Pediatricians' Career Satisfaction and Wellbeing by Sex Before and During the COVID-19 Pandemic

OBJECTIVE

To compare pediatrician career satisfaction and wellbeing by sex during the coronavirus disease 2019 pandemic with prepandemic years using longitudinal survey data.

METHODS

Data from a cohort study, the American Academy of Pediatrics Pediatrician Life and Career Experience Study, were used to examine career satisfaction and wellbeing from 2012 to 2021 among 2002-2004 and 2009-2011 residency graduates (n = 1760). Mixed effects logistic regression, including key pediatrician characteristics, examined career satisfaction and wellbeing measures for sex (female vs male), pandemic year (2012-2019 vs 2020-2021), and their interaction effect. Adjusted predicted percentage values (PVs) were determined.

RESULTS

In total, 73.4% of participants identified as female. Adjusting for key pediatrician characteristics, differences were found by sex for satisfaction and 4 of 5 wellbeing measures, by pandemic year for 2 wellbeing measures, and the interaction of sex and pandemic year for 3 wellbeing measures. Female pediatricians reported higher levels of anxiety, sadness, and work stress, with greater differences during the pandemic. For example, female pediatricians (PV = 22.6, confidence interval [CI] = 21.0-24.3) were more likely than male pediatricians (PV = 14.2, CI = 12.0-16.4) to report anxiety during pre-pandemic years, and the difference between female pediatricians (PV = 29.3, CI = 26.7-32.0) and male pediatricians (PV = 12.4, CI = 9.3-15.5) increased during pandemic years (sex by pandemic year interaction, P < .001).

CONCLUSIONS

Compared with male pediatricians, female pediatricians reported worse anxiety, sadness, and stress at work, and the differences were more pronounced during the pandemic.

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.

Reduced Postdischarge Incidents After Implementation of a Hospital-to-Home Transition Intervention for Children With Medical Complexity

OBJECTIVES

Prior research suggests that errors occur frequently for patients with medical complexity during the hospital-to-home transition. Less is known about effective postdischarge communication strategies for this population. We aimed to assess rates of 30-day (1) postdischarge incidents and (2) readmissions and emergency department (ED) visits before and after implementing a hospital-to-home intervention.

METHODS

We conducted a prospective intervention study of children with medical complexity discharged at a children's hospital from April 2018 to March 2020. A multistakeholder team developed a bundled intervention incorporating the I-PASS handoff framework including a postdischarge telephone call, restructured discharge summary, and handoff communication to outpatient providers. The primary outcome measure was rate of postdischarge incidents collected via electronic medical record review and family surveys. Secondary outcomes were 30-day readmissions and ED visits.

RESULTS

There were 199 total incidents and the most common were medication related (60%), equipment issues (15%), and delays in scheduling/provision of services (11%). The I-PASS intervention was associated with a 36.4% decrease in the rate of incidents per discharge (1.51 versus 0.95, P = 0.003). There were fewer nonharmful errors and quality issues after intervention (1.27 versus 0.85 per discharge, P = 0.02). The 30-day ED visit rate was significantly lower after intervention (12.6% versus 3.4%, per 100 discharges, P = 0.05). Thirty-day readmissions were 15.8% versus 10.2% postintervention (P = 0.32).

CONCLUSIONS

A postdischarge communication intervention for patients with medical complexity was associated with fewer postdischarge incidents and reduced 30-day ED visits. Standardized postdischarge communication may play an important role in improving quality and safety in the transition from hospital-to-home for vulnerable populations.

Improving Handoffs in the Perioperative Environment: A Conceptual Framework of Key Theories, System Factors, Methods, and Core Interventions to Ensure Success

BACKGROUND

Patient handoffs involve the transition of information and responsibility for care from one health care provider to another. They occur frequently during a patient's perioperative care continuum, potentially introducing communication errors that could result in harmful, even fatal consequences. The perioperative environment poses distinct challenges to team communication and patient safety, which in turn leaves the surgical patient uniquely vulnerable to adverse events.

CONCEPTUAL FRAMEWORK

The best way to achieve safe, coordinated handoffs throughout the perioperative continuum has yet to be established. However, a variety of theoretical principles, methods, and interventions have been used successfully in operative and nonoperative contexts among multiple disciplines. Informed by a literature review, the authors describe a conceptual framework for the development, implementation, and sustainment of a multimodal perioperative handoff improvement bundle. The conceptual framework presented here begins with overarching objectives for patient-centered handoff improvement efforts. The article outlines theoretical principles that could be used to guide and inform future multimodal interventions, as well as health care system factors to consider. Further, the authors propose employing data-driven quality improvement and research methodologies to conduct, measure, achieve, and sustain long-term success. Finally, this report describes essential evidence-based interventional components to employ.

IMPLICATIONS

Future efforts to improve handoff safety in the perioperative environment will require a comprehensive evidence-based approach. The authors believe the conceptual framework presented here outlines essential components for success. It integrates proven theoretical frameworks, consideration of system factors, data-driven iterative methods, and synergistic patient-centered interventions.

Implementation of the I-PASS handoff program in diverse clinical environments: A multicenter prospective effectiveness implementation study

BACKGROUND

Handoff miscommunications are a leading source of medical errors. Harmful medical errors decreased in pediatric academic hospitals following implementation of the I-PASS handoff improvement program. However, implementation across specialties has not been assessed.

OBJECTIVE

To determine if I-PASS implementation across diverse settings would be associated with improvements in patient safety and communication.

DESIGN

Prospective Type 2 Hybrid effectiveness implementation study.

SETTINGS AND PARTICIPANTS

Residents from diverse specialties across 32 hospitals (12 community, 20 academic).

INTERVENTION

External teams provided longitudinal coaching over 18 months to facilitate implementation of an enhanced I-PASS program and monthly metric reviews.

MAIN OUTCOME AND MEASURES

Systematic surveillance surveys assessed rates of resident-reported adverse events. Validated direct observation tools measured verbal and written handoff quality.

RESULTS

2735 resident physicians and 760 faculty champions from multiple specialties (16 internal medicine, 13 pediatric, 3 other) participated. 1942 error surveillance reports were collected. Major and minor handoff-related reported adverse events decreased 47% following implementation, from 1.7 to 0.9 major events/person-year (p < .05) and 17.5 to 9.3 minor events/person-year (p < .001). Implementation was associated with increased inclusion of all five key handoff data elements in verbal (20% vs. 66%, p < .001, n = 4812) and written (10% vs. 74%, p < .001, n = 1787) handoffs, as well as increased frequency of handoffs with high quality verbal (39% vs. 81% p < .001) and written (29% vs. 78%, p < .001) patient summaries, verbal (29% vs. 78%, p < .001) and written (24% vs. 73%, p < .001) contingency plans, and verbal receiver syntheses (31% vs. 83%, p < .001). Improvement was similar across provider types (adult vs. pediatric) and settings (community vs. academic).

Quality Improvement Initiative to Improve Timing of Enteral Feeds in Pediatric Acute Pancreatitis

BACKGROUND

Acute pancreatitis (AP) represents a significant disease burden in the pediatric population. The management of AP includes fluid resuscitation, pain management, and early enteral feeds. Contrary to old dogma, early enteral feeding has been shown to improve outcomes and reduce hospital length of stay (LOS), yet uptake of this approach has not been standardized. Our aim was to standardize the management of AP, increasing the percentage of patients receiving early enteral nutrition from 40% to 65% within 12 months.

METHODS

Between January 2013 and September 2021, we conducted a quality improvement initiative among patients hospitalized with AP. Interventions included the development of a clinical care pathway, integration of an AP order set, and physician education. Our primary outcome was the percentage of patients receiving enteral nutrition within 48 hours of admission, and our secondary outcome was hospital LOS. Balancing measures included hospital readmission rates.

RESULTS

A total of 652 patients were admitted for AP during the project, of which 322 (49%) were included after pathway implementation. Before pathway development, the percentage of patients receiving early enteral nutrition was 40%, which increased significantly to 84% after our interventions. This improvement remained stable. Median LOS decreased significantly from 5.5 to 4 days during this timeframe. Our balancing measure of readmission rates did not change during the project period.

