Pediatric hospital medicine core competencies: development and methodology.

BACKGROUND: Pediatric hospital medicine is the most rapidly growing site-based pediatric specialty. There are over 2500 unique members in the three core societies in which pediatric hospitalists are members: the American Academy of Pediatrics (AