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OBJECTIVE Previous studies reveal improved perception of time spent, as well as overall experience, for patients when their inpatient provider is seated during an encounter. With our study, we aim to establish whether family experience and perception of time is improved when a pediatric inpatient provider team sits for patient and family-centered rounds. PATIENTS AND METHODS From February 2017 to November 2017, 99 inpatient encounters were randomly assigned to either a sitting or standing rounding team. Mean total time spent on rounds, family perception of time spent on rounds, and overall family experience with rounds (by using top-box analysis of physician communication questions) were compared between the 2 groups. RESULTS Total time spent on rounds was similar between the 2 groups (14.2 minutes in the sitting group and 12.7 minutes in the standing group; P = .23), and families in general overestimated the time spent with physicians in both groups (15.9 minutes in sitting group and 14.8 minutes in the standing group; P = .45). There were no significant differences in top-box experience responses (62% in sitting and 55% in standing; P = .12). CONCLUSIONS Sitting during the patient and family-centered rounds encounter did not affect actual or perceived time spent during rounds. Families may have a slightly more positive experience with seated rounds, but the difference in this study did not reach a level of statistical significance.

In April 2020, the coronavirus disease 2019 (COVID-19) pandemic raged through our hospital system in Connecticut.1 Medical teams for adult patients mobilized their staff and units for the incessant surge. Patient volume and acuity on the adult units began to rise amid the uncertainty of personal protective equipment (PPE) supplies, fear of a formidable impact, and potential depletion of the clinical workforce. In preparation, the pediatrics department chair of our children’s hospital within a larger academic medical center asked for volunteers to help the adult teams. The pediatric wards were strangely quiet as patients and families stayed away from the hospital and elective surgeries were canceled. In comparison, admissions to adult units in our hospital continued to rise exponentially (3 cases of COVID-19 on March 15 and 354 on April 9), further displaying the disproportionate impact of the pandemic on adults. Because pediatric hospitalizations to COVID-19 remained low and the demand for beds for hospitalized adults continued to rise, we initially gave two of our pediatric units to internal medicine clinician teams for adult admissions. Along with more hospitalized patients, the need for more clinicians to care for patients became more apparent. We heard that our pediatric critical care and pediatric emergency department faculty were helping to staff with adult medical ICUs. We knew that would be us soon and began work to brush up on our internal medicine skills.2 Instead of waiting to be asked, we decided proactively to offer our services to the internal medicine department as a team of pediatric nurses, pediatric housestaff, and pediatric hospitalists under the guidance of medicine-pediatrics hospitalists and medicine-pediatrics housestaff. Shortly, we were deployed to open a new adult COVID-19 …

This study aims to evaluate the impact of hospital setting on outcomes for infants with neonatal abstinence syndrome. We conducted a retrospective study in two hospitals and three different hospital units. The inpatient group (n = 60) was managed on general inpatient floors, the NICU group (n = 50) was managed primarily in an NICU, and the combination group (n = 49) was managed in both NICU and inpatient units. The primary outcome was length of stay. Secondary outcomes included breastfeeding rates, morphine usage rates, and hospital costs. The length of stay in the inpatient group (8.5 days) was significantly lower than the combination group (18 days) and NICU group (23 days) (p

Background Some pediatric chief residents perform supervisory clinical duties during chief residency, but these activities are highly variable and descriptions are limited. Our goals were to characterize inpatient service performed by pediatric chief residents and to explore factors that influence their experiences as inpatient attending physicians. Methods Pediatric chief residents at Accreditation Council for Graduate Medical Education–accredited programs in 2016 were invited to complete a 40-item electronic questionnaire about their inpatient service obligation as well as attitudes regarding this experience. Data were analyzed using Chi-square, analysis of variance tests, and logistic regression. Open-ended responses underwent content analysis. Results There were 116 completed surveys from a national sample of 223 (response rate 52%); 66% served as inpatient attending physicians during chief residency. On average, chief residents spent 5.5 weeks (range 1–16) in this role with a daily census of 11.5 patients (range 5–20). Those entering primary care were significantly less likely to spend time as an inpatient attending compared with chiefs entering fellowship or hospital medicine (45.7 vs 67.3 vs 83.3%, P = .01). Overall, 92% regarded their inpatient clinical experience positively and indicated they would like the same (40%) or more time (52%) in this role. The average favorability rating was 8.2 of 10, and this was not associated with clinical workload or career choice. Conclusions Most chief residents serve as inpatient attending physicians during chief residency. They rate their inpatient experience positively despite wide variability in clinical experiences, patient population, and clinical load. Further studies should examine the value of this experience and its impact on chief residents’ future practice.

