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Explore how pediatric residents perceive the impact of a curriculum addressing racism on their knowledge, motivation, skills and behaviors, and investigate the contextual factors that promote or impede the curriculum's effectiveness.Open-ended, semistructured interviews were conducted at 2 academic medical centers between August 2019 and 2020 among pediatric residents who participated in the curriculum. Interviews were recorded, transcribed, and analyzed by using inductive content analysis.Pediatric residents (n = 16) were predominantly white (66.7%), female (86.7%) interns (60%) from the Midwest (40%). Six major themes emerged describing the perceived impact of the curriculum on: knowledge - (1) Understanding of race and racism as structural forces in a historical context; motivation - (2) Owning the issue of racism, (3) Having the curriculum makes a statement; skills - (4) Critical self-reflection, (5) Perceived development of skills to mitigate biases; and action-planning - (6) Turning insight into strategies to combat racism and improve patient care. Two additional themes emerged describing contextual factors that promoted or impeded the curriculum such as the content of the curriculum itself, the racial demographics of the participants, the implementation infrastructure and environmental factors such as the culture of the training program.Medical education addressing racism can facilitate the perceived acquisition of foundational knowledge regarding race and racism; motivation and skill-building to combat racism; and action planning aimed at improving patient care. Contextual factors should be considered when developing and implementing such curricula to not only promote racial equity but avoid unintended harms.

Poverty affects child health and well-being in short- and long-term ways, directly and indirectly influencing a range of health outcomes through linked social and environmental challenges. Given these links, pediatricians have long advocated for poverty reduction in both clinical settings and society. Pediatricians and others who work in pediatric settings are well-suited to address poverty given frequent touchpoints with children and families and the trust that develops over repeated encounters. Many pediatricians also recognize the need for cross-sector engagement, mobilization, and innovation in building larger collaborative efforts to combat the harmful effects of poverty. A range of methods, like co-design, community organizing, and community-engaged quality improvement, are necessary to achieve measurable progress. Moreover, advancing meaningful representation and inclusion of those from underrepresented racial and ethnic minority groups will augment efforts to address poverty within and equity across communities. Such methods promote and strengthen key clinical-community partnerships poised to address poverty's upstream root causes and its harmful consequences downstream. This article focuses on those clinical-community intersections and cross-sector, multi-disciplinary programs like Medical-Legal Partnerships, Medical-Financial Partnerships, clinic-based food pantries, and embedded behavioral health services. Such programs and partnerships increase access to services difficult for children living in poverty to obtain. Partnerships can also broaden to include community-wide learning networks and asset-building coalitions, poised to accelerate meaningful change. Pediatricians and allied professionals can play an active role; they can convene, catalyze, partner, and mobilize to create solutions designed to mitigate the harmful effects of poverty on child health.

Racism and sexism that manifest as microaggressions are commonly experienced by members of minoritized groups. These actions and comments erode their subjects’ vitality and sense of belonging. Individuals from minoritized groups are often left in a quandary, weighing the potential benefits and risks of addressing the comments. Placing the burden to interrupt bias on our marginalized colleagues is unjust. In part, it is inappropriate to expect them to dismantle a system that they did not create. It is essential for individuals with privilege who observe microaggressions to address the speaker and support their colleagues. In this Ethics Rounds, we present 2 cases in which individuals from minoritized groups experience racism and sexism that manifest as microaggressions. The first case involves a Black female physician making recommendations in a business meeting being characterized by a male colleague as emotional. The commentators analyze how both gender and race constrain the range of acceptable emotions one may exhibit and the harm that this causes. The second case involves a Black intern being identified by a parent as a custodian. Commentators describe how such microaggressions can harm trainees’ performance and sense of belonging. In both cases, observers did nothing or only spoke to the subject in private. Commentators provide specific guidance regarding actions that bystanders can take to become upstanders and how they can decenter themselves and their discomfort and leverage their privilege to interrupt microaggressions. By becoming upstanders, individuals can remove the disproportionate responsibility for addressing microaggressions from marginalized colleagues.

OBJECTIVES At the onset of the coronavirus disease 2019 pandemic, disruptions to pediatric care and training were immediate and significant. We sought to understand the impact of the pandemic on residency training from the perspective of pediatric residents. METHODS We conducted a cross-sectional survey of categorical pediatric residents at US training programs at the end of the 2019–2020 academic year. This voluntary survey included questions that explored the impact of the coronavirus disease 2019 pandemic on resident training experiences, postresidency employment plans, and attitudes and perceptions. Data were analyzed by using descriptive statistics and mixed-effects regression models. We performed a sensitivity analysis using respondents from programs with a >40% response rate for questions regarding resident attitudes and perceptions. RESULTS Residents from 127 of 201 training programs (63.2%) completed the survey, with a response rate of 18.9% (1141 of 6032). Respondents reported multiple changes to their training experience including rotation schedule adjustments, clinic cancellations, and an increase in the use of telemedicine. Respondents also reported inconsistent access to personal protective equipment and increased involvement in the care of adult patients. Graduating resident respondents reported concerns related to employment. Respondents also noted a negative impact on their personal wellness. CONCLUSIONS Responding residents reported that nearly every aspect of their training was impacted by the pandemic. Describing their experiences may help residency program and hospital leaders supplement missed educational experiences, better support residents through the remaining months of the pandemic, and better prepare for extraordinary circumstances in the future.