CONCLUSIONS

Through multiple interventions, including the implementation of an AP clinical pathway, we significantly increased the proportion of patients receiving early enteral nutrition and decreased hospital LOS without increasing hospital readmission rates.

A Mixed-Methods Assessment of Coronavirus Disease of 2019-Era Telehealth Acute Care Visits in the Medical Home

OBJECTIVES

To compare acute care virtual visits with in-person visits with respect to equity of access, markers of quality and safety, and parent and provider experience, before and during the coronavirus disease 2019 pandemic.

STUDY DESIGN

We compared patient demographics, antimicrobial prescribing rates, emergency department (ED) use, and patient-experience scores for virtual visits and in-person care at 2 academic pediatric primary care practices using χ² testing and interrupted time series analyses. Parent and provider focus groups explored themes related to virtual visit experience and acceptability.

RESULTS

We compared virtual acute care visits conducted in March 2020-February 2021 (n = 8868) with in-person acute care visits conducted in February 2019-March 2020 (n = 24 120) and March 2020-February 2021 (n = 6054). There were small differences in patient race/ethnicity across the different cohorts (P < .01). Virtual visits were associated with a 9.6% (-11.5%, -7.8%, P < .001) decrease in all antibiotic prescribing and a 13.2% (-22.1%, -4.4%, P < .01) decrease in antibiotic prescribing for acute respiratory tract infections. Unanticipated visits to the ED did not significantly differ among visit types. Patient experience scores were significantly greater (P < .05) for virtual acute care in overall rating of care and likelihood to recommend. Focus group themes included safety, distractibility, convenience, treatment, and technology. Providers were broadly accepting of virtual care while parental views were more mixed.

CONCLUSIONS

Telehealth acute care visits may not have negative effects on quality and safety, as measured by antimicrobial prescribing and unanticipated ED visit rates. Efforts to increase parental acceptance and avoid creating disparities in access to virtual care will be essential to continued success of telehealth acute care visits.

Improving HPV Vaccination Rates in a Racially and Ethnically Diverse Pediatric Population

BACKGROUND AND OBJECTIVES

Nationally, 54.2% of youth are fully vaccinated for human papilloma virus (HPV) with persistent gender and racial/ethnic disparities. We used a quality improvement approach to improve completion of the HPV vaccine series by age 13 years. As a secondary aim, we examined racial/ethnic and gender differences in vaccine uptake.

METHODS

The study setting included 2 pediatric, academic, primary care practices in Massachusetts. We designed a multilevel patient-, provider-, and systems-level intervention addressing parental hesitancy, provider communication, and clinical operations. Rates of HPV series completion by age 13 were monitored using a control p chart. Bivariate and multivariate analyses evaluated vaccine completion differences on the basis of clinic size, gender, and race/ethnicity.

RESULTS

Between July 1, 2014, and September 30, 2021, control p charts showed special cause variation with HPV vaccine initiation by age 9 years, increasing from 1% to 52%, and vaccine completion by 13 years, increasing from 37% to 77%. Compared with White and Black children, Hispanic children were more likely to initiate the HPV vaccine at age 9 (adjusted odds ratio [95% confidence interval] = (1.4-2.6)] and complete the series by age 13 (adjusted odds ratio [95% confidence interval] = 2.3 (1.7-3.0).

CONCLUSIONS

A multilevel intervention was associated with sustained HPV vaccine series completion by age 13 years. Hispanic children were more likely to be vaccinated. Qualitative family input was critical to intervention design. Provider communication training addressed vaccine hesitancy. Initiation of the vaccine at age 9 and clinicwide vaccine protocols were key to sustaining improvements.

Different Measures and Ways to Categorize Pediatrician Burnout and the Association with Satisfaction

OBJECTIVE

Compare pediatrician burnout when measured and categorized in different ways to better understand burnout and the association with satisfaction.

STUDY DESIGN

We analyzed national survey data from a cohort study of early to midcareer pediatricians. In 2017, participants randomly received 1 of 3 question sets measuring burnout components (emotional exhaustion, depersonalization, and personal accomplishment): group A received the Maslach Burnout Inventory, group B received a previously used measure, and group C received a new severe measure. Repeated measures ANOVA tested differences across burnout categorizations: high emotional exhaustion and high depersonalization and low personal accomplishment; high emotional exhaustion and high depersonalization; and high emotional exhaustion or high depersonalization. Logistic regression tested relationships between burnout profiles (engaged, intermediate, and burnout) and satisfaction. Seventy-one percent of participants completed the survey (1279/1800).

RESULTS

Burnout varied depending on measurement (groups A, B, and C) and categorization. For example, for group A, when categorized as high emotional exhaustion, high depersonalization, and low personal accomplishment, burnout was lower (4.8%) than categorized as high emotional exhaustion and depersonalization (15.2%) (P < .001) or categorized as high emotional exhaustion or depersonalization (44.6%) (P < .001). Most participants were satisfied with their career (83.6%). Using burnout profiles, 38.4%-85.1% fell in the engaged profile. For each group, burnout profiles were associated with satisfaction. For example, group A participants in the burnout or intermediate profile were less likely than those engaged to be satisfied with their careers (aOR, 0.08 [95% CI, 0.03-0.24]; and aOR, 0.23 [95% CI, 0.10-0.56], respectively).

CONCLUSIONS

The way burnout is measured and categorized affects burnout prevalence and its association with satisfaction. Transparency in methodology used is critical to interpreting results.

Association of Patient and Family Reports of Hospital Safety Climate With Language Proficiency in the US

IMPORTANCE

Patients with language barriers have a higher risk of experiencing hospital safety events. This study hypothesized that language barriers would be associated with poorer perceptions of hospital safety climate relating to communication openness.

OBJECTIVE

To examine disparities in reported hospital safety climate by language proficiency in a cohort of hospitalized children and their families.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study conducted from April 29, 2019, through March 1, 2020, included pediatric patients and parents or caregivers of hospitalized children at general and subspecialty units at 21 US hospitals. Randomly selected Arabic-, Chinese-, English-, and Spanish-speaking hospitalized patients and families were approached before hospital discharge and were included in the analysis if they provided both language proficiency and health literacy data. Participants self-rated language proficiency via surveys. Limited English proficiency was defined as an answer of anything other than "very well" to the question "how well do you speak English?"

MAIN OUTCOMES AND MEASURES

Primary outcomes were top-box (top most; eg, strongly agree) 5-point Likert scale ratings for 3 Children's Hospital Safety Climate Questionnaire communication openness items: (1) freely speaking up if you see something that may negatively affect care (top-box response: strongly agree), (2) questioning decisions or actions of health care providers (top-box response: strongly agree), and (3) being afraid to ask questions when something does not seem right (top-box response: strongly disagree [reverse-coded item]). Covariates included health literacy and sociodemographic characteristics. Logistic regression was used with generalized estimating equations to control for clustering by site to model associations between openness items and language proficiency, adjusting for health literacy and sociodemographic characteristics.

RESULTS

Of 813 patients, parents, and caregivers who were approached to participate in the study, 608 completed surveys (74.8% response rate). A total of 87.7% (533 of 608) of participants (434 [82.0%] female individuals) completed language proficiency and health literacy items and were included in the analyses; of these, 14.1% (75) had limited English proficiency. Participants with limited English proficiency had lower odds of freely speaking up if they see something that may negatively affect care (adjusted odds ratio [aOR], 0.26; 95% CI, 0.15-0.43), questioning decisions or actions of health care providers (aOR, 0.19; 95% CI, 0.09-0.41), and being unafraid to ask questions when something does not seem right (aOR, 0.44; 95% CI, 0.27-0.71). Individuals with limited health literacy (aOR, 0.66; 95% CI, 0.48-0.91) and a lower level of educational attainment (aOR, 0.59; 95% CI, 0.36-0.95) were also less likely to question decisions or actions.