A 39-year-old woman presented with localized urticaria following N95 respirator use in a COVID-19 unit. After approximately 15 minutes of wear, she developed pruritus on her face, without associated angioedema or dyspnea. She had no history of cutaneous reactions to N95 respirators. Physical examination revealed several wheals with surrounding erythema limited to the area occluded by the N95 respirator (figure 1). On evaluation, firm stroking of the volar aspect of her forearm produced linear wheals (figure 2); she was subsequently diagnosed with dermatographism. Symptoms resolved within 1 …

Introduction Effective feedback is essential for trainees to achieve clinical competence. An unsupportive institutional feedback culture can diminish the credibility and subsequent uptake of feedback. Data on feedback culture in pediatric training programs is limited. We, therefore, used a validated feedback environment survey (FES) tool to assess and compare the cultures in our pediatric residency and fellowship programs. Methods Pediatric fellows and residents at Yale New Haven Hospital were invited to anonymously complete the FES using Qualtrics. The FES has a 7-point Likert scale response format, measures various aspects of the feedback environment, and has demonstrated good reliability, internal structure and relationship to other variables validity in an industrial setting. Fellow and resident ratings were compared using two-sided Fisher's exact test. Results Fifty-two (65%) residents and 21 (47%) fellows completed the survey. Most trainees reported that they respect their attendings’ opinion (76.7%), feel that they are fair (67.1%) and have confidence in their feedback (64.3%). However, the majority felt that the feedback they received was not useful (60.2%) and that attendings did not encourage them to ask for feedback (67.1%). When compared to fellows, more residents felt that attendings were unfamiliar with their performance (61.5% vs. 14.3%, p Conclusions We have demonstrated deficiencies in the feedback culture of our pediatric residency and fellowship programs, which are more pronounced in the residency program. Identification of the factors contributing to the difference is important and will inform targeted interventions.

OBJECTIVES: Firearm-related deaths remain a top cause of mortality in American children and adolescents. In a 2012 policy statement, the American Academy of Pediatrics urged pediatricians to incorporate questions about the availability of firearms into their patient history taking. We aim to evaluate the frequency of screening for home firearms in an academic tertiary-care hospital inpatient setting. METHODS: This retrospective chart review examined patients with the following pediatric diagnoses admitted to a tertiary-care pediatric hospital from 2006 to 2015: asthma, bronchiolitis, cellulitis, jaundice, single liveborn infant, bacterial and viral pneumonia, and all mood disorders. Data analysts then searched the patient charts that met these inclusion criteria for documentation of firearm screening as indicated by use of the terms “firearm,” “pistol,” “gun,” “handgun,” “bullet,” “ammunition,” or “rifle” in the admissions history and physical. RESULTS: Evidence of screening for firearms in the home was found in 1196 of the 40 658 charts included in the study (2.94%). The most frequently screened diagnosis and admitting service were mood disorders and child psychiatry, respectively (1159 of 3107; 37.3%). Only 19.8% of identified gun-owning families received specific anticipatory guidance. CONCLUSIONS: Firearm screening and gun safety education occurred infrequently in the inpatient setting. Inpatient encounters may provide an opportunity for increased screening and education because the hospital environment also includes additional resources, exposure to a greater number of providers, and the presence of more family members or caregivers. Further studies are warranted to explore barriers to inpatient screening and possible mechanisms for improvement.

This study aims to evaluate the impact of hospital setting on outcomes for infants with neonatal abstinence syndrome.We conducted a retrospective study in two hospitals and three different hospital units. The inpatient group (n = 60) was managed on general inpatient floors, the NICU group (n = 50) was managed primarily in an NICU, and the combination group (n = 49) was managed in both NICU and inpatient units. The primary outcome was length of stay. Secondary outcomes included breastfeeding rates, morphine usage rates, and hospital costs.The length of stay in the inpatient group (8.5 days) was significantly lower than the combination group (18 days) and NICU group (23 days) (p 0.01). The inpatient group had significantly lower rates of morphine treatment and hospital costs with no difference in breastfeeding rates.Infants with neonatal abstinence syndrome had a significantly shorter length of stay and less use of morphine when managed on inpatient units versus NICU.

