Communication and Shared Understanding Between Parents and Resident-Physicians at Night

Real Patient Participation in Workplace-Based Assessment of Health Professional Trainees: A Scoping Review

The aim of this scoping review is to outline the existing landscape of how real patients participate in the workplace-based assessment of trainees across diverse healthcare professions. In 2019-2020, the authors searched MEDLINE, EMBASE, CINAHL, PsycINFO, ERIC, and Web of Science databases for studies that included descriptions of experiences whereby patients received care from a health professional trainee and participated in workplace-based assessments of that trainee. Full-text articles published in English from 2009 to 2020 were included in the search. Of the 8770 studies screened; 77 full-text articles were included. Analysis showed that strategies for patient participation in workplace-based assessment varied widely. Aspects studied ranged from validation of an assessment tool to evaluation of the impact of an educational intervention on trainees' performance. Assessment of patient satisfaction was the most common approach to patient involvement. The majority of studies were conducted in North America and in the context of physician training. Formal patient participation in the assessment of health professional trainees appears heterogeneous across health professions. Gaps in the literature are evident; therefore, this review points to an inclusive approach to workplace-based assessment to ensure patient feedback of the trainees who care for them is represented.

Implementing a Family-Centered Rounds Intervention Using Novel Mentor-Trios

BACKGROUND AND OBJECTIVES

Patient and Family Centered I-PASS (PFC I-PASS) emphasizes family and nurse engagement, health literacy, and structured communication on family-centered rounds organized around the I-PASS framework (Illness severity-Patient summary-Action items-Situational awareness-Synthesis by receiver). We assessed adherence, safety, and experience after implementing PFC I-PASS using a novel "Mentor-Trio" implementation approach with multidisciplinary parent-nurse-physician teams coaching sites.

METHODS

Hybrid Type II effectiveness-implementation study from 2/29/19-3/13/22 with ≥3 months of baseline and 12 months of postimplementation data collection/site across 21 US community and tertiary pediatric teaching hospitals. We conducted rounds observations and surveyed nurses, physicians, and Arabic/Chinese/English/Spanish-speaking patients/parents.

RESULTS

We conducted 4557 rounds observations and received 2285 patient/family, 1240 resident, 819 nurse, and 378 attending surveys. Adherence to all I-PASS components, bedside rounding, written rounds summaries, family and nurse engagement, and plain language improved post-implementation (13.0%-60.8% absolute increase by item), all P < .05. Except for written summary, improvements sustained 12 months post-implementation. Resident-reported harms/1000-resident-days were unchanged overall but decreased in larger hospitals (116.9 to 86.3 to 72.3 pre versus early- versus late-implementation, P = .006), hospitals with greater nurse engagement on rounds (110.6 to 73.3 to 65.3, P < .001), and greater adherence to I-PASS structure (95.3 to 73.6 to 72.3, P < .05). Twelve of 12 measures of staff safety climate improved (eg, "excellent"/"very good" safety grade improved from 80.4% to 86.3% to 88.0%), all P < .05. Patient/family experience and teaching were unchanged.

CONCLUSIONS

Hospitals successfully used Mentor-Trios to implement PFC I-PASS. Family/nurse engagement, safety climate, and harms improved in larger hospitals and hospitals with better nurse engagement and intervention adherence. Patient/family experience and teaching were not affected.

Error disclosure in neonatal intensive care: a multicentre, prospective, observational study

IMPORTANCE

Surveys based on hypothetical situations suggest that health-care providers agree that disclosure of errors and adverse events to patients and families is a professional obligation but do not always disclose them. Disclosure rates and reasons for the choice have not previously been studied.

OBJECTIVE

To measure the proportion of errors disclosed by neonatal intensive care unit (NICU) professionals to parents and identify motives for and barriers to disclosure.

DESIGN

Prospective, observational study nested in a randomised controlled trial (Study on Preventing Adverse Events in Neonates (SEPREVEN); ClinicalTrials.gov). Event disclosure was not intended to be related to the intervention tested.

SETTING

10 NICUs in France with a 20-month follow-up, starting November 2015.

PARTICIPANTS

n=1019 patients with NICU stay ≥2 days with ≥1 error.

EXPOSURE

Characteristics of errors (type, severity, timing of discovery), patients and professionals, self-reported motives for disclosure and non-disclosure.

MAIN OUTCOME AND MEASURES

Rate of error disclosure reported anonymously and voluntarily by physicians and nurses; perceived parental reaction to disclosure.