CONCLUSIONS AND RELEVANCE

This cohort study found that limited English proficiency was associated with lower odds of speaking up, questioning decisions or actions of providers, and being unafraid to ask questions when something does not seem right. This disparity may contribute to higher hospital safety risk for patients with limited English proficiency. Dedicated efforts to improve communication with patients and families with limited English proficiency are necessary to improve hospital safety and reduce disparities.

Standardizing Opioid Prescribing in a Pediatric Hospital: A Quality Improvement Effort

BACKGROUND

Opioids are indicated for moderate-to-severe pain caused by trauma, ischemia, surgery, cancer and sickle cell disease, and vaso-occlusive episodes (SCD-VOC). There is only limited evidence regarding the appropriate number of doses to prescribe for specific indications. Therefore, we developed and implemented an opioid prescribing algorithm with dosing guidelines for specific procedures and conditions. We aimed to reach and sustain 90% compliance within 1 year of implementation.

METHODS

We conducted this quality improvement effort at a pediatric academic quaternary care institution. In 2018, a multidisciplinary team identified the need for a standard approach to opioid prescribing. The algorithm guides prescribers to evaluate the medical history, physical examination, red flags, pain type, and to initiate opioid-sparing interventions before prescribing opioids. Opioid prescriptions written between January 2015 and September 2020 were included. Examples from 2 hospital departments will be highlighted. Control charts for compliance with guidelines and variability in the doses prescribed are presented for selected procedures and conditions.

RESULTS

Over 5 years, 83 037 opioid prescriptions in 53 804 unique patients were entered electronically. The encounters with ≥1 opioid prescription decreased from 48% to 25% between 2015 and 2019. Compliance with the specific guidelines increased to ∼85% for periacetabular osteotomies and SCD-VOC and close to 100% for anterior-cruciate ligament surgery. In all 3 procedures and conditions, variability in the number of doses prescribed decreased significantly.

CONCLUSION

We developed an algorithm, guidelines, and a process for improvement. The number of opioid prescriptions and variability in opioid prescribing decreased. Future evaluation of specific initiatives within departments is needed.

Patient Safety in Ambulatory Pediatrics

Purpose of Review

The majority of patient care occurs in the ambulatory setting, and pediatric patients are at high risk of medical error and harm. Prior studies have described various safety threats in ambulatory pediatrics, and little is known about effective strategies to minimize error. The purpose of this review is to identify best practices for optimizing safety in ambulatory pediatrics.

Recent Findings

The majority of the patient safety literature in ambulatory pediatrics describes frequencies and types of medical errors. Study of effective interventions to reduce error, and particularly to reduce harm, have been limited. There is evidence that medical complexity and social context are important modifiers of risk. Telemedicine has emerged as a care delivery model with potential to ameliorate and exacerbate safety threats. Though there is variation across studies, developing a safety culture, partnerships with patients and families, and use of structured communication are strategies that support patient safety.

Summary

There is no standardized taxonomy for errors in ambulatory pediatrics, but errors related to medications, vaccines, diagnosis, and care coordination and care transitions are commonly described. Evidence-based approaches to optimize safety include standardized prescribing and medication reconciliation practices, appropriate use of decision support tools in the electronic health record, and communication strategies like teach-back. Further high-quality intervention studies in pediatric ambulatory care that assess impact on patient harm and clinical outcomes should be prioritized.

I-PASS Mentored Implementation Handoff Curriculum: Frontline Provider Training Materials

INTRODUCTION

The I-PASS Handoff Program is a comprehensive handoff curriculum that has been shown to decrease rates of medical errors and adverse events during patient handoffs. Frontline providers are the key individuals participating in handoffs of patient care. It is important they receive robust handoff training.

METHODS

The I-PASS Mentored Implementation Handoff Curriculum frontline provider training materials were created as part of the original I-PASS Study and adapted for the Society of Hospital Medicine (SHM) I-PASS Mentored Implementation Program. The adapted materials embrace a flipped classroom approach with an emphasis on adult learning theory principles. The training includes an overview of I-PASS handoff techniques, TeamSTEPPS team communication strategies, verbal handoff simulation scenarios, and a printed handoff document exercise.

RESULTS

As part of the SHM I-PASS Mentored Implementation Program, 2,735 frontline providers were trained at 32 study sites (16 adult and 16 pediatric) across North America. At the end of their training, 1,762 frontline providers completed the workshop evaluation form (64% response rate). After receiving the training, over 90% agreed/strongly agreed that they were able to distinguish a good- from a poor-quality handoff, articulate the elements of the I-PASS mnemonic, construct a high-quality patient summary, advocate for an appropriate environment for handoffs, and participate in handoff simulations. Universally, the training provided them with knowledge and skills relevant to their patient care activities.

DISCUSSION

The I-PASS frontline training materials were rated highly by those trained and are an integral part of a successful I-PASS Handoff Program implementation.

Implementing receiver-driven handoffs to the emergency department to reduce miscommunication

BACKGROUND

Miscommunications during care transfers are a leading cause of medical errors. Recent consensus-based recommendations to standardise information transfer from outpatient clinics to the emergency department (ED) have not been formally evaluated. We sought to determine whether a receiver-driven structured handoff intervention is associated with 1) increased inclusion of standardised elements; 2) reduced miscommunications and 3) increased perceived quality, safety and efficiency.

METHODS

We conducted a prospective intervention study in a paediatric ED and affiliated clinics in 2016-2018. We developed a bundled handoff intervention included a standard template, receiver training, awareness campaign and iterative feedback. We assessed a random sample of audio-recorded handoffs and associated medical records to measure rates of inclusion of standardised elements and rate of miscommunications. We surveyed key stakeholders pre-intervention and post-intervention to assess perceptions of quality, safety and efficiency of the handoff process.

RESULTS

Across 162 handoffs, implementation of a receiver-driven intervention was associated with significantly increased inclusion of important elements, including illness severity (46% vs 77%), tasks completed (64% vs 83%), expectations (61% vs 76%), pending tests (0% vs 64%), contingency plans (0% vs 54%), detailed callback request (7% vs 81%) and synthesis (2% vs 73%). Miscommunications decreased from 48% to 26%, a relative reduction of 23% (95% CI -39% to -7%). Perceptions of quality (35% vs 59%), safety (43% vs 73%) and efficiency (17% vs 72%) improved significantly post-intervention.

CONCLUSIONS

Implementation of a receiver-driven intervention to standardise clinic-to-ED handoffs was associated with improved communication quality. These findings suggest that expanded implementation of similar programmes may significantly improve the care of patients transferred to the paediatric ED.

Gender Discrepancies Related to Pediatrician Work-Life Balance and Household Responsibilities

BACKGROUND

Physicians must balance career and home responsibilities, yet previous studies on work-life balance are focused primarily on work-based tasks. We examined gender discrepancies and factors related to household responsibilities and work-life balance among pediatricians.

METHODS

We used 2015 data from the American Academy of Pediatrics Pediatrician Life and Career Experience Study, a longitudinal study of early-career pediatricians. χ² tests and multivariable logistic regression were used to examine the effects of gender on household responsibilities, satisfaction, and work-life balance attainment. We formally reviewed responses from 2 open-ended questions on work-life balance challenges and strategies for common themes.

RESULTS

Seventy-two percent of participants completed the survey (1293 of 1801). Women were more likely than men to report having primary responsibility for 13 of 16 household responsibilities, such as cleaning, cooking, and routine care of children (all P < .001). All gender differences except budget management remained significant when controlling for part-time work status and spouse or partner work status (P < .05). Women were less satisfied with their share of responsibilities relative to others (52% vs 62%; P < .001), and few women and men report being very successful at achieving balance between their job and other life areas (15% vs 19%, respectively; P = .05). Open-ended responses (n = 1145) revealed many barriers to achieving work-life balance. Strategies to increase work-life balance included reducing work hours, outsourcing household-related work, and adjustments to personal responsibilities and relationships.

CONCLUSIONS

Female pediatricians spend more time on household responsibilities than male pediatricians, and gender is a key factor associated with work-life balance satisfaction.

Gender Differences in Earnings of Early- and Midcareer Pediatricians

BACKGROUND

The US physician workforce includes an increasing number of women, with pediatrics having the highest percentage. In recent research on physicians, it is indicated that men earn more than women. It is unclear how this finding extends to pediatricians.

