. When stratified by hospital type, neither teaching nor nonteaching hospitals experienced significant temporal AE rate variations. CONCLUSIONS: AE rates in pediatric inpatients are high and did not improve from 2007 to 2012. Pediatric AE rates were substantially higher in teaching hospitals as well as in patients with more chronic conditions.

IMPORTANCE: While the relationship between resident work hours and patient safety has been extensively studied, little research has evaluated the role of attending physician supervision on patient safety. OBJECTIVE: To determine the effect of increased attending physician supervision on an inpatient resident general medical service on patient safety and educational outcomes. DESIGN, SETTING, AND PARTICIPANTS: This 9-month randomized clinical trial performed on an inpatient general medical service of a large academic medical center used a crossover design. Participants were clinical teaching attending physicians and residents in an internal medicine residency program. INTERVENTIONS: Twenty-two faculty provided either (1) increased direct supervision in which attending physicians joined work rounds on previously admitted patients or (2) standard supervision in which attending physicians were available but did not join work rounds. Each faculty member participated in both arms in random order. MAIN OUTCOMES AND MEASURES: The primary safety outcome was rate of medical errors. Resident education was evaluated via a time-motion study to assess resident participation on rounds and via surveys to measure resident and attending physician educational ratings. RESULTS: Of the 22 attending physicians, 8 (36%) were women, with 15 (68%) having more than 5 years of experience. A total of 1259 patients (5772 patient-days) were included in the analysis. The medical error rate was not significantly different between standard vs increased supervision (107.6; 95% CI, 85.8-133.7 vs 91.1; 95% CI, 76.9-104.0 per 1000 patient-days; P = .21). Time-motion analysis of 161 work rounds found no difference in mean length of time spent discussing established patients in the 2 models (202; 95% CI, 192-212 vs 202; 95% CI, 189-215 minutes; P = .99). Interns spoke less when an attending physician joined rounds (64; 95% CI, 60-68 vs 55; 95% CI, 49-60 minutes; P = .008). In surveys, interns reported feeling less efficient (41 [55%] vs 68 [73%]; P = .02) and less autonomous (53 [72%] vs 86 [91%]; P = .001) with an attending physician present and residents felt less autonomous (11 [58%] vs 30 [97%]; P

* Abbreviation: CHIP — : Children’s Health Insurance Program Despite our nation’s relatively poor performance on many major health indicators (eg, life expectancy, infant mortality, obesity rates), the United States has the most expensive health care system in the world.1 As a nation, we spend 17.9% of our gross domestic product on health care, or ∼$10 348 per person per year.2 The largest share of this spending comes from the federal government. Because increased focus has been turned to curbing health care costs, a possible approach to reducing federal health care spending would be to tighten eligibility requirements for public insurance, including Medicaid and the Children’s Health Insurance Program (CHIP). Indeed, President Trump’s proposed 2018 budget included a plan to reduce eligibility for CHIP, which was projected to result in a net saving of $5.8 billion over 10 years.3 Although Congress recently reauthorized the CHIP at stable funding levels, the administration’s 2019 budget proposal continues to propose >$1 trillion in Medicaid cuts over a decade, with the reallocation of some funds coming in the form of block grants to states.4 In this issue of Pediatrics , Bettenhausen et al5 report the results of a retrospective cohort study of hospitalizations from … Address correspondence to Christopher P. Landrigan, MD, MPH, Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital, Enders 1, 300 Longwood Ave, Boston, MA 02115. E-mail: christopher.landrigan{at}childrens.harvard.edu

OBJECTIVES: Broad-spectrum antibiotics are commonly used for the empiric treatment of acute hematogenous osteomyelitis and often target methicillin-resistant Staphylococcus aureus (MRSA) with medication-associated risk and unknown treatment benefit. We aimed to compare clinical outcomes among patients with osteomyelitis who did and did not receive initial antibiotics used to target MRSA. METHODS: A retrospective cohort study of 974 hospitalized children 2 to 18 years old using the Pediatric Health Information System database, augmented with clinical data. Rates of hospital readmission, repeat MRI and 72-hour improvement in inflammatory markers were compared between treatment groups. RESULTS: Repeat MRI within 7 and 180 days was more frequent among patients who received initial MRSA coverage versus methicillin-sensitive S aureus (MSSA)–only coverage (8.6% vs 4.1% within 7 days [P = .02] and 12% vs 5.8% within 180 days [P < .01], respectively). Ninety- and 180-day hospital readmission rates were similar between coverage groups (9.0% vs 8.7% [P = .87] and 10.9% vs 11.2% [P = .92], respectively). Patients with MRSA- and MSSA-only coverage had similar rates of 72-hour improvement in C-reactive protein values, but patients with MRSA coverage had a lower rate of 72-hour white blood cell count normalization compared with patients with MSSA-only coverage (4.2% vs 16.4%; P = .02). CONCLUSIONS: In this study of children hospitalized with acute hematogenous osteomyelitis, early antibiotic treatment used to target MRSA was associated with a higher rate of repeat MRI compared with early antibiotic treatment used to target MSSA but not MRSA. Hospital readmission rates were similar for both treatment groups.

OBJECTIVES: The Association of American Medical Colleges published a list of entrustable professional activities (EPAs) that graduating medical students should be able to perform on day 1 of residency without direct supervision. We sought to explore the perceptions of residents and pediatric hospitalists about the level of supervision new interns need in conducting these EPAs. METHODS: An electronic survey was sent to pediatric hospitalists who supervise interns in a large pediatric residency program in which they were asked to rate the amount of supervision they perceive new interns need when performing 11 EPAs. Another survey was sent to residents in which they were asked how much supervision they needed at the beginning of their intern year when performing the same EPAs. Hospitalist and resident responses were compared. RESULTS: The majority of hospitalists thought new interns could perform only 5 of the 11 EPAs without direct supervision. For 5 of the EPAs, residents’ perceptions of their own abilities to perform the EPA independently as interns were significantly greater than the hospitalists’ perceptions of interns’ abilities. For example, 91% of residents thought they were able to recommend and interpret common diagnostic and screening tests when they were interns without direct supervision, compared with only 30% of attending physicians (P < .001). CONCLUSIONS: Hospitalists and residents in a pediatric residency training program reported that new interns were not consistently able to perform the Association of American Medical Colleges’ core EPAs without supervision. Furthermore, residents and pediatric hospitalists perceived new interns’ abilities to perform the EPAs without direct supervision significantly differently.

BACKGROUND Handoffs of patient care are a leading root cause of medical errors. Standardized techniques exist to minimize miscommunications during verbal handoffs, but studies to guide standardization of printed handoff documents are lacking. OBJECTIVE To determine whether variability exists in the content of printed handoff documents and to identify key data elements that should be uniformly included in these documents. SETTING Pediatric hospitalist services at 9 institutions in the United States and Canada. METHODS Sample handoff documents from each institution were reviewed, and structured group interviews were conducted to understand each institution's priorities for written handoffs. An expert panel reviewed all handoff documents and structured group-interview findings, and subsequently made consensus-based recommendations for data elements that were either essential or recommended, including best overall printed handoff practices. RESULTS Nine sites completed structured group interviews and submitted data. We identified substantial variation in both the structure and content of printed handoff documents. Only 4 of 23 possible data elements (17%) were uniformly present in all sites' handoff documents. The expert panel recommended the following as essential for all printed handoffs: assessment of illness severity, patient summary, action items, situation awareness and contingency plans, allergies, medications, age, weight, date of admission, and patient and hospital service identifiers. Code status and several other elements were also recommended. CONCLUSIONS Wide variation exists in the content of printed handoff documents. Standardizing printed handoff documents has the potential to decrease omissions of key data during patient care transitions, which may decrease the risk of downstream medical errors. Journal of Hospital Medicine 2015;10:517–524. © 2015 Society of Hospital Medicine

Despite widespread adoption of in-house call for ICU attendings, there is a paucity of research on optimal scheduling of intensivists to provide continuous on-site coverage. Overnight call duties have traditionally been added onto 7 days of continuous daytime clinical service. We designed an alternative ICU staffing model to increase continuity of attending physician care for patients while also decreasing interruptions to attendings' nonclinical weeks.Computer-based simulation of a 1-year schedule.A simulated ICU divided into two daytime teams each covered by a different attending and both covered by one overnight on-call attending.Simulated patients were randomly admitted on different service days to assess continuity of care.A "shared service schedule" was compared to a standard "7 days on schedule." For the 7 days on schedule, an attending covered a team for 7 consecutive days and off-service attendings cross-covered each night. For the shared schedule, four attendings shared the majority of daytime and nighttime service for two teams over 2 weeks, with recovery periods built into the scheduled service time.Continuity of care as measured by the Continuity of Attending Physician Index increased by 9% with the shared schedule. Annually, the shared service schedule was predicted to increase free weekends by 3.4 full weekends and 1.3 weekends with either Saturday or Sunday off. Full weeks without clinical obligations increased by 4 weeks. Mean time between clinical obligations increased by 5.8 days.A shared service schedule is predicted to improve continuity of care while increasing free weekends and continuity of uninterrupted nonclinical weeks for attendings. Computer-based simulation allows assessment of benefits and tradeoffs of the alternative schedule without disturbing existing clinical systems.