BACKGROUND AND OBJECTIVES Patients with limited English proficiency (LEP) have increased risk of adverse events after hospitalization. At our institution, LEP families did not routinely receive translated discharge instructions in their preferred language. Our objective for this study was to increase the percentage of patients with LEP on the hospital medicine (HM) service receiving translated discharge instructions from 12% to 80%. METHODS Following the Model for Improvement, we convened an interdisciplinary team that included HM providers, pediatric residents, language access services staff, and nurses to design and test interventions aimed at key drivers through multiple plan-do-study-act cycles. Interventions addressed the translation request process, care team education, standardizing discharge instructions for common conditions, and identification and mitigation of failures. We used established rules for analyzing statistical process control charts to evaluate the percentage of patients with translated discharge instructions for all languages and for Spanish. RESULTS During the study period, 540 patients with LEP were discharged from the HM service. Spanish was the preferred language for 66% of patients with LEP. The percentage of patients with LEP who received translated discharge instructions increased from 12% to 50% in 3 months and to 77% in 18 months. For patients whose preferred language was Spanish, the percentage increased from 16% to 69% in 4 months and to 96% in 18 months. CONCLUSIONS Interventions targeting knowledge of the translation process and standardized Spanish discharge instructions were associated with an increased percentage of families receiving translated discharge instructions. Future work will be used to assess the impact of these interventions on postdischarge disparities, including emergency department revisits and readmissions.

Introduction Despite learning health systems' focus on improvement in health outcomes, inequities in outcomes remain deep and persistent. To achieve and sustain health equity, it is critical that learning health systems (LHS) adapt and function in ways that directly prioritize equity. Methods We present guidance, including seven core practices, borne from theory, evidence, and experience, for actors within LHS pursuing equity. Results We provide a foundational definition of equity. We then offer seven core practices for how LHS may effectively pursue equity in health: establish principle, measure for equity, lead from lived experience, co‐produce, redistribute power, practice a growth mindset, and engage beyond the healthcare system. We include three use cases that illustrate ways in which we have begun to center equity in the work of our own LHS. Conclusion The achievement of equity requires real transformation at individual, institutional, and structural levels and requires sustained and persistent effort.

Competency-based training should be paired with objective assessments. To date, there has been limited objective assessment of resident-as-teacher curricula (RATC). We sought to assess the impact of a longitudinal RATC on postgraduate year-1 (PGY1) resident teaching competency using Observed Structured Teaching Encounters (OSTEs) for the skills of 1) brief didactic teaching [DT], 2) feedback [FB], and 3) precepting [PR].A controlled, prospective, educational study was conducted from May 2015 to June 2016. The RATC consisted of a workshop series with reinforcement of key skills (DT, FB) during clinical rotations. Intervention residents participated in the RATC and completed OSTEs at the beginning and end of the academic year. A control group, PGY1 residents that matriculated the year previously, completed the OSTEs before starting their PGY2 year. OSTEs were reviewed by 2 blinded study personnel. We assessed reliability between raters via intraclass correlation coefficients and differences in OSTE scores via least squared mean differences (LSMD).In total, 92.5% (n = 37) of eligible control and 100% (n = 41) of eligible intervention residents participated. The OSTEs demonstrated excellent agreement between reviewers (DT: 0.99, FB: 0.89, PR: 0.98). A significant pre-post difference was demonstrated in the intervention group for DT (LSMD [95% confidence interval], 3.14 [2.49-3.79], P.0001), FB (0.93 [0.49-1.37], P.0001), and PR (0.64 [0.09-1.18], P.022). A significant difference between the control and intervention groups was demonstrated for DT (3.00 [2.05-3.96], P.0001).Skill-based OSTEs can be used to detect changes in residents' teaching competency and may represent a potential component of programmatic evaluation of resident-as-teacher curricula.

BACKGROUND Despite national recommendations for early transition to enteral antimicrobials, practice variability has existed at our hospital. OBJECTIVE The aim of this study was to increase the proportion of enterally administered antibiotic doses for Pediatric Hospital Medicine patients aged >60 days admitted for uncomplicated community-acquired pneumonia or skin and soft tissue infections from 44% to 75% in eight months. METHODS This quality improvement study was conducted at a large, urban, academic children's hospital. The study population included Hospital Medicine patients aged >60 days with diagnoses of pneumonia or skin and soft tissue infections. Interventions included education on intravenous and enteral antibiotic charge differentials, documentation of transition plan, structured discussions of transition criteria, and real-time identification of failures with feedback. Our process measure was the total number of enteral antibiotic doses divided by all antibiotic doses in patients receiving enteral medications on the same day. An annotated statistical process control chart tracked the impact of interventions on the administration route of antibiotic doses over time. Additional outcome measures included antimicrobial costs per patient encounter using average wholesale prices and length of stay. RESULTS The percentage of enterally administered antibiotic doses increased from 44% to 80% within eight months. Antimicrobial costs per patient encounter and the associated standard deviation of costs for our target diagnoses decreased by 70% and 84%, respectively. Average length of stay did not change. CONCLUSIONS Standardized communication about criteria for transition from intravenous to enteral antibiotics can lead to earlier transitions for patients with pneumonia or skin and soft tissue infections, subsequently reducing costs and prescribing variability.