METHODS

We examined cross-sectional 2016 data on earnings from the American Academy of Pediatrics Pediatrician Life and Career Experience Study, a longitudinal study of early- and midcareer pediatricians. To estimate adjusted differences in pediatrician earnings between men and women, we conducted 4 ordinary least squares regression models. Model 1 examined gender, unadjusted; model 2 controlled for labor force characteristics; model 3 controlled for both labor force and physician-specific job characteristics; and model 4 controlled for labor force, physician-specific job, and work-family characteristics.

RESULTS

Sixty-seven percent of Pediatrician Life and Career Experience Study participants completed the 2016 surveys (1213 out of 1801). The analytic sample was restricted to participants who completed training and worked in general pediatrics, hospitalist care, or subspecialty care (n = 998). Overall pediatrician-reported mean annual income was $189 804. Before any adjustment, women earned ∼76% of what men earned, or ∼$51 000 less. Adjusting for common labor force characteristics such as demographics, work hours, and specialty, women earned ∼87% of what men earned, or ∼$26 000 less. Adjusting for a comprehensive set of labor force, physician-specific job, and work-family characteristics, women earned ∼94% of what men earned, or ∼$8000 less.

CONCLUSIONS

Early- to midcareer female pediatricians earned less than male pediatricians. This difference persisted after adjustment for important labor force, physician-specific job, and work-family characteristics. In future work, researchers should use longitudinal analyses and further explore family obligations and choices.

Association of Pediatric Resident Physician Depression and Burnout With Harmful Medical Errors on Inpatient Services

PURPOSE

To determine whether higher rates of medical errors were associated with positive screenings for depression or burnout among resident physicians.

METHOD

The authors conducted a prospective cohort study from 2011 to 2013 in seven pediatric academic medical centers in the United States and Canada. Resident physicians were screened for burnout and depression using the Maslach Burnout Inventory-Human Services Survey (MBI-HSS) and Harvard Department of Psychiatry/National Depression Screening Day Scale (HANDS). A two-step surveillance methodology, involving a research nurse and two physician reviewers, was used to measure and categorize errors. Bivariate and mixed-effects regression models were used to evaluate the relationship between burnout, depression, and rates of harmful, nonharmful, and total errors.

RESULTS

A total of 388/537 (72%) resident physicians completed the MBI-HSS and HANDS surveys. Seventy-six (20%) and 178 (46%) resident physicians screened positive for depression and burnout, respectively. Screening positive for depression was associated with a 3.0-fold higher rate of harmful errors (incidence rate ratio = 2.99 [95% CI 1.40-6.36], P = .005). However, there was no statistically significant association between depression and total or nonharmful errors or between burnout and harmful, nonharmful, or total errors.

CONCLUSIONS

Resident physicians with a positive depression screen were three times more likely than those who screened negative to make harmful errors. This association suggests resident physician mental health could be an important component of patient safety. If further research confirms resident physician depression increases the risk of harmful errors, it will become imperative to determine what interventions might mitigate this risk.

Process Metrics and Outcomes to Inform Quality Improvement in Pediatric Hospital Medicine

This article provides an overview of the selection, development, and use of process and outcome measures for pediatric hospital medicine quality improvement initiatives. It reviews commonly used categories of process and outcome measures and provides a list of common sources and repositories of previously validated measures. It also provides a blueprint for the development of novel measures. The relative merits of various data collection methods are discussed (eg, medical record abstraction, administrative, surveys), along with guiding principles for disseminating the results of quality improvement evaluations on a local and national level.

"All the ward's a stage": a qualitative study of the experience of direct observation of handoffs

Direct observation of clinical skills is central to assessment in a competency-based medical education model, yet little is known about how direct observation is experienced by trainees and observers. The objective of the study is to explore how direct observation was experienced by residents and faculty in the context of the I-PASS Handoff Study. In this multi-center qualitative study, we conducted focus groups and semi-structured interviews of residents and faculty members at eight tertiary pediatric centers in North America that implemented the I-PASS Handoff Bundle. We employed qualitative thematic analysis to interpret the data. Barriers to and strategies for direct observation were described relating to the observer, trainee, and clinical environment. Residents and faculty described a mutual awareness that residents change their performance of handoffs when observed, in contrast to their usual behavior in a clinical setting. Changes in handoff performance may depend on the nature of the observer or 'audience'. Direct observation also highlighted the importance of handoffs to participants, recognized as a clinical activity that warrants feedback and assessment. Dramaturgical theory can be used to understand our finding of 'front-stage' (observed) versus 'backstage' (unobserved) handoffs as distinct performances, tailored to an "audience". Educators must be cognizant of changes in performance of routine clinical activities when using direct observation to assess clinical competence.

Improving rates of ferrous sulfate prescription for suspected iron deficiency anaemia in infants

BACKGROUND

Iron deficiency anaemia (IDA) in infancy is prevalent and associated with impaired neurodevelopment; however, studies suggest that treatment and follow-up rates are poor.

OBJECTIVES

To improve the rate of ferrous sulfate prescription for suspected IDA among infants aged 8-13 months to 75% or greater within 24 months.

METHODS

We implemented a multidisciplinary process improvement effort aimed at standardising treatment for suspected IDA at two academic paediatric primary care clinics. We developed a clinical pathway with screening and treatment recommendations, followed by multiple plan-do-study-act cycles including provider education, targeted reminders when ferrous sulfate was not prescribed and development of standardised procedures for responding to abnormal lab values. We tracked prescription and screening rates using statistical process control charts. In post hoc analyses, we examined rates of haemoglobin (Hgb) recheck and normalisation for the preintervention versus postintervention groups.

RESULTS

The prescription rate for suspected IDA increased from 41% to 78% following implementation of the intervention. Common reasons for treatment failure included prescription of a multivitamin instead of ferrous sulfate, and Hgb not flagged as low by the electronic medical record. Screening rates remained stable at 89%. Forty-one per cent of patients with anaemia in the preintervention group had their Hgb rechecked within 6 months, compared with 56% in the postintervention group (p<0.001). Furthermore, 30% of patients with anaemia in the postintervention group had normalised their Hgb by 6 months, compared with 20% in the preintervention group (p<0.05).

CONCLUSIONS

A multipronged interdisciplinary quality improvement intervention enabled: (1) development of standardised practices for treating suspected IDA among infants aged 8-13 months, (2) improvement of prescription rates and (3) maintenance of high screening rates. Rates of Hgb recheck and normalisation also increased in the intervention period.​.

I-PASS Mentored Implementation Handoff Curriculum: Champion Training Materials

INTRODUCTION

The I-PASS Handoff Program is a comprehensive handoff curriculum that has been shown to decrease rates of medical errors and adverse events during patient handoffs. I-PASS champions are a critical part of the implementation and sustainment of this curriculum, and therefore, a rigorous program to support their training is necessary.

METHODS

The I-PASS Handoff champion training materials were created for the original I-PASS Study and adapted for the Society of Hospital Medicine (SHM) I-PASS Mentored Implementation Program. The adapted materials embrace a flipped classroom approach and adult learning theory. The training includes an overview of I-PASS handoff techniques, an opportunity to practice evaluating handoffs with the I-PASS observation tools using a handoff video vignette, and other key implementation principles.

RESULTS

As part of the SHM I-PASS Mentored Implementation Program, 366 champions were trained at 32 sites across North America and participated in a total of 3,491 handoff observations. A total of 346 champions completed the I-PASS Champion Workshop evaluation form at the end of their training (response rate: 94.5%). After receiving the training, over 90% agreed/strongly agreed that it provided them with knowledge or skills critical to their patient care activities and that they were able to distinguish the difference between high- and poor-quality handoffs, competently use the I-PASS handoff assessment tools, and articulate the importance of handoff observations.

CONCLUSION

The I-PASS champion training materials were rated highly by those trained and are an integral part of a successful I-PASS Handoff Program implementation.