Background In 2009 the I-PASS Study Group was formed by patient safety, medical education, health services research, and clinical experts from multiple institutions in the United States and Canada. When the I-PASS Handoff Program, which was developed by the I-PASS Study Group, was implemented in nine hospitals, it was associated with a 30% reduction in injuries due to medical errors and significant improvements in handoff processes, without any adverse effects on provider work flow. Methods To effectively disseminate and adapt I-PASS for use across specialties and disciplines, a series of federally and privately funded dissemination and implementation projects were carried out following the publication of the initial study. The results of these efforts have informed ongoing initiatives intended to continue adapting and scaling the program. Results As of this writing, I-PASS Study Group members have directly worked with more than 50 hospitals to facilitate implementation of I-PASS. To further disseminate I-PASS, Study Group members delivered hundreds of academic presentations, including plenaries at scientific meetings, workshops, and institutional Grand Rounds. Some 3,563 individuals, representing more than 500 institutions in the 50 states in the United States, the District of Columbia, Puerto Rico, and 57 other countries, have requested access to I-PASS materials. Most recently, the I-PASSSM Patient Safety Institute has developed a virtual immersion training platform, mobile handoff observational tools, and processes to facilitate further spread of I-PASS. Conclusion Implementation of I-PASS has been associated with substantial improvements in patient safety and can be applied to a variety of disciplines and types of patient handoffs. Widespread implementation of I-PASS has the potential to substantially improve patient safety in the United States and beyond.

OBJECTIVES: To define hospital factors associated with proportion of time spent by pediatric residents in direct patient care. METHODS: We assessed 6222 hours of time-motion observations from a representative sample of 483 pediatric-resident physicians delivering inpatient care across 9 pediatric institutions. The primary outcome was percentage of direct patient care time (DPCT) during a single observation session (710 sessions). We used one-way analysis of variance to assess a significant difference in the mean percentage of DPCT between hospitals. We used the intraclass correlation coefficient analysis to determine within- versus between-hospital variations. We compared hospital characteristics of observation sessions with ≥12% DPCT to characteristics of sessions with RESULTS: Mean proportion of physician DPCT was 13.2% (SD = 8.6; range, 0.2%–49.5%). DPCT was significantly different between hospitals (P < .001). The intraclass correlation coefficient was 0.25, indicating more within-hospital than between-hospital variation. Observation sessions with ≥12% DPCT were more likely to occur at hospitals with Magnet designation (odds ratio [OR] = 3.45, P = .006), lower medical complexity (OR = 2.57, P = .04), and higher patient-to-trainee ratios (OR = 2.48, P = .05). CONCLUSIONS: On average, trainees spend

Miscommunications are a leading cause of serious medical errors. Data from multicenter studies assessing programs designed to improve handoff of information about patient care are lacking.We conducted a prospective intervention study of a resident handoff-improvement program in nine hospitals, measuring rates of medical errors, preventable adverse events, and miscommunications, as well as resident workflow. The intervention included a mnemonic to standardize oral and written handoffs, handoff and communication training, a faculty development and observation program, and a sustainability campaign. Error rates were measured through active surveillance. Handoffs were assessed by means of evaluation of printed handoff documents and audio recordings. Workflow was assessed through time-motion observations. The primary outcome had two components: medical errors and preventable adverse events.In 10,740 patient admissions, the medical-error rate decreased by 23% from the preintervention period to the postintervention period (24.5 vs. 18.8 per 100 admissions, P0.001), and the rate of preventable adverse events decreased by 30% (4.7 vs. 3.3 events per 100 admissions, P0.001). The rate of nonpreventable adverse events did not change significantly (3.0 and 2.8 events per 100 admissions, P=0.79). Site-level analyses showed significant error reductions at six of nine sites. Across sites, significant increases were observed in the inclusion of all prespecified key elements in written documents and oral communication during handoff (nine written and five oral elements; P0.001 for all 14 comparisons). There were no significant changes from the preintervention period to the postintervention period in the duration of oral handoffs (2.4 and 2.5 minutes per patient, respectively; P=0.55) or in resident workflow, including patient-family contact and computer time.Implementation of the handoff program was associated with reductions in medical errors and in preventable adverse events and with improvements in communication, without a negative effect on workflow. (Funded by the Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, and others.).

Patient handoffs are a key source of communication failures and adverse events in hospitals. Despite Accreditation Council for Graduate Medical Education requirements for residency training programs to provide formal handoff skills training and to monitor handoffs, well-established curricula and validated skills assessment tools are lacking. Developing a handoff curriculum is challenging because of the need for standardized processes and faculty development, cultural resistance to change, and diverse institution- and unit-level factors. In this article, the authors apply a logic model to describe the process they used from June 2010 to February 2014 to develop, implement, and disseminate an innovative, comprehensive handoff curriculum in pediatric residency training programs as a fundamental component of the multicenter Initiative for Innovation in Pediatric Education-Pediatric Research in Inpatient Settings Accelerating Safe Sign-outs (I-PASS) Study. They describe resources, activities, and outputs, and report preliminary learner outcomes using data from resident and faculty evaluations of the I-PASS Handoff Curriculum: 96% of residents and 97% of faculty agreed or strongly agreed that the curriculum promoted acquisition of relevant skills for patient care activities. They also share lessons learned that could be of value to others seeking to adopt a structured handoff curriculum or to develop large-scale curricular innovations that involve redesigning firmly established processes. These lessons include the importance of approaching curricular implementation as a transformational change effort, assembling a diverse team of junior and senior faculty to provide opportunities for mentoring and professional development, and linking the educational intervention with the direct measurement of patient outcomes.