RESULTS

Among 1822 errors concerning 1019 patients (mean gestational age: 30.8±4.5 weeks), 752 (41.3%) were disclosed. Independent risk factors for non-disclosure were nighttime discovery of error (OR 2.40; 95% CI 1.75 to 3.30), milder consequence (for moderate consequence: OR 1.85; 95% CI 0.89 to 3.86; no consequence: OR 6.49; 95% CI 2.99 to 14.11), a shorter interval between admission and error, error type and fewer beds. The most frequent reported reasons for non-disclosure were parental absence at its discovery and a perceived lack of serious consequence.

CONCLUSION AND RELEVANCE

In the particular context of the SEPREVEN randomised controlled trial of NICUs, staff did not disclose the majority of errors to parents, especially in the absence of moderate consequence for the infant.

TRIAL REGISTRATION NUMBER

NCT02598609.

Racial and Ethnic Differences in Communication Quality During Family-Centered Rounds

OBJECTIVES

To evaluate racial and ethnic differences in communication quality during family centered rounds.

METHODS

We conducted an observational study of family-centered rounds on hospital day 1. All enrolled caregivers completed a survey following rounds and a subset consented to audio record their encounter with the medical team. We applied a priori defined codes to transcriptions of the audio-recorded encounters to assess objective communication quality, including medical team behaviors, caregiver participatory behaviors, and global communication scores. The surveys were designed to measure subjective communication quality. Incident Rate Ratios (IRR) were calculated with regression models to compare the relative mean number of behaviors per encounter time minute by race and ethnicity.

RESULTS

Overall, 202 of 341 eligible caregivers completed the survey, and 59 had accompanying audio- recorded rounds. We found racial and ethnic differences in participatory behaviors: English-speaking Latinx (IRR 0.5; 95% confidence interval [CI] 0.3-0.8) Black (IRR 0.6; 95% CI 0.4-0.8), and Spanish-speaking Latinx caregivers (IRR 0.3; 95% CI 0.2-0.5) participated less than white caregivers. Coder-rated global ratings of medical team respect and partnership were lower for Black and Spanish-speaking Latinx caregivers than white caregivers (respect 3.1 and 2.9 vs 3.6, P values .03 and .04, respectively: partnership 2.4 and 2.3 vs 3.1, P values .03 and .04 respectively). In surveys, Spanish-speaking caregivers reported lower subjective communication quality in several domains.

CONCLUSIONS

In this study, Black and Latinx caregivers were treated with less partnership and respect than white caregivers.

SAFER Care: Improving Caregiver Comprehension of Discharge Instructions

BACKGROUND

One in five pediatric patients suffers from adverse events related to hospital discharge. Current literature lacks evidence on effective interventions to improve caregiver comprehension (CC) of discharge instructions. We examined if a standardized framework for written and verbal discharge counseling was associated with increased CC of key discharge instructions after discharge from a general pediatric inpatient unit.

METHODS

An interprofessional team created the SAFER Care framework to encourage standard, comprehensive discharge counseling. Plan-do-study-act cycles included electronic health record smartphrases, educational initiatives, data feedback, visual aids, and family outreach. Caregivers were surveyed by phone within 4 days of discharge. Our primary outcome was the proportion of caregivers correctly responding to all questions related to discharge care, comparing pre- and postintervention periods. Data were plotted on a statistical process control chart to assess the effectiveness of interventions.

RESULTS

A total of 171 surveys were analyzed in the preintervention period, and 262 surveys were analyzed in the postintervention period. A total of 37% of caregivers correctly responded to all questions in the preintervention period, compared with 62% of caregivers in the postintervention period, meeting rules for special cause variation.

CONCLUSIONS

Development of the SAFER Care framework and its use in written and verbal discharge counseling was associated with significantly improved CC of discharge instructions in a general pediatric inpatient unit. Further studies should be focused on expanding this to other populations, particularly limited-English-proficiency families.

Hidden health IT hazards: a qualitative analysis of clinically meaningful documentation discrepancies at transfer out of the pediatric intensive care unit

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.

Health Literacy in the Inpatient Setting: Implications for Patient Care and Patient Safety

Health literacy plays a role in the events leading up to children's hospitalizations, during hospital admission, and after discharge. Hospitals and providers should use a universal precautions approach and routinely incorporate health-literacy-informed strategies in communicating with all patients and families to ensure that they can understand health information, follow medical instructions, participate actively in their own/their child's care, and successfully navigate the health care system. Interventions that incorporate health-literacy-informed strategies and that target patients/families and health care systems should be implemented to improve patient outcomes and patient-centered and family-centered care.