Patient safety after implementation of a coproduced family centered communication programme: multicenter before and after intervention study

OBJECTIVE

To determine whether medical errors, family experience, and communication processes improved after implementation of an intervention to standardize the structure of healthcare provider-family communication on family centered rounds.

DESIGN

Prospective, multicenter before and after intervention study.

SETTING

Pediatric inpatient units in seven North American hospitals, 17 December 2014 to 3 January 2017.

PARTICIPANTS

All patients admitted to study units (3106 admissions, 13171 patient days); 2148 parents or caregivers, 435 nurses, 203 medical students, and 586 residents.

INTERVENTION

Families, nurses, and physicians coproduced an intervention to standardize healthcare provider-family communication on ward rounds ("family centered rounds"), which included structured, high reliability communication on bedside rounds emphasizing health literacy, family engagement, and bidirectional communication; structured, written real-time summaries of rounds; a formal training programme for healthcare providers; and strategies to support teamwork, implementation, and process improvement.

MAIN OUTCOME MEASURES

Medical errors (primary outcome), including harmful errors (preventable adverse events) and non-harmful errors, modeled using Poisson regression and generalized estimating equations clustered by site; family experience; and communication processes (eg, family engagement on rounds). Errors were measured via an established systematic surveillance methodology including family safety reporting.

RESULTS

The overall rate of medical errors (per 1000 patient days) was unchanged (41.2 (95% confidence interval 31.2 to 54.5) pre-intervention v 35.8 (26.9 to 47.7) post-intervention, P=0.21), but harmful errors (preventable adverse events) decreased by 37.9% (20.7 (15.3 to 28.1) v 12.9 (8.9 to 18.6), P=0.01) post-intervention. Non-preventable adverse events also decreased (12.6 (8.9 to 17.9) v 5.2 (3.1 to 8.8), P=0.003). Top box (eg, "excellent") ratings for six of 25 components of family reported experience improved; none worsened. Family centered rounds occurred more frequently (72.2% (53.5% to 85.4%) v 82.8% (64.9% to 92.6%), P=0.02). Family engagement 55.6% (32.9% to 76.2%) v 66.7% (43.0% to 84.1%), P=0.04) and nurse engagement (20.4% (7.0% to 46.6%) v 35.5% (17.0% to 59.6%), P=0.03) on rounds improved. Families expressing concerns at the start of rounds (18.2% (5.6% to 45.3%) v 37.7% (17.6% to 63.3%), P=0.03) and reading back plans (4.7% (0.7% to 25.2%) v 26.5% (12.7% to 7.3%), P=0.02) increased. Trainee teaching and the duration of rounds did not change significantly.

CONCLUSIONS

Although overall errors were unchanged, harmful medical errors decreased and family experience and communication processes improved after implementation of a structured communication intervention for family centered rounds coproduced by families, nurses, and physicians. Family centered care processes may improve safety and quality of care without negatively impacting teaching or duration of rounds.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02320175.

I-PASS Mentored Implementation Handoff Curriculum: Implementation Guide and Resources

Introduction

Communication failures during shift-to-shift handoffs of patient care have been identified as a leading cause of adverse events in health care institutions. The I-PASS Handoff Program is a comprehensive handoff program that has been shown to decrease rates of medical errors and adverse events. As part of the spread and adaptation of this program, a comprehensive implementation guide was created to assist individuals in the implementation process.

Methods

The I-PASS Mentored Implementation Guide grew out of materials created for the original I-PASS Study, Society of Hospital Medicine (SHM) mentored implementation programs, and the experience of members of the I-PASS Study Group. The guide provides a comprehensive framework of all elements required to implement the large-scale I-PASS Handoff Program and contains detailed information on generating institutional support, training activities, a campaign, measuring impact, and sustaining the program.

Results

Thirty-two sites across North America utilized the guide as part of the SHM program. The guide served as a main reference for 477 hours of mentoring phone calls between site leads and their mentors. Postprogram surveys from wave 2 sites revealed that 85% (N = 34) of respondents felt the quality of the guide was very good/excellent. Site leads noted that they referenced the guide most often during the early part of the program and that they referenced the sections on the curriculum and handoff observations most often.

Discussion

The I-PASS Mentored Implementation Guide is an essential resource for those looking to implement the large-scale I-PASS Handoff Program at their institution.

I-PASS Handoff Program: Use of a Campaign to Effect Transformational Change

BACKGROUND

Behavior change is notoriously difficult to achieve within health care systems. Successful implementation of the I-PASS handoff bundle with subsequent decreases in medical errors and preventable adverse events represents an example of successful transformational change within academic medical centers.

OBJECTIVE

We designed a campaign to support and enhance uptake of the I-PASS handoff bundle at 9 study sites from 2011 to 2013.

METHODS

Following Kotter's model of transformational change, we established urgency using local data and institutional mandates, and site leaders built local guiding coalitions with institutional leaders, key faculty, and Chief Residents. We created and communicated our vision using a branded campaign and empowered others to act by soliciting and acting on feedback and supporting systems changes. Site leaders planned for and created short-term wins by recognizing residents who engaged with I-PASS, consolidated improvements, and institutionalized new approaches.

RESULTS

Implementation of I-PASS was successful, with achievement of substantial improvements in rates of medical errors and preventable adverse events. Data from the initial I-PASS study have continued to drive a national campaign that has included national recognition by leaders in the field of patient safety and pediatrics. Momentum has increased significantly to support mentored implementation of the I-PASS handoff program at over 35 academic medical centers across North America.

CONCLUSIONS

I-PASS provides an example of transformational change achieved through a combination of educational interventions and change management to address resistance/barriers, supported by a robust campaign. We encourage others in academic medicine to consider using change models, including campaigns, to support health care improvement programs.

Attitudes and Experiences of Early and Midcareer Pediatricians With the Maintenance of Certification Process

OBJECTIVE

Maintenance of certification (MOC) value and relevance have been recent topics of controversy and discussion in medicine. Systematically assessing pediatrician's attitudes and experiences to encourage and inform future modifications is important.

METHODS

We surveyed 866 pediatricians in 2014 who graduated from residency 10 to 12 years ago and are part of a larger longitudinal study. Cross-sectional quantitative and qualitative data on understanding, attitudes, barriers, and needs specific to MOC part 2 (self-assessment/continued learning activities) and part 4 (quality improvement projects) were analyzed. McNemar tests compared responses on questions specific to part 2 with those specific to part 4. Multivariable logistic regression considered differences in participants who did and did not have positive part 4 attitudes.

RESULTS

A total of 77.8% completed the survey. Comparing part 4 to part 2, there was less understanding of requirements (59.9%, 72.9%, P < .001), more agreement that relevant available activities is a barrier (67.6%, 44.0%, P < .001), stronger agreement that more choices would be helpful (72.8%, 53.8%, P < .001), and less perceived impact on patient care or lifelong learning (12.5%, 47.2%, P < .001). Participants reporting that part 4 improves care were less likely to agree that time to fulfill requirements (adjusted odds ratio = 0.30, 95% confidence interval 0.18-0.51) and relevant available activities (adjusted odds ratio = 0.22, 95% confidence interval 0.13-0.39) were barriers. Qualitative analysis revealed themes including time, cost, and relevance.

CONCLUSIONS

Pediatricians expressed significant frustration with the MOC process, poor understanding of requirements, and barriers with the process, especially for part 4. Increasing diplomate education on the process and increasing available and relevant activities may be important to optimize physician's continuous learning.

Inpatient Hospital Factors and Resident Time With Patients and Families

OBJECTIVES

To define hospital factors associated with proportion of time spent by pediatric residents in direct patient care.

METHODS

We assessed 6222 hours of time-motion observations from a representative sample of 483 pediatric-resident physicians delivering inpatient care across 9 pediatric institutions. The primary outcome was percentage of direct patient care time (DPCT) during a single observation session (710 sessions). We used one-way analysis of variance to assess a significant difference in the mean percentage of DPCT between hospitals. We used the intraclass correlation coefficient analysis to determine within- versus between-hospital variations. We compared hospital characteristics of observation sessions with ≥12% DPCT to characteristics of sessions with <12% DPCT (12% is the DPCT in recent resident trainee time-motion studies). We conducted mixed-effects regression analysis to allow for clustering of sessions within hospitals and accounted for correlation of responses across hospital.