Background Achieving effective communication between medical providers and families with limited English proficiency (LEP) in the hospital is difficult. Objective Our objective was to identify barriers to and drivers of effective interpreter service use when caring for hospitalized LEP children from the perspectives of pediatric medical providers and interpreters. Design/participants/setting We used Group Level Assessment (GLA), a structured qualitative participatory method that allows participants to directly produce and analyze data in an interactive group session. Participants from a single academic children's hospital generated individual responses to prompts and identified themes and relevant action items. Themes were further consolidated by our research team and verified by stakeholder groups. Results Four GLA sessions were conducted including 64 participants: hospital medicine physicians and pediatric residents (56%), inpatient nursing staff (16%), and interpreter services staff (28%). Barriers identified included: (1) difficulties accessing interpreter services; (2) uncertainty in communication with LEP families; (3) unclear and inconsistent expectations and roles of team members; and (4) unmet family engagement expectations. Drivers of effective communication were: (1) utilizing a team-based approach between medical providers and interpreters; (2) understanding the role of cultural context in providing culturally effective care; (3) practicing empathy for patients and families; and (4) using effective family-centered communication strategies. Conclusions Participants identified unique barriers and drivers that impact communication with LEP patients and their families during hospitalization. Future directions include exploring the perspective of LEP families and utilizing team-based and family-centered communication strategies to standardize and improve communication practices.

Background:CHD is the most common birth defect type, with one-fourth of patients requiring intervention in the first year of life. Caregiver understanding of CHD may vary. Health literacy may be one factor contributing to this variability.Methods:The study occurred at a large, free-standing children’s hospital. Recruitment occurred at a free-of-charge CHD camp and during outpatient cardiology follow-up visits. The study team revised the CHD Guided Questions Tool from an eighth- to a sixth-grade reading level. Caregivers of children with CHD completed the “Newest Vital Sign” health literacy screen and demographic surveys. Health literacy was categorised as “high” (Newest Vital Sign score 4–6) or “low” (score 0–3). Caregivers were randomised to read either the original or revised Guided Questions Tool and completed a validated survey measuring understandability and actionability of the Guided Questions Tool. Understandability and actionability data analysis used two-sample t-testing, and within demographic group differences in these parameters were assessed via one-way analysis of variance.Results:Eighty-two caregivers participated who were largely well educated with a high income. The majority (79.3%) of participants scored “high” for health literacy. No differences in understanding (p = 0.43) or actionability (p = 0.11) of the original and revised Guided Questions Tool were noted. There were no socio-economic-based differences in understandability or actionability (p > 0.05). There was a trend towards improved understanding of the revised tool (p = 0.06).Conclusions:This study demonstrated that readability of the Guided Questions Tool could be improved. Future work is needed to expand the study population and further understand health literacy’s impact on the CHD community.

BACKGROUND: Febrile infants aged 0 to 60 days are often hospitalized for a 36-to-48 hour observation period to rule out invasive bacterial infections (IBI). Evidence suggests that monitoring blood and cerebrospinal fluid (CSF) cultures for 24 hours may be appropriate for most infants. We aimed to decrease the average culture observation time (COT) from 38 to 30 hours among hospitalized infants 0 to 60 days old over 12 months. METHODS: This quality improvement initiative occurred at a large children’s hospital, in conjunction with development of a multidisciplinary evidence-based guideline for the management of febrile infants. We included infants aged 0 to 60 days admitted with fever without a clear infectious source. We excluded infants who had positive blood, urine, or CSF cultures within 24 hours of incubation and infants who were hospitalized for other indications (eg, bronchiolitis). Interventions included guideline dissemination, education regarding laboratory monitoring practices, standardized order sets, and near-time identification of failures. Our primary outcome was COT, defined as time between initiation of culture incubation and hospital discharge in hours. Interventions were tracked on an annotated statistical process control chart. Our balancing measure was identification of IBI after hospital discharge. RESULTS: In our cohort of 184 infants aged 0 to 60 days, average COT decreased from 38 hours to 32 hours after structured guideline dissemination and order-set standardization; this decrease was sustained over 17 months. IBI was not identified in any patients after discharge. CONCLUSIONS: Implementation of an evidence-based guideline through education, transparency of laboratory procedures, creation of standardized order sets, and near-time feedback was associated with shorter COT for febrile infants aged 0 to 60 days.

