Understanding trust between pediatric hospitalists and outpatient clinicians during hospital admissions: A multisite qualitative analysis

BACKGROUND

During transitions between sites of care, clinicians must build trust with colleagues to make decisions that ensure safe, high-quality care.

OBJECTIVES

This study explored factors that could influence trust between outpatient clinicians and pediatric hospitalists when children are referred for hospital admission.

DESIGN, SETTING, AND PARTICIPANTS

We conducted an analysis of 41 semistructured interviews with outpatient clinicians and pediatric hospitalists from May 2020 through October 2021 across three healthcare systems participating in a multisite comparative effectiveness study of pediatric direct and emergency department admissions.

INTERVENTION, MAIN OUTCOMES, AND MEASURES

Qualitative interviews. A conceptual model for trust between outpatient clinicians and pediatric hospitalists during hospital admission referral. Interviews were professionally transcribed, verified for accuracy, and analyzed using a combination of inductive and deductive.

RESULTS

We identified two primary domains: (1) interpersonal trust and (2) trust-by-proxy. Interpersonal trust included five relational factors that influenced collaboration between clinicians: antecedent relationships, confidence in others clinical abilities, understanding others' practice culture, recognition of available resources, and power dynamic. An individual clinicians' assessment of risk and past clinical experiences also influenced trust during clinical decision-making. Trust-by-proxy represented system-level factors that could influence trust, independent of any pre-existing relationships, including communication infrastructure, guidelines and protocols, the organizational culture, and professional courtesy.

CONCLUSION

Interpersonal and system-level factors influence trust between outpatient clinicians and hospitalists during decision-making encounters. System-level factors may serve as a proxy for trust when clinicians do not have pre-existing interpersonal relationships. These factors could be explored as an explicit target of interventions to improve interdisciplinary collaboration and decision-making between hospitalists and primary care clinicians.

Pediatric Mental Health Boarding

CONTEXT

The growing prevalence of pediatric mental and behavioral health disorders, coupled with scarce psychiatric resources, has resulted in a substantial increase in the number of youth waiting in emergency departments (EDs) and medical units for inpatient psychiatric care.

OBJECTIVE

To characterize the prevalence of pediatric mental health boarding and identify associated patient and hospital factors.

DATA SOURCES

Medline and PsycINFO.

STUDY SELECTION

All studies describing frequencies, durations, processes, outcomes, and/or risk factors associated with pediatric mental health boarding in youth ≤21 years of age.

DATA EXTRACTION

Publications meeting inclusion criteria were charted by 2 authors and critically appraised for quality.

RESULTS

Eleven studies met inclusion criteria; 10 were retrospective cohort studies and 9 were conducted at single centers. All of the single-center studies were conducted at children's hospitals or pediatric EDs in urban or suburban settings. Study sample sizes ranged from 27 to 44 328. Among youth requiring inpatient psychiatric care, 23% to 58% experienced boarding and 26% to 49% boarded on inpatient medical units. Average boarding durations ranged from 5 to 41 hours in EDs and 2 to 3 days in inpatient units. Risk factors included younger age, suicidal or homicidal ideation, and presentation to a hospital during nonsummer months. Care processes and outcomes were infrequently described. When reported, provision of psychosocial services varied widely.

LIMITATIONS

Boarding definitions were heterogeneous, study sample sizes were small, and rural regions and general hospitals were underrepresented.

CONCLUSIONS

Pediatric mental health boarding is prevalent and understudied. Additional research representing diverse hospital types and geographic regions is needed to inform clinical interventions and health care policy.

Bifenthrin activates homotypic aggregation in human T-cell lines

BACKGROUND

Here, we addressed the concern that, despite the lack of overt toxicity, exposure to low levels of the common household pyrethroid pesticide, bifenthrin, could cause harm to the immune system. To do this, we measure the effect of bifenthrin on phytohemagglutinin (PHA) activation of homotypic aggregation in human T-cell lines.

MATERIAL/METHODS

The human CD4+ H9, and Jurkat cell lines and the human promonocyte U937 cell line, were exposed to varying concentrations of bifenthrin. Cell viability was determined using the AlmarBlue Toxicity Assay. Concentrations of bifenthrin which did not reduce cell viability were determined and these concentrations were tested for the effect of bifenthrin on PHA-mediated homotypic aggregation. Blocking antibodies to ICAM and LFA-1 were used to disrupt aggregation and a nonspecific IgG was used as a control.

RESULTS

Bifenthrin was found to be nontoxic at concentrations ranging from 10(-4) to 10(-13) M. Bifenthrin did not inhibit PHA induced cell aggregation in all cell lines tested. However, at 10(-4) M, bifenthrin to form aggregates stimulated homotypic aggregation in the H9 and Jurkat T-cell lines. The bifenthrin-induced aggregate formation, like that seen with PHA, was blocked by treating the cells with antibodies to either LFA-1 or ICAM.

CONCLUSIONS

The results here show that bifenthrin activates T-cell function by stimulating ICAM/LFA-1 mediated homotypic aggregation. This data suggests that exposure to bifenthrin, even at "acceptable" limits, can increase the risk for and frequency of inflammatory responses and diseases such as asthma.

Bifenthrin inhibits neurite outgrowth in differentiating PC12 cells

BACKGROUND

Bifenthrin is a third generation member of the synthetic pyrethroid family of insecticides. As a new pesticide within a relatively new class of pesticides, bifenthrin is considered relatively safe. Here, we used the PC12 neuronal cell line to examine the effect of bifenthrin on the formation of neurites and the potential developmental neurotoxicity of this pesticide.

MATERIAL/METHODS

PC12 cells were exposed to varying concentrations of technical grade bifenthrin or Ortho Home Defense. Cell viability was determined using the AlmarBlue Toxicity Assay. Nontoxic concentrations of these chemicals were concomitantly with nerve growth factor and neurite outgrowth was assessed.

RESULTS

Ortho Home Defense preparation reduced PC12 cell viability by approximately 50% and 70% at dilutions that correlate to bifenthrin concentrations of 10(-5) M and 10(-4) M, respectively. In contrast, technical grade bifenthrin, was not toxic to PC12 cells at 10(-3) M, which was the highest concentration tested that was soluble. At "nontoxic" concentrations of 10(-7) M and 10(-6) M, the Ortho Home Defense inhibited nerve growth factor-mediated neurite outgrowth by 30% and 55% respectively. Furthermore the nontoxic concentrations of technical grade bifenthrin of 10(-6) M and 10(-3) M inhibited neurite outgrowth by approximately 35% and 75% respectively.

CONCLUSIONS

These data suggest that the toxicity of the Ortho Home Defense preparation was due to the "inert" additives in the preparation and not the bifenthrin itself. Further, these data suggest that, even in the absence of overt toxicity, bifenthrin may have deleterious effects to developing nervous system.