RESULTS

Mean proportion of physician DPCT was 13.2% (SD = 8.6; range, 0.2%-49.5%). DPCT was significantly different between hospitals (P < .001). The intraclass correlation coefficient was 0.25, indicating more within-hospital than between-hospital variation. Observation sessions with ≥12% DPCT were more likely to occur at hospitals with Magnet designation (odds ratio [OR] = 3.45, P = .006), lower medical complexity (OR = 2.57, P = .04), and higher patient-to-trainee ratios (OR = 2.48, P = .05).

CONCLUSIONS

On average, trainees spend <8 minutes per hour in DPCT. Variation exists in DPCT between hospitals. A less complex case mix, increased patient volume, and Magnet designation were independently associated with increased DPCT.

Families as Partners in Hospital Error and Adverse Event Surveillance

Importance

Medical errors and adverse events (AEs) are common among hospitalized children. While clinician reports are the foundation of operational hospital safety surveillance and a key component of multifaceted research surveillance, patient and family reports are not routinely gathered. We hypothesized that a novel family-reporting mechanism would improve incident detection.

Objective

To compare error and AE rates (1) gathered systematically with vs without family reporting, (2) reported by families vs clinicians, and (3) reported by families vs hospital incident reports.

Design, Setting, and Participants

We conducted a prospective cohort study including the parents/caregivers of 989 hospitalized patients 17 years and younger (total 3902 patient-days) and their clinicians from December 2014 to July 2015 in 4 US pediatric centers. Clinician abstractors identified potential errors and AEs by reviewing medical records, hospital incident reports, and clinician reports as well as weekly and discharge Family Safety Interviews (FSIs). Two physicians reviewed and independently categorized all incidents, rating severity and preventability (agreement, 68%-90%; κ, 0.50-0.68). Discordant categorizations were reconciled. Rates were generated using Poisson regression estimated via generalized estimating equations to account for repeated measures on the same patient.

Main Outcomes and Measures

Error and AE rates.

Results

Overall, 746 parents/caregivers consented for the study. Of these, 717 completed FSIs. Their median (interquartile range) age was 32.5 (26-40) years; 380 (53.0%) were nonwhite, 566 (78.9%) were female, 603 (84.1%) were English speaking, and 380 (53.0%) had attended college. Of 717 parents/caregivers completing FSIs, 185 (25.8%) reported a total of 255 incidents, which were classified as 132 safety concerns (51.8%), 102 nonsafety-related quality concerns (40.0%), and 21 other concerns (8.2%). These included 22 preventable AEs (8.6%), 17 nonharmful medical errors (6.7%), and 11 nonpreventable AEs (4.3%) on the study unit. In total, 179 errors and 113 AEs were identified from all sources. Family reports included 8 otherwise unidentified AEs, including 7 preventable AEs. Error rates with family reporting (45.9 per 1000 patient-days) were 1.2-fold (95% CI, 1.1-1.2) higher than rates without family reporting (39.7 per 1000 patient-days). Adverse event rates with family reporting (28.7 per 1000 patient-days) were 1.1-fold (95% CI, 1.0-1.2; P = .006) higher than rates without (26.1 per 1000 patient-days). Families and clinicians reported similar rates of errors (10.0 vs 12.8 per 1000 patient-days; relative rate, 0.8; 95% CI, .5-1.2) and AEs (8.5 vs 6.2 per 1000 patient-days; relative rate, 1.4; 95% CI, 0.8-2.2). Family-reported error rates were 5.0-fold (95% CI, 1.9-13.0) higher and AE rates 2.9-fold (95% CI, 1.2-6.7) higher than hospital incident report rates.

Conclusions and Relevance

Families provide unique information about hospital safety and should be included in hospital safety surveillance in order to facilitate better design and assessment of interventions to improve safety.

Reliability of Verbal Handoff Assessment and Handoff Quality Before and After Implementation of a Resident Handoff Bundle

OBJECTIVE

1) To develop validity evidence for the use of the Verbal Handoff Assessment Tool (VHAT) and examine the reliability of VHAT scores, and 2) to determine whether implementation of a resident handoff bundle (RHB) was associated with improved verbal patient handoffs among pediatric resident physicians.

METHODS

In a pre-post design, prospectively audio recorded verbal patient handoffs conducted at Boston Children's Hospital before and after implementation of the RHB were rated using the VHAT, which was developed for this study (primary outcome). Using generalizability theory, we evaluated the reliability of VHAT scores.

RESULTS

Overall, VHAT scores increased after RHB implementation (mean 142 vs 191, possible score 0-500; P < .0001). When accounting for clustering according to resident physician, hospital unit, unit census, and patient complexity, implementation of the RHB was associated with a 63-point increase in VHAT score. Using generalizability theory, we determined that a resident's mean VHAT score on the basis of a handoff of 15 patients assessed by a single observer was sufficiently reliable for relative ranking decisions (ie, norm-based; generalizability coefficient, 0.81), whereas a VHAT score on the basis of a handoff of 21 patients would be sufficiently reliable for high-stakes, standard-based decisions (Phi, 0.80).

CONCLUSIONS

Verbal handoffs improved after implementation of a RHB, although gains were variable across the 2 clinical units. The VHAT shows promise as an assessment tool for resident handoff skills. If used for competency or entrustment decisions, a resident's mean VHAT score should be on the basis of observation of verbal handoff of ≥21 patients.

Work-Life Balance, Burnout, and Satisfaction of Early Career Pediatricians

BACKGROUND AND OBJECTIVE

Data describing factors associated with work-life balance, burnout, and career and life satisfaction for early career pediatricians are limited. We sought to identify personal and work factors related to these outcomes.

METHODS

We analyzed 2013 survey data of pediatricians who graduated residency between 2002 and 2004. Dependent variables included: (1) balance between personal and professional commitments, (2) current burnout in work, (3) career satisfaction, and (4) life satisfaction. Multivariable logistic regression examined associations of personal and work characteristics with each of the 4 dependent variables.

RESULTS

A total of 93% of participants completed the survey (n = 840). A majority reported career (83%) and life (71%) satisfaction. Fewer reported current appropriate work-life balance (43%) or burnout (30%). In multivariable modeling, excellent/very good health, having support from physician colleagues, and adequate resources for patient care were all found to be associated with a lower prevalence of burnout and a higher likelihood of work-life balance and career and life satisfaction. Having children, race, and clinical specialty were not found to be significantly associated with any of the 4 outcome measures. Female gender was associated with a lower likelihood of balance and career satisfaction but did not have an association with burnout or life satisfaction.

CONCLUSIONS

Burnout and struggles with work-life balance are common; dissatisfaction with life and career are a concern for some early career pediatricians. Efforts to minimize these outcomes should focus on encouragement of modifiable factors, including health supervision, peer support, and ensuring sufficient patient care resources.

The Creation of Standard-Setting Videos to Support Faculty Observations of Learner Performance and Entrustment Decisions

Entrustable professional activities (EPAs) provide a framework to standardize medical education outcomes and advance competency-based assessment. Direct observation of performance plays a central role in entrustment decisions; however, data obtained from these observations are often insufficient to draw valid high-stakes conclusions. One approach to enhancing the reliability and validity of these assessments is to create videos that establish performance standards to train faculty observers. Little is known about how to create videos that can serve as standards for assessment of EPAs.The authors report their experience developing videos that represent five levels of performance for an EPA for patient handoffs. The authors describe a process that begins with mapping the EPA to the critical competencies needed to make an entrustment decision. Each competency is then defined by five milestones (behavioral descriptors of performance at five advancing levels). Integration of the milestones at each level across competencies enabled the creation of clinical vignettes that were converted into video scripts and ultimately videos. Each video represented a performance standard from novice to expert. The process included multiple assessments by experts to guide iterative improvements, provide evidence of content validity, and ensure that the authors successfully translated behavioral descriptions and vignettes into videos that represented the intended performance level for a learner. The steps outlined are generalizable to other EPAs, serving as a guide for others to develop videos to train faculty. This process provides the level of content validity evidence necessary to support using videos as standards for high-stakes entrustment decisions.