Racism- a system operating at the intrapersonal, interpersonal, institutional, and structural levels- is a serious threat to the health and wellbeing of children and adolescents. This narrative review highlights racism as a social determinant of health, and describes how racism breeds disparate pediatric health outcomes in infant health, asthma, Type 1 diabetes, mental health, and pediatric surgical conditions. Key examples include the association of residential racial segregation and the alarming infant mortality rate among Black infants as well as the role of redlining and discriminatory housing practices on asthma morbidity among Black children and adolescents. Furthermore, inequitable care practices such as (1) racial and ethnic disparities in insulin pump usage in patients with Type 1 diabetes, (2) lower rates pharmacotherapy initiation in racialized children with mental health disorders, and (3) decreased pain medication management and confirmatory imaging in Black children with acute appendicitis, highlight the role of interpersonal racism in propagating poor health outcomes. An urgent call to action is needed to address pediatric health inequities and ensure all children can live healthy lives. Key strategies must tackle racism at the individual, institutional, and structural levels and include building a diverse workforce, prioritizing research to describe the impact of racism on pediatric health outcomes, initiating improvement efforts to close equity gaps, building community partnerships, co-designing solutions alongside patients and families, and advocating for policy change to address the social conditions that impact children and adolescents of color.

1. Tierney M. Morrison, MD* 2. Jacinta Cooper, MD, PhD† 3. Kelly O’Shea, MD* 4. Ndidi Unaka, MEd, MD‡ 1. *Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 2. †Department of Pediatric Emergency Medicine, University of Alabama at Birmingham, Birmingham AL 3. ‡Department of Pediatrics, University of Cincinnati College of Medicine, and Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH A 2-year-old boy with a history of delayed immunizations who has received all recommended vaccinations except for varicella presents to the emergency department with progressive bilateral lower leg and facial edema and 5 days of upper respiratory symptoms, including cough, congestion, and rhinorrhea. He is evaluated in the critical care area for treatment of hypoxemia with oxygen saturations in the 70s on room air, requires 18 L/min oxygen via high-flow nasal cannula with a fraction of inspired oxygen of 100%, and is subsequently admitted to the PICU. On physical examination, he is in the 12th percentile for weight, down from the 57th percentile at birth; poor weight gain is most notable during the 6 months before this admission. He has increased work of breathing with subcostal retractions and suprasternal tugging, diffuse crackles bilaterally, and end expiratory wheezing in all lung fields. The patient’s abdomen is soft and nontender but distended, with prominent hepatomegaly. The liver edge is palpable 3 cm below the right costal margin. Splenomegaly is not noted on presenting physical examination. Chest radiography demonstrates diffuse, bilateral pulmonary opacities. The cardiomediastinal silhouette is largely obscured by overlying pulmonary parenchymal opacities and is consistent with moderate cardiomegaly, and pulmonary vasculature is ill-defined. The differential diagnosis for the patient’s respiratory distress includes reactive airway disease (given the noted wheezing on auscultation) and pulmonary edema from acute respiratory distress syndrome (given lower extremity and facial edema …

Enhancing Patient and Family Experience (PFE) is vital to the delivery of quality healthcare services. Sociodemographic differences affect health outcomes and experiences, but research is limited on biases in PFE survey methodology. We sought to assess survey participation rates across sociodemographic characteristics. This retrospective study analyzed a health system’s ambulatory PFE survey data, collected January 1 – July 31, 2019. Outcomes of interest were rates of survey response, completion, and comments. Predictors included respondent-reported race, ethnicity, language, and measure of social deprivation attached to a respondent’s home address. Addresses were geocoded to census tracts. The tract’s degree of socioeconomic deprivation was defined using the Deprivation Index (DPI). Associations between outcomes and predictors were assessed using the Chi square test. 77,627 unique patient encounters were analyzed. Patients were predominantly White (76%); 5% were Hispanic; and 1% were Spanish-speaking. The overall response, completion, and comment rates were 20.1%, 17.6%, and 4.1%, respectively. There were significant differences across assessed sociodemographic characteristics in response, completion, and comment rates. White patients were most likely to respond, complete, and leave a comment. Spanish-speaking respondents and those living in the most deprived areas were more likely to respond and complete the survey, but less likely to comment than English-speaking respondents and those living in less deprived areas, respectively. PFE survey participation differs across a range of sociodemographic characteristics, potentially introducing noteworthy biases. Health systems should minimize differences in how they collect feedback and account for potential biases when responding to experience data. Experience Framework This article is associated with the Policy & Measurement lens of The Beryl Institute Experience Framework. (https://www.theberylinstitute.org/ExperienceFramework). Access other PXJ articles related to this lens. Access other resources related to this lens.