Communication with Diverse Patients: Addressing Culture and Language

Effective communication is key when providing quality health care. The dynamics of communication within the health care team and with the patient and family can be challenging. These challenges stem from the sharing of complex information, highly emotional topics, and health literacy barriers. Linguistic and cultural barriers can further aggravate these challenges. This section provides an overview of linguistic and cultural challenges related to patient-provider communication, strategies for effective communication with patients with limited English Proficiency via the use of interpreter services, and tips for how to teach these skills to health care providers.

Family-Centered Rounds: Past, Present, and Future

Bedside rounds have evolved concurrently with hospitalist medicine and patient-centered care. Family-centered rounds are the foundation of effective communication in the in-patient pediatric setting. Participant perspectives (family members, patients, nurses, faculty, and trainees) on family-centered rounds differ and goals may not always align. Further, the practical components of how rounds are conducted varies and have continued opportunities for improvement. This article summarizes the most recent experience with rounds in an attempt to identify unified and effective strategies moving forward.

Inpatients Sign On: An Opportunity to Engage Hospitalized Patients and Caregivers Using Inpatient Portals

BACKGROUND

Inpatient portals are online patient portals linked to electronic health records that provide hospitalized patients and caregivers secure access to real-time clinical information and tools to enhance their communication with providers and hospital experience.

OBJECTIVE

The main objective of this commentary was to provide a perspective that inpatient portals are innovative tools poised to engage patients and caregivers during hospitalization and, thus, enhance patient-centered care.

RESULTS

Inpatient portals are desired by patients and caregivers and may contribute to improved recognition of their inpatient care team, knowledge of their treatment plan and overall inpatient experience. A sociotechnical systems approach is recommended to mitigate potential unintended consequences of inpatient portal use and support effective portal design, implementation and evaluation.

CONCLUSIONS

This article highlights the potential of using inpatient portals to engage hospitalized patients and caregivers and proposes next steps to evaluate this emerging technology.

Health Disparities in the Hospitalized Child

Health care disparities exist along the continuum of care for children admitted to the hospital; they start before admission, impact hospital course, and continue after discharge. During an acute illness, risk of admission, length of stay, hospital costs, communication during family-centered rounds, and risk of readmission have all been shown to vary by socioeconomic status, race, and ethnicity. Understanding factors beyond the acute illness that increase a child's risk of admission, increase hospital course complications, and lower discharge quality is imperative for the new generation of pediatric hospitalists focused on improving health for a population of children. In this article, we describe a framework to conceptualize socioeconomic, racial, and ethnic health disparities for the hospitalized child. Additionally, we offer actions pediatric hospitalists can take to address disparities within their practices.

Opportunities and Challenges for Improving the Patient Experience in the Acute and Postacute Care Setting Using Patient Portals: The Patient's Perspective

Efforts to improve the patient experience are increasingly focusing on engaging patients and their "care partners" by using patient portals. The Acute Care Patient Portal Task Force was supported by the Gordon and Betty Moore Foundation to convene a national meeting of an interdisciplinary group of stakeholders, including patient advocates, to consider how the acute and postacute care patient experience can be improved by using patient-facing technologies. We identified key opportunities and challenges for enhancing cognitive support, promoting respect while maintaining boundaries, and facilitating patient and family empowerment through the lens of the patient. Institutions, clinicians, and vendors would benefit tremendously by considering these 3 patient-centered themes when partnering with patients and family advisors to implement and realize the full potential of patient portals to enhance the acute and postacute care experience.

Parent-Provider Miscommunications in Hospitalized Children

BACKGROUND

Miscommunications lead to medical errors and suboptimal hospital experience. Parent-provider miscommunications are understudied.

OBJECTIVES

(1) Examine characteristics of parent-provider miscommunications about hospitalized children, (2) describe associations among parent-provider miscommunications, parent-reported errors, and hospital experience, and (3) compare parent and attending physician reports of parent-provider miscommunications.

METHODS

Prospective cohort study of 471 parents of 0- to 17-year-old medical inpatients in a pediatric hospital between May 1, 2013 and October 1, 2014. At discharge, parents reported parent-provider miscommunication and type (selecting all applicable responses), overall experience, and errors during hospitalization. During discharge billing, the attending physicians (n = 52) of a subset of patients (n = 217) also reported miscommunications, enabling comparison of parent and attending physician reports. We used logistic regression to examine characteristics of parent-reported miscommunications; McNemar's test to examine associations between miscommunications, errors, and top-box (eg, "excellent") experience; and generalized estimating equations to compare parent- and attending physician-reported miscommunication rates.