A Longitudinal Study of Pediatricians Early in Their Careers: PLACES

The American Academy of Pediatrics (AAP) launched the Pediatrician Life and Career Experience Study (PLACES), a longitudinal study that tracks the personal and professional experiences of early career pediatricians, in 2012. We used a multipronged approach to develop the study methodology and survey domains and items, including review of existing literature and qualitative research with the target population. We chose to include 2 cohorts of US pediatricians on the basis of residency graduation dates, including 1 group who were several years out of residency (2002-2004 Residency Graduates Cohort) and a second group who recently graduated from residency at study launch (2009-2011 Residency Graduates Cohort). Recruitment into PLACES was a 2-stage process: (1) random sample recruitment from the target population and completion of an initial intake survey and (2) completion of the first Annual Survey by pediatricians who responded positively to stage 1. Overall, 41.2% of pediatricians randomly selected to participate in PLACES indicated positive interest in the study by completing intake surveys; of this group, 1804 (93.7%) completed the first Annual Survey and were considered enrolled in PLACES. Participants were more likely to be female, AAP members, and graduates of US medical schools compared with the target sample; weights were calculated to adjust for these differences. We will survey PLACES pediatricians 2 times per year. PLACES data will allow the AAP to examine career and life choices and transitions experienced by early-career pediatricians.

Variation in printed handoff documents: Results and recommendations from a multicenter needs assessment

BACKGROUND

Handoffs of patient care are a leading root cause of medical errors. Standardized techniques exist to minimize miscommunications during verbal handoffs, but studies to guide standardization of printed handoff documents are lacking.

OBJECTIVE

To determine whether variability exists in the content of printed handoff documents and to identify key data elements that should be uniformly included in these documents.

SETTING

Pediatric hospitalist services at 9 institutions in the United States and Canada.

METHODS

Sample handoff documents from each institution were reviewed, and structured group interviews were conducted to understand each institution's priorities for written handoffs. An expert panel reviewed all handoff documents and structured group-interview findings, and subsequently made consensus-based recommendations for data elements that were either essential or recommended, including best overall printed handoff practices.

RESULTS

Nine sites completed structured group interviews and submitted data. We identified substantial variation in both the structure and content of printed handoff documents. Only 4 of 23 possible data elements (17%) were uniformly present in all sites' handoff documents. The expert panel recommended the following as essential for all printed handoffs: assessment of illness severity, patient summary, action items, situation awareness and contingency plans, allergies, medications, age, weight, date of admission, and patient and hospital service identifiers. Code status and several other elements were also recommended.

CONCLUSIONS

Wide variation exists in the content of printed handoff documents. Standardizing printed handoff documents has the potential to decrease omissions of key data during patient care transitions, which may decrease the risk of downstream medical errors.

Summary of STARNet: Seamless Transitions and (Re)admissions Network

The Seamless Transitions and (Re)admissions Network (STARNet) met in December 2012 to synthesize ongoing hospital-to-home transition work, discuss goals, and develop a plan to centralize transition information in the future. STARNet participants consisted of experts in the field of pediatric hospital medicine quality improvement and research, and included physicians and key stakeholders from hospital groups, private payers, as well as representatives from current transition collaboratives. In this report, we (1) review the current knowledge regarding hospital-to-home transitions; (2) outline the challenges of measuring and reducing readmissions; and (3) highlight research gaps and list potential measures for transition quality. STARNet met with the support of the American Academy of Pediatrics' Quality Improvement Innovation Networks and the Section on Hospital Medicine.

Changes in medical errors after implementation of a handoff program

BACKGROUND

Miscommunications are a leading cause of serious medical errors. Data from multicenter studies assessing programs designed to improve handoff of information about patient care are lacking.

METHODS

We conducted a prospective intervention study of a resident handoff-improvement program in nine hospitals, measuring rates of medical errors, preventable adverse events, and miscommunications, as well as resident workflow. The intervention included a mnemonic to standardize oral and written handoffs, handoff and communication training, a faculty development and observation program, and a sustainability campaign. Error rates were measured through active surveillance. Handoffs were assessed by means of evaluation of printed handoff documents and audio recordings. Workflow was assessed through time-motion observations. The primary outcome had two components: medical errors and preventable adverse events.

RESULTS

In 10,740 patient admissions, the medical-error rate decreased by 23% from the preintervention period to the postintervention period (24.5 vs. 18.8 per 100 admissions, P<0.001), and the rate of preventable adverse events decreased by 30% (4.7 vs. 3.3 events per 100 admissions, P<0.001). The rate of nonpreventable adverse events did not change significantly (3.0 and 2.8 events per 100 admissions, P=0.79). Site-level analyses showed significant error reductions at six of nine sites. Across sites, significant increases were observed in the inclusion of all prespecified key elements in written documents and oral communication during handoff (nine written and five oral elements; P<0.001 for all 14 comparisons). There were no significant changes from the preintervention period to the postintervention period in the duration of oral handoffs (2.4 and 2.5 minutes per patient, respectively; P=0.55) or in resident workflow, including patient-family contact and computer time.

CONCLUSIONS

Implementation of the handoff program was associated with reductions in medical errors and in preventable adverse events and with improvements in communication, without a negative effect on workflow. (Funded by the Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, and others.).

Impact of educational video on critical congenital heart disease screening

OBJECTIVE

To assess the status of pulse oximetry screening and barriers to implementing screening programs.

METHODS

This was a prospective pre-post intervention survey of nurse managers and medical directors of hospital-based birthing centers in Oregon, Idaho, and Southern Washington. The intervention was a 7-minute video demonstrating and discussing pulse oximetry screening for critical congenital heart disease.

RESULTS

Analysis of matched pairs showed a significant increase in the use of pulse oximetry screening during the study period from 52% to 73% (P < .0001). Following implementation of the video, the perception of all queried potential barriers decreased significantly among individuals from hospitals self-identified as nonscreening at baseline. Viewing the educational video was associated with an increase in the percentage of individuals from nonscreening hospitals that rated screening as "very beneficial" (45% vs 90%, P = .0001).

CONCLUSIONS

An educational video was associated with improved opinions of pulse oximetry screening among hospitals not currently screening.

Development, implementation, and dissemination of the I-PASS handoff curriculum: A multisite educational intervention to improve patient handoffs

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

Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle

IMPORTANCE

Handoff miscommunications are a leading cause of medical errors. Studies comprehensively assessing handoff improvement programs are lacking.

OBJECTIVE

To determine whether introduction of a multifaceted handoff program was associated with reduced rates of medical errors and preventable adverse events, fewer omissions of key data in written handoffs, improved verbal handoffs, and changes in resident-physician workflow.

DESIGN, SETTING, AND PARTICIPANTS

Prospective intervention study of 1255 patient admissions (642 before and 613 after the intervention) involving 84 resident physicians (42 before and 42 after the intervention) from July-September 2009 and November 2009-January 2010 on 2 inpatient units at Boston Children's Hospital.

INTERVENTIONS

Resident handoff bundle, consisting of standardized communication and handoff training, a verbal mnemonic, and a new team handoff structure. On one unit, a computerized handoff tool linked to the electronic medical record was introduced.

MAIN OUTCOMES AND MEASURES

The primary outcomes were the rates of medical errors and preventable adverse events measured by daily systematic surveillance. The secondary outcomes were omissions in the printed handoff document and resident time-motion activity.