Background Effective means of preparing interns for transition to residency remains elusive. Recent studies indicate program directors perceive new interns to be underprepared for residency. While intern orientation is ubiquitous, content can vary greatly and often does not assess trainee competence. Objective To determine the content of intern orientation across several pediatric residency programs and evaluate intern perceptions of the effectiveness of orientation. Methods This cross-sectional study included pediatric residency programs in the Mid-America region. A survey with questions regarding orientation activities including content, allotted time, format, and assessment was sent to 24 program directors. Current interns at these programs were surveyed regarding their perceptions of the effectiveness of activities completed during orientation. Descriptive statistics were used to analyze survey responses. Results Fifty-eight percent of program directors responded to the initial survey. Median time in orientation was 65.5 hours (range 30-120). Variation was noted across programs in content and format. Only 9 activities were represented among all survey participants. Additionally, 93 interns from 15 programs completed the intern survey. Approximately 80% of interns perceived the overall time spent in orientation was “just right”; however, 37% felt too little time was spent on orientation to intern roles, and 38% perceived that too little time was spent on review of clinical skills. Fifty-four percent of respondents felt electronic health record training was slightly or not at all effective. Conclusions Pediatric intern orientation varied across the institutions surveyed and intern responses indicate that time on clinical skills and intern roles should be increased. This study is the first to characterize the activities included in pediatric orientation and their perceived value to interns. Next steps include expanding the study to additional pediatric programs and utilizing findings to help inform best practices for orientation and onboarding of pediatric residents.

Background Early transition of parenteral (IV) to enteral antibiotics is recommended to decrease hospital length of stay and healthcare costs. Without clear criteria to guide transition, patients at our hospital often remained on IV antibiotics until discharge despite clinical improvement. Objectives Increase the percentage of timely-transitioned anti-biotic doses (total enteral antibiotic doses divided by all anti-biotic doses in patients receiving other enteral medications) for Hospital Medicine (HM) patients admitted for uncomplicated pneumonia or skin and soft tissue infections (SSTI) from 44% to 75% by August 31, 2017. Methods Improvement efforts targeted five HM teams at a large paediatric academic hospital. Our multidisciplinary team included HM attendings, fellows, residents, and pharmacists. Several key drivers (Figure 1) informed our interventions. Interventions included education on IV and enteral antibiotic cost differential, incorporation of antibiotic transition plan in electronic health record (EHR) note templates, structured discussions of transition criteria for patients on IV antibiotics, and real-time identification of failures and feedback. An automated system that interfaced with our EHR provided data on medication administration route and missed opportunities for timely-transitioned antibiotic doses. An annotated statistical process control chart assessed the impact of interventions over time (figure 2). Results The percentage of timely-transitioned antibiotic doses increased from 44% to 80% within 8 months. The most effective interventions were early identification of transition criteria through structured huddles and real-time identification and mitigation of failures. Conclusions Identification of clear criteria for transition from IV to enteral antibiotics can increase timely transitions for patients with uncomplicated pneumonia and SSTI.

A 4-year-old boy with developmental delay was admitted for evaluation of a new rash in the setting of leukocytosis and eosinophilia. The patient was healthy until 1 week before admission when he developed cough, congestion, and malaise. Upon presentation, he was on day 5 of amoxicillin, prescribed by an outside provider for unclear indications, but he took no other medications on a regular basis. The day before presentation, his mother noted “red, flat, pimple-like” lesions on his upper thighs that progressively spread down his legs and resembled “bruises.” At a local hospital, a complete blood count (CBC) demonstrated a white blood cell (WBC) count of 66 600/mm3. Although the patient was afebrile and non–toxic appearing, a blood culture was obtained, and he received intramuscular ceftriaxone due to the profound leukocytosis and concerns for possible infection. He was subsequently transferred to the emergency department of our hospital for further evaluation. In the emergency department, vitals were notable for a pulse of 100 beats per minute, temperature of 35.2°C, respiratory rate of 32 breaths per minute, and oxygen saturation of 98% on room air and normal BMI for age. Physical examination was notable for a nontender, nonpruritic rash consisting of purpuric papules and macules of various stages of development on the bilateral lower extremities (Fig 1). He was otherwise well appearing with no joint or abdominal tenderness and no hepatosplenomegaly. Initial laboratories were notable for WBC count of 56 100/mm3 with 59% eosinophils and an absolute eosinophil count (AEC) of 33 100/mm3, a normal hematocrit of 37.2%, normal platelet count of 300 K/mcL, and normal coagulation markers. The patient was noted to have an elevated lactate dehydrogenase of 555 unit/L but normal uric acid level. A urinalysis obtained via a catheterized specimen was notable for trace protein and moderate blood; …

Background Readable discharge instructions may help caregivers understand and implement care plans following hospitalization. Many caregivers of hospitalized children, however, have limited literacy. We aimed to increase the percentage of discharge instructions written at 7th grade level or lower for hospital medicine patients from 13% to 80% in 6 months. Methods Quality improvement efforts targeted a 42-bed unit at the community satellite of our large, urban academic hospital. A multidisciplinary team of physicians, nurses, and parents focused on key drivers: family engagement in discharge process, standardization of discharge instructions, staff engagement in discharge preparedness, and audit and feedback of data. Improvement cycles included 1) education and implementation of a general discharge instruction template in the electronic health record (EHR); 2) visible reminders and tips for writing readable discharge instructions; 3) implementation of disease-specific discharge instruction templates in the EHR; and 4) individualized feedback to staff on readability and content of their written discharge instructions. Instructions were individually scored for readability using an online platform. An annotated control chart assessed the impact of interventions over time. Results Through sequential interventions over 6 months, the percentage of discharge instructions written at 7th grade or lower readability level increased from 13% to 98% and has been sustained for 4 months. The reliable use of the EHR templates was associated with our largest improvements. Conclusion Use of standardized discharge instruction templates and rapid feedback to staff improved the readability of instructions. Next steps include adaptation and spread to other patient populations.