RESULTS

Parents completed 406 surveys (86.2% response rate). 15.3% of parents (n = 62) reported miscommunications. Parents of patients with nonpublic insurance (odds ratio: 1.99; 95% confidence interval: 1.03-3.85) and longer lengths of stay (odds ratio: 1.12; 95% confidence interval: 1.02-1.23) more commonly reported miscommunications. Parents reporting miscommunications were 5.3 times more likely to report errors and 78.6% less likely to report top-box overall experience (P < .001 for both). Among patients with both parent and attending physician surveys, 16.1% (n = 35) of parents and 3.7% (n = 8) of attending physicians reported miscommunications (P < .001). Both parents and attending physicians attributed miscommunications most often to family receipt of conflicting information.

CONCLUSIONS

Parent-provider miscommunications were associated with parent-reported errors and suboptimal hospital experience. Parents reported parent-provider miscommunications more often than attending physicians did.

Parental Management of Discharge Instructions: A Systematic Review

CONTEXT

Parents often manage complex instructions when their children are discharged from the inpatient setting or emergency department (ED); misunderstanding instructions can put children at risk for adverse outcomes. Parents' ability to manage discharge instructions has not been examined before in a systematic review.

OBJECTIVE

To perform a systematic review of the literature related to parental management (knowledge and execution) of inpatient and ED discharge instructions.

DATA SOURCES

We consulted PubMed/Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane CENTRAL (from database inception to January 1, 2017).

STUDY SELECTION

We selected experimental or observational studies in the inpatient or ED settings in which parental knowledge or execution of discharge instructions were evaluated.

DATA EXTRACTION

Two authors independently screened potential studies for inclusion and extracted data from eligible articles by using a structured form.

RESULTS

Sixty-four studies met inclusion criteria; most (n = 48) were ED studies. Medication dosing and adherence errors were common; knowledge of medication side effects was understudied (n = 1). Parents frequently missed follow-up appointments and misunderstood return precaution instructions. Few researchers conducted studies that assessed management of instructions related to diagnosis (n = 3), restrictions (n = 2), or equipment (n = 1). Complex discharge plans (eg, multiple medicines or appointments), limited English proficiency, and public or no insurance were associated with errors. Few researchers conducted studies that evaluated the role of parent health literacy (ED, n = 5; inpatient, n = 0).

LIMITATIONS

The studies were primarily observational in nature.

CONCLUSIONS

Parents frequently make errors related to knowledge and execution of inpatient and ED discharge instructions. Researchers in the future should assess parental management of instructions for domains that are less well studied and focus on the design of interventions to improve discharge plan management.

Parent and Provider Experience and Shared Understanding After a Family-Centered Nighttime Communication Intervention

OBJECTIVE

To assess parent and provider experience and shared understanding after a family-centered, multidisciplinary nighttime communication intervention (nurse-physician brief, family huddle, family update sheet).

METHODS

We performed a prospective intervention study at a children's hospital from May 2013 to October 2013 (preintervention period) and May 2014 to October 2014 (postintervention period). Participants included 464 parents, 176 nurses, and 52 resident physicians of 582 hospitalized 0- to 17-year-old patients. Pre- versus postintervention, we compared parent/provider top-box scores (eg, "excellent") for experience with communication across several domains; and level of agreement (shared understanding) between parent, nurse, and resident reports of patients' reason for admission, overnight medical plan, and overall medical plan, as rated independently by blinded clinician reviewers (agreement = 74.7%, kappa = .60).

RESULTS

Top-box parent experience improved for 1 of 4 domains: Experience and Communication With Nighttime Doctors (23.6% to 31.5%). Top-box provider experience improved for all 3 domains, including Communication and Shared Understanding With Families (resident rated, 16.5% to 35.1%; nurse rated, 32.2% to 37.9%) and Experience, Communication, and Shared Understanding With Other Providers (resident rated, 20.3% to 35.0%; nurse rated, 14.7% to 21.5%). Independently rated shared understanding remained unchanged for most domains but improved for parent-nurse composite shared understanding (summed agreement for reason for admission, overall plan, and overnight plan; 36.2% to 48.2%) and nurse-resident shared understanding regarding reason for admission (67.1% to 71.2%) and regarding overall medical plan (45.0% to 58.6%). All P <.05.

CONCLUSIONS

A family-centered, multidisciplinary nighttime communication intervention was associated with improvements in some, but not all, domains of parent/provider experience and shared understanding, particularly provider experience and nurse-family shared understanding. The intervention was promising but requires further refinement.