Introduction: The American Academy of Pediatrics recommends Patient- and Family-centered Rounds (PFCRs) to improve communication between the healthcare team and families while allowing the latter to participate in medical decision-making. PFCRs have a secondary goal of increasing rounds’ efficiency and providing a positive learning environment for residents and students. There are many published best practices for PFCR. Our study provides an observational evaluation of PFCR in an academic tertiary medical center using a checklist created from such published best practices. Methods: We created a standardized observation checklist based on published guidelines. Study members observed 200 individual rounding encounters using this instrument. All inpatient, nonsurgical rounding teams in the fall of 2014 were included and analyzed using descriptive statistics. Results: The average rounding encounter included 9 team members, lasted 9 minutes and 24 seconds, with the medical team entering the patient room for 80.0% of encounters. Families were invited to participate in 60% of the encounters. Lay language was utilized in 62% of the encounters, although 99.5% of the encounters staff used medical terminology. Nursing was present in 64.5% of encounters but presented in only 13.5% of those encounters. The teaching-attending modeled patient interaction behaviors such as eye contact, nodding, and leaning forward in 31%–51% of encounters. Conclusions: Despite published best practices, medical teams at a large tertiary care center did not adhere to many components of published PCFR guidelines. Future studies should focus on family and physician experience to identify improvement strategies for rounds.

Background Community hospitals offer opportunity for increased pediatric resident autonomy yet may require more direct use of resuscitation skills than more resource-rich settings. Rapid cycle deliberate practice (RCDP) simulation teaches critical skill mastery using feedback-replay loops and can be used for resident education. Objective: We sought to establish a RCDP simulation program and improve pediatric residents’ preparation to handle medical emergencies at our community hospital training site. Methods We designed and conducted high fidelity RCDP simulation every 2 weeks on the community hospital ward. RCDP led by trained faculty and chief residents focused on Pediatric Advanced Life Support skills and activating clinical support for pediatric respiratory distress. Resident physicians on rotation at the community hospital (Bridgeport) and on duty nurses participated. We later asked all 35 resident participants to complete an anonymous web-based survey to assess non-simulated and simulated pediatric code experience. 2 open-ended questions assessed RCDP experience and its impact on the community hospital rotation. We performed descriptive statistics and qualitative thematic analysis by 2 reviewers to identify themes of residents’ experiences. Results 77% (n=27) of residents responded. 68% had participated in at least one non-simulated pediatric code during residency; 43% in 1-2, 18% in 3-5, and 7% in >5. Yale New Haven (YNH) PICU was the most common location of code participation (47%, n=14), 17% (n=5) at the Bridgeport ED, 13% (n=4) at the YNH Pediatric ED, 7% (n=2) on a YNH ward, and 7% (n=2) on the Bridgeport ward. Only 1 resident had ever acted as team leader in a pediatric code. 4 major themes of resident experience were identified: practical community-hospital specific preparation, teamwork, improved confidence, and helpful formative feedback. Conclusions We established a community hospital-focused RCDP simulation program. Residents report that RCDP provided relevant, practical preparation and improved confidence in the ability to deal with respiratory distress at the community hospital site.

Many internal medicine residency programs have transitioned to an X + Y clinic schedule, in which weekly continuity clinics are removed and clinic experience is instead condensed into 2-week blocks interspersed throughout the year, but few pediatric training programs have adopted this approach. We initiated X + Y scheduling in the 2015 academic year, with the hypothesis that outpatient continuity could be maintained or improved while inpatient handoffs would be reduced. We also hypothesized that learner experience with X + Y scheduling would be positive.Continuity and handoffs were compared over a 7-month period in 2013 to 2014 and 2015 to 2016. Outpatient continuity was calculated as the proportion of visits in which the patient was seen by the designated primary care provider (PCP). Handoffs were calculated through analysis of the online resident schedule with comparison of weekly totals for all inpatient teams. Resident perceptions were obtained in an online survey of residents who experienced both systems.With X + Y scheduling, overall outpatient continuity improved from 2914 of 9882 (29.5%) of visits seen by a patient's PCP to 3066 of 9769 (31.4%) (P = .004), but preventive visit continuity decreased from 2170 of 4687 (46.2%) to 2025 of 4709 (43%) (P = .001). Inpatient handoffs decreased with X + Y scheduling from 30 to 20 weekly handoffs (P.001). In total, 85% of residents reported a positive experience with X + Y scheduling.An X + Y scheduling approach in pediatrics is a viable alternative to weekly clinics, resulting in improved learner experience, reductions in inpatient handoffs, and small mixed effects on outpatient continuity.

Background and Objectives: There are few data evaluating the role of inpatient rebound bilirubin levels in the management of infants readmitted after their birth hospitalization for indirect hyperbilirubinemia. The goal of the present study was to evaluate the clinical utility of inpatient rebound bilirubin levels within this patient population. Methods: A retrospective cohort study was conducted of 226 infants readmitted after their birth hospitalization for indirect hyperbilirubinemia. Data from 130 infants with rebound bilirubin levels drawn at a mean of 6.1 ± 2.4 hours after discontinuation of phototherapy were compared with data from 96 infants without rebound bilirubin levels. The primary outcome was readmission to the hospital, and secondary outcomes included length of stay and discharge time. A subgroup analysis compared characteristics of children who required repeat phototherapy versus those who did not. Results: Overall, 5 of 130 patients from the rebound group were readmitted compared with 4 of 96 patients from the no-rebound group (P = .98). Length of stay was significantly longer for patients with rebound bilirubin levels (27.7 vs 23.2 hours; P = .001). Patients with bilirubin levels lowered to ≤14 mg/dL were less likely to receive repeat phototherapy than those with levels >14 mg/dL (2 of 129 vs 12 of 97; P = .001). Conclusions: Early inpatient rebound bilirubin levels do not successfully predict which patients will require hospital readmission for repeat phototherapy. Children with bilirubin levels lowered to ≤14 mg/dL with phototherapy are unlikely to receive repeat phototherapy.