Children with medical complexity are a rapidly growing inpatient population with frequent, lengthy, and costly hospitalizations. During hospitalization, these patients require care coordination among multiple subspecialties and their outpatient medical homes. At a large freestanding children’s hospital, a new inpatient model of care was developed in an effort to consistently provide coordinated, family-centered, and efficient care. In addition to expanding the multidisciplinary team to include a pharmacist, dietician, and social worker, the team redesign included: (1) medication reconciliation rounds, (2) care coordination rounds, and (3) multidisciplinary weekly handoff with outpatient providers. During weekly medication reconciliation rounds, the team pharmacist reviews each patient’s current medications with the team. In care coordination rounds, the team collaborates with unit care managers to identify discharge needs and complete discharge tasks. Finally, at the end of the week, the outgoing hospital medicine attending physician hands off patient care to the incoming attending with input from the team’s pharmacist, dietician, and social worker. Families and providers noted improvements in care coordination with the new care model. Remaining challenges include balancing resident autonomy and attending supervision, as well as supporting providers in delivering care that can be emotionally challenging. Aspects of this care model could be tested and adapted at other hospitals that care for children with medical complexity. Additionally, future work should study the impact of inpatient complex care models on patient health outcomes and experience.

Despite nearly three in four African American (AA) children being born to unwed mothers, AA fathers maintain relatively high levels of parenting engagement, whether or not they live with their children. While father involvement correlates with decreased adverse child health outcomes, the nature of AA father involvement in child health—including engagement in the pediatric medical home—remains largely unexplored. Our study aimed to assess perceptions of pediatric medical home participation among a cohort of urban, AA fathers. Group level assessments (GLA; N = 17) were conducted among AA fathers in an urban, Midwestern neighborhood to examine perceptions regarding pediatric medical home involvement. Study participants generated themes based on GLA responses, and study staff used grounded theory as a framework for qualitative analysis of thematic data. Fathers desired to have their parental role acknowledged by mothers and pediatricians. They perceived unrecognized parenting strengths, including being role models, teachers, and providers for their children. Respondents endorsed uncertainty navigating the pediatric health care system, unawareness of their children’s pediatric appointments, and feeling excluded from health care decision-making by their children’s mothers and pediatric providers. In our cohort, AA fathers have a strong desire to be involved in their children’s healthy development, but feel marginalized in their parenting role. AA fathers want improved communication with physicians and their children’s mothers and to be actively included in health care decision-making. Enhanced efforts to engage fathers in the pediatric medical home may lead to improved health outcomes and reduced disparities for minority children.

The average American adult reads at an 8th-grade level. Discharge instructions written above this level might increase the risk of adverse outcomes for children as they transition from hospital to home. We conducted a cross-sectional study at a large urban academic children's hospital to describe readability levels, understandability scores, and completeness of written instructions given to families at hospital discharge. Two hundred charts for patients discharged from the hospital medicine service were randomly selected for review. Written discharge instructions were extracted and scored for readability (Fry Readability Scale [FRS]), understandability (Patient Education Materials Assessment Tool [PEMAT]), and completeness (5 criteria determined by consensus). Descriptive statistics enumerated the distribution of readability, understandability, and completeness of written discharge instructions. Of the patients included in the study, 51% were publicly insured. Median age was 3.1 years, and median length of stay was 2.0 days. The median readability score corresponded to a 10th-grade reading level (interquartile range, 8-12; range, 1-13). Median PEMAT score was 73% (interquartile range, 64%-82%; range, 45%-100%); 36% of instructions scored below 70%, correlating with suboptimal understandability. The diagnosis was described in only 33% of the instructions. Although explicit warning signs were listed in most instructions, 38% of the instructions did not include information on the person to contact if warning signs developed. Overall, the readability, understandability, and completeness of discharge instructions were subpar. Efforts to improve the content of discharge instructions may promote safe and effective transitions home. Journal of Hospital Medicine 2017;12:98-101.