RESULTS

Medical errors decreased from 33.8 per 100 admissions (95% CI, 27.3-40.3) to 18.3 per 100 admissions (95% CI, 14.7-21.9; P < .001), and preventable adverse events decreased from 3.3 per 100 admissions (95% CI, 1.7-4.8) to 1.5 (95% CI, 0.51-2.4) per 100 admissions (P = .04) following the intervention. There were fewer omissions of key handoff elements on printed handoff documents, especially on the unit that received the computerized handoff tool (significant reductions of omissions in 11 of 14 categories with computerized tool; significant reductions in 2 of 14 categories without computerized tool). Physicians spent a greater percentage of time in a 24-hour period at the patient bedside after the intervention (8.3%; 95% CI 7.1%-9.8%) vs 10.6% (95% CI, 9.2%-12.2%; P = .03). The average duration of verbal handoffs per patient did not change. Verbal handoffs were more likely to occur in a quiet location (33.3%; 95% CI, 14.5%-52.2% vs 67.9%; 95% CI, 50.6%-85.2%; P = .03) and private location (50.0%; 95% CI, 30%-70% vs 85.7%; 95% CI, 72.8%-98.7%; P = .007) after the intervention.

CONCLUSIONS AND RELEVANCE

Implementation of a handoff bundle was associated with a significant reduction in medical errors and preventable adverse events among hospitalized children. Improvements in verbal and written handoff processes occurred, and resident workflow did not change adversely.

Pressure ulcer risk assessment and prevention: a systematic comparative effectiveness review

BACKGROUND

Pressure ulcers are associated with substantial health burdens but may be preventable.

PURPOSE

To review the clinical utility of pressure ulcer risk assessment instruments and the comparative effectiveness of preventive interventions in persons at higher risk.

DATA SOURCES

MEDLINE (1946 through November 2012), CINAHL, the Cochrane Library, grant databases, clinical trial registries, and reference lists.

STUDY SELECTION

Randomized trials and observational studies on effects of using risk assessment on clinical outcomes and randomized trials of preventive interventions on clinical outcomes.

DATA EXTRACTION

Multiple investigators abstracted and checked study details and quality using predefined criteria.

DATA SYNTHESIS

One good-quality trial found no evidence that use of a pressure ulcer risk assessment instrument, with or without a protocolized intervention strategy based on assessed risk, reduces risk for incident pressure ulcers compared with less standardized risk assessment based on nurses' clinical judgment. In higher-risk populations, 1 good-quality and 4 fair-quality randomized trials found that more advanced static support surfaces were associated with lower risk for pressure ulcers compared with standard mattresses (relative risk range, 0.20 to 0.60). Evidence on the effectiveness of low-air-loss and alternating-air mattresses was limited, with some trials showing no clear differences from advanced static support surfaces. Evidence on the effectiveness of nutritional supplementation, repositioning, and skin care interventions versus usual care was limited and had methodological shortcomings, precluding strong conclusions.

LIMITATION

Only English-language articles were included, publication bias could not be formally assessed, and most studies had methodological shortcomings.

CONCLUSION

More advanced static support surfaces are more effective than standard mattresses for preventing ulcers in higher-risk populations. The effectiveness of formal risk assessment instruments and associated intervention protocols compared with less standardized assessment methods and the effectiveness of other preventive interventions compared with usual care have not been clearly established.

Pediatric hospitalists' influences on education and career plans

BACKGROUND

Pediatric hospitalist (PH) presence is rapidly increasing, yet little is known about pediatric resident exposure to hospitalists, or how this affects resident education/career decisions.

OBJECTIVES

To determine resident exposure to pediatric hospitalists; examine resident opinions regarding hospitalists' roles; examine resident opinion of hospital medicine career training needs; explore how resident exposure to hospitalists affects career choices.

METHODS

Survey of random sample of 300 residents from the American Academy of Pediatrics Section on Residents database.

RESULTS

Two-hundred seventy-nine pediatric residents surveyed; 120(43%) responded with variance by question; 90% work with hospitalists during residency. Of this national sample, 82% cite hospitalists as enhancing education. A majority (64%) believe pediatric hospitalists are better than primary care physicians at caring for complex inpatients; 28% felt PH provided better care for routine admissions. Over one-third surveyed are considering a career in Pediatric Hospital Medicine (PHM); 7% plan to enter the field upon graduation. Residents cited opportunities to participate in education, flexible hours, and better salaries as the top 3 reasons to become a hospitalist. Ten percent felt there was no difference between resident and hospitalist positions; 21% see PHM as a short-term job without long-term potential. Of residents entering Primary Care, a majority (59%) stated that the availability of hospitalists would positively influence their choice of a practice position; 7% said they were "less likely to choose to practice Primary Care Pediatrics because of hospitalists."

CONCLUSIONS

PH have a role in physician training. While PHM has become a career consideration for trainees, more work needs to be done to improve the perception of PHM as a viable long-term career.

Pediatrics in the year 2020 and beyond: preparing for plausible futures

Although the future of pediatrics is uncertain, the organizations that lead pediatrics, and the professionals who practice within it, have embraced the notion that the pediatric community must anticipate and lead change to ultimately improve the health of children and adolescents. In an attempt to proactively prepare for a variety of conceivable futures, the board of directors of the American Academy of Pediatrics established the Vision of Pediatrics 2020 Task Force in 2008. This group was charged to think broadly about the future of pediatrics, to gather input on key trends that are influencing the future, to create likely scenarios of the future, and to recommend strategies to best prepare pediatric clinicians and pediatric organizations for a range of potential futures. The work of this task force led to the development of 8 "megatrends" that were identified as highly likely to have a profound influence on the future of pediatrics. A separate list of "wild-card" scenarios was created of trends with the potential to have a substantial influence but are less likely to occur. The process of scenario-planning was used to consider the effects of the 8 megatrends on pediatrics in the year 2020 and beyond. Consideration of these possible scenarios affords the opportunity to determine potential future pediatric needs, to identify potential solutions to address those needs, and, ultimately, to proactively prepare the profession to thrive if these or other future scenarios become realities.

Peering into the future: pediatrics in a changing world

Over the last decade, health care has experienced continuous, capricious, and ever-accelerating change. In response, the American Academy of Pediatrics convened the Vision of Pediatrics (VOP) 2020 Task Force in 2008. This task force was charged with identifying forces that affect child and adolescent health and the implications for the field of pediatrics. It determined that shifts in demographics, socioeconomics, health status, health care delivery, and scientific advances mandate creative responses to these current trends. Eight megatrends were identified as foci for the profession to address over the coming decade. Given the unpredictable speed and direction of change, the VOP 2020 Task Force concluded that our profession needs to adopt an ongoing process to prepare for and lead change. The task force proposed that pediatric clinicians, practices, organizations, and interest groups embark on a continual process of preparing, envisioning, engaging, and reshaping (PEER) change. This PEER cycle involves (1) preparing our capacity to actively participate in change efforts, (2) envisioning possible futures and potential strategies through ongoing conversations, (3) engaging change strategies to lead any prioritized changes, and (4) reshaping our futures on the basis of results of any change strategies and novel trends in the field. By illustrating this process as a cycle of inquiry and action, we deliberately capture the continuous aspects of successful change processes that attempt to peer into a multiplicity of futures to anticipate and lead change.

Direct observation of resident-patient encounters in continuity clinic: a controlled study of parent satisfaction and resident perceptions

CONTEXT

Direct observation (DO) by teaching physicians of medical care provided by resident physicians offers a method to evaluate clinical skills beyond traditional measures that focus solely on medical knowledge assessment.

OBJECTIVES

We sought to determine if the presence of the teaching physician observer affects parental satisfaction with care and to assess resident perceptions of DO in a general pediatrics residency clinic.

METHODS

A cross-sectional parent survey compared visit satisfaction of parents who experienced a DO with controls in a traditional clinic visit. Additionally, a pre-post survey measured resident perceptions of direct observation before and after implementation of DO in the clinic.

FINDINGS

Parents frequently described their overall satisfaction with care as "excellent" after DO and traditional visits (DO 70%, 95% CI, 50-86% and control 80%, CI 66-89%). However, parents in DO visits were less likely to rate their satisfaction with the amount of time spent in the room as excellent (DO 78%, CI 58-91%; Control 95%, CI 85-99%). Most resident physicians were in favor of the DO process (63%) and agreed that DO provides feedback about history-taking (94%), physical examination (94%) and interpersonal skills (91%).

CONCLUSIONS

Direct observation by attending physicians does not decrease overall parental satisfaction during clinical encounters. Additionally, residents have a generally favorable opinion of direct observation and believe that it can provide useful feedback.