OBJECTIVES: Neonatal abstinence syndrome (NAS) is a growing problem and poses a significant burden on the health care system. The traditional Finnegan Neonatal Abstinence Scoring System (FNASS) assessment approach may lead to unnecessary opioid treatment of infants with NAS. We developed a novel assessment approach and describe its effect on the management of infants with NAS. METHODS: We retrospectively compared treatment decisions of 50 consecutive opioid-exposed infants managed on the inpatient unit at the Yale New Haven Children’s Hospital. All infants had FNASS scores recorded every 2 to 6 hours but were managed by using the Eat, Sleep, Console (ESC) assessment approach. Actual treatment decisions made by using the ESC approach were compared with predicted treatment decisions based on recorded FNASS scores. The primary outcome was postnatal treatment with morphine. RESULTS: By using the ESC approach, 6 infants (12%) were treated with morphine compared with 31 infants (62%) predicted to be treated with morphine by using the FNASS approach (P < .001). The ESC approach started or increased morphine on 8 days (2.7%) compared with 76 days (25.7%) predicted by using the FNASS approach (P < .001). There were no readmissions or adverse events reported. CONCLUSIONS: Infants managed by using the ESC approach were treated with morphine significantly less frequently than they would have been by using the FNASS approach. The ESC approach is an effective method for the management of infants with NAS that limits pharmacologic treatment and may lead to substantial reductions in length of stay.

BACKGROUND AND OBJECTIVES: The incidence of neonatal abstinence syndrome (NAS), a constellation of neurologic, gastrointestinal, and musculoskeletal disturbances associated with opioid withdrawal, has increased dramatically and is associated with long hospital stays. At our institution, the average length of stay (ALOS) for infants exposed to methadone in utero was 22.4 days before the start of our project. We aimed to reduce ALOS for infants with NAS by 50%. METHODS: In 2010, a multidisciplinary team began several plan-do-study-act cycles at Yale New Haven Children’s Hospital. Key interventions included standardization of nonpharmacologic care coupled with an empowering message to parents, development of a novel approach to assessment, administration of morphine on an as-needed basis, and transfer of infants directly to the inpatient unit, bypassing the NICU. The outcome measures included ALOS, morphine use, and hospital costs using statistical process control charts. RESULTS: There were 287 infants in our project, including 55 from the baseline period (January 2008 to February 2010) and 44 from the postimplementation period (May 2015 to June 2016). ALOS decreased from 22.4 to 5.9 days. Proportions of methadone-exposed infants treated with morphine decreased from 98% to 14%; costs decreased from $44 824 to $10 289. No infants were readmitted for treatment of NAS and no adverse events were reported. CONCLUSIONS: Interventions focused on nonpharmacologic therapies and a simplified approach to assessment for infants exposed to methadone in utero led to both substantial and sustained decreases in ALOS, the proportion of infants treated with morphine, and hospital costs with no adverse events.

The opioid abuse problem in the United States has grown into an epidemic, with an estimated 2.5 million Americans currently dependent on heroin or prescription pain medications.1 One of the many consequences of this growing public health crisis has been a marked increase in the number of infants born to mothers who used opioids during pregnancy. The rate of neonatal abstinence syndrome (NAS), the syndrome of withdrawal these infants may suffer after birth, quintupled from 2000 to 2012.2 Often, these infants occupy NICU beds for weeks or even months.3 Despite these skyrocketing numbers, long lengths of stay, and an enormous strain on the medical system, our standard management of these infants has remained largely unchanged for decades. With a critical reappraisal of our current approach and an eye toward innovation, we can alter our entire paradigm for managing infants with NAS and create opportunities for significant improvements in both patient outcomes and health care expenditures. The current approach used by many institutions for the management of NAS has its roots in a study published >40 years ago. In 1975, the Finnegan Neonatal Abstinence Scoring System (FNASS) was developed and is now widely accepted as the primary tool to assess infants with NAS. The FNASS is a 21-item tool that lists signs of withdrawal and assigns a point value to …