Case: An 18-year-old male presented to the emergency department with a 5-day history of a palpable purpuric rash, arthralgias, dark-colored urine, and severe abdominal pain. The patient was admitted to the hospital medicine service for further management. A urinalysis showed mild hematuria and trace proteinuria. An abdominal ultrasound was normal. He was diagnosed with Henoch-Schonlein purpura (HSP) and was started on prednisone by the hospital medicine team. His symptoms improved significantly, and he was subsequently discharged from the hospital on hospital day 4 (day 9 of illness) to complete a 2-week taper of prednisone (initially started on 80 mg/day with instructions to decrease the dose by 20 mg every 5 days) and to follow up with his primary care physician. On day 15 of illness, the patient presented to the emergency department with worsening upper and lower extremity edema, arthralgia, and palpable purpura, new-onset shortness of breath, hemoptysis, and epistaxis. No fever was reported. He was at the time taking 60 mg of oral prednisone per day. On physical examination, the patient was pale in appearance but was not in acute distress. Vital signs showed elevated blood pressure of 148/69 mm Hg, temperature of 36°C (96.8°F), heart rate of 89 beats per minute, respiratory rate of 18 breaths per minute, and oxygen saturation of 99% on room air. He had normal respiratory effort, and lungs were clear on auscultation with good air movement. A new systolic ejection murmur best heard at the left upper sternal border was appreciated, and the patient was also noted to have pitting edema in the lower extremities bilaterally. Abdominal examination was reassuring, and there were normal bowel sounds with no abdominal tenderness or distention. Laboratory evaluation revealed a slight increase in the serum creatinine level from 0.59 to 0.68 mg/dL, significant proteinuria (300 mg/dL; urine …

Resident duty hour restrictions may expose families to more trainees during hospitalization and hinder recognition of medical team members. This may negatively impact family satisfaction. Our study sought to determine the effects of a face sheet tool on families' identification and satisfaction rating of the medical team. One of 2 general pediatric units at a large academic center was assigned to intervention; the other served as the concurrent control. Families on the intervention unit were given a face sheet tool with medical team members' photos and role descriptions. Upon discharge, caregivers matched names, photos, and roles to providers they encountered, answered a 10-question satisfaction survey, and answered an overall hospital experience satisfaction question. Caregivers encountered a median of 8 (range, 3–14) medical team members. Caregivers in the intervention group were more likely to correctly identify providers by name (median correct, 25% vs 11% for controls; P

Background and Objective:Residents play a critical role in the education of peers and medical students, yet attainment of teaching skills is not routinely assessed. The primary aim of this study was to develop a novel, skill-based Observed Structured Teaching Evaluation (OSTE) and self-assessment survey to measure the impact of a resident-as-teacher curriculum on teaching competency. The secondary aim was to determine interrater reliability of the OSTE.Methods:A prospective study quantitatively assessed intern teaching competency via videotaped teaching encounters (videos) before and after a month-long hospital medicine rotation and self-assessment surveys over a 5-month period. The intervention group received the resident-as-teacher curriculum. Videos were evaluated by 2 blinded faculty via an OSTE covering 9 skills within 3 core components: preparation, teaching, and reflection. Pre- to post–HM rotation month differences were evaluated within and between groups using the Wilcoxon signed rank test and Wilcoxon rank-sum test, respectively.Results:Twenty-two of 25 (88%) control and 27 of 28 (96%) intervention interns participated; 100% of participants completed the study. The intervention group’s pre-post difference for the total OSTE score and the average self-assessed competence statistically improved; however, no significant difference was seen between groups. The difference in preparation scores was significant for the intervention compared with the control. The OSTE’s interrater reliability demonstrated good agreement with weighted kappas of 0.86 for preparation, 0.71 for teaching, and 0.93 for reflection.Conclusions:Implementation of an objective, skill-based OSTE detected observable changes in interns’ teaching competency after implementation of a brief resident-as-teacher curriculum. The OSTE’s good interrater reliability may allow standardized assessment of skill attainment over time.

Introduction Millennial trainees prefer innovative, multimodal education on topics including the physical exam (PE). Attendings inconsistently meet these needs on family-centered rounds. To enhance PE teaching, a Web site (PEToolkit) was created, but its use was infrequent. We aimed to increase PEToolkit use from 2 to 5 page counts per week in 7 months. Methods This quality improvement project took place at a large academic center in 1 Hospital Medicine team. Key drivers informed interventions, and an annotated run chart tracked progress. We tracked secondary measures, including changes in perception of teaching skill among attendings and resident-observed methods of PE teaching, through survey methodology. Results Median page counts increased to 5 counts per week in 7 months. The most impactful interventions included training senior residents to teach with the PEToolkit Web site and team feedback on Web site usage midweek. Survey responses from 37 attendings showed that those with more exposure to PEToolkit had increased self-perceived skill of PE teaching (P = 0.02). Survey responses from 52 residents showed that those on the intervention team reported more use of video for PE teaching (P < 0.001) and higher frequency of PE teaching (P = 0.02), compared with those on the nonintervention team. Conclusions We increased PEToolkit Web site use during family-centered rounds, thereby emphasizing the importance of PE teaching in this setting in an innovative way. Engagement of learners, frequent feedback, and coaching should be considered when incorporating technology in teaching.

Avondale, a disadvantaged neighborhood in Cincinnati, lags behind on a number of indicators of child well-being. Childhood obesity has become increasingly prevalent, as one third of Avondale’s kindergarteners are obese or overweight. The study objective was to determine perceptions of the quantity of and obstacles to childhood physical activity in the Avondale community. Caregivers of children from two elementary schools were surveyed to assess their child’s physical activity and barriers to being active. Three hundred forty surveys were returned out of 1,047 for a response rate of 32%. On school days, 41% of caregivers reported that their children spent more than 2 hours watching television, playing video games, or spending time on the computer. While over half of respondents reported that their children get more than 2 hours of physical activity on school days, 14% of children were reported to be physically active less than 1 hour per day. Caregivers identified violence, cost of extracurricular activities, and lack of organized activities as barriers to their child’s physical activity. The overwhelming majority of caregivers expressed interest in a program to make local playgrounds safer. In conclusion, children in Avondale are not participating in enough physical activity and are exposed to more screen time than is recommended by the AAP. Safety concerns were identified as a critical barrier to address in future advocacy efforts in this community. This project represents an important step toward increasing the physical activity of children in Avondale and engaging the local community.

Pulmonary artery sling is a very rare congenital vascular anomaly. Patients usually present in infancy with symptoms of airway compression. Patients with trisomy 21 often have upper airway obstruction, most commonly related to pharyngeal causes or subglottic stenosis. Although the incidence of congenital heart defects in patients with trisomy 21 is very high, a review of the literature showed only one previously reported case of pulmonary artery sling in an infant with trisomy 21. We report a case of pulmonary artery sling and complete atrioventricular canal defect in a one-month-old female with trisomy 21. Echocardiography is an important diagnostic method for pulmonary artery sling, but this anomaly may be easily overlooked in the presence of more commonly anticipated defects in this population.

OBJECTIVE: In 2009, The Joint Commission challenged hospitals to reduce the risk of health care–associated infections through hand hygiene compliance. At our hospital, physicians had lower compliance rates than other health care workers, just 68% on general pediatric units. We used improvement methods and reliability science to increase compliance with proper hand hygiene to >95% by inpatient general pediatric teams. METHODS: Strategies to improve hand hygiene were tested through multiple plan-do-study-act cycles, first by 1 general inpatient medical team and then spread to 4 additional teams. At the start of each rotation, residents completed an educational module and posttest about proper hand hygiene. Team compliance data were displayed daily in the resident conference room. Real-time identification and mitigation of failures by a hand-washing champion encouraged shared accountability. Organizational support ensured access to adequate hand hygiene supplies. The main outcome measure was percent compliance with acceptable hand hygiene, defined as use of an alcohol-based product or hand-washing with soap and turning off the faucet without using fingers or palm. Compliance was defined as acceptable hand hygiene before and after contact with the patient or care environment. Covert bedside observers recorded at least 8 observations of physicians’ compliance per day. RESULTS: Physician compliance with proper hand hygiene improved to >95% within 6 months and was sustained for 11 months. CONCLUSIONS: Instituting a hand-washing champion for immediate identification and mitigation of failures was key in sustaining results. Improving physician compliance with proper hand hygiene is achievable and a first step in decreasing health care–associated infections.

The relationship between hemoglobin dexoygenation and sickling is well known. However, the relationship between hypoxia and severity of disease in sickle cell patients has not been well established. Recently, nocturnal hypoxemia has been associated with higher incidence of CNS events including strokes, and elevated TCDs. We present our case series on 13 patients(12 SS, 1 SC) with sickle cell disease (SCD) who have nocturnal hypoxia. Approximately 75 patients were screened at the University of Michigan Sickle Cell clinic for nocturnal hypoxia either by symptoms of obstructive sleep apnea or by longitudinal baseline clinic 02 saturations (02 Sat 2.5, n=9, median 2.74/mean 2.74,) frequent pain episodes(>3visits to ER or hospitalizations/year, n=7, with 5 pts >5/year ), recurrent acute chest syndrome( ≥ 3 episodes, n= 10), CNS events (n=3 silent infarcts, vascular stenosis), priapism( (n=4, among 6 males ). Also reported were possible causes of the underlying hypoxia including obstructive sleep apnea(OSA)(n=7 of 11 pts), asthma(n= 10 of 13 pts), and chronic lung disease( n=8). In conclusion, the persistence of nocturnal hypoxia in pediatric sickle cell disease could possibly contribute to the development of severe complications of sickle cell disease. Treatment of underlying hypoxia (ie nighttime oxygen, maximize asthma treatment, T&A for OSA)may help prevent complications and lead to the improvement clinical symptoms. Further, chronic nocturnal hypoxia may complicate pulmonary disease and accelerated the development of PHTN. More studies are needed to clarify the mechanism of hypoxia in SCD. Table I. Clinical &Demographic Data of 13 SCD Patients with Nocturnal Hypoxia. Age:(6–22y/o, mean 15) Sex: M=6 F=7 Clinical: Total Mild Mod Sev. Genotype: SS=12, SC=1 Mean Range Nctnl Hypoxia(4 Hypopneic Events(9) 32.5+38 0–132 ACS 2 5 5 TRJet Velocity 2.74+.42 2–3.5 Severe Pain Crises/yr 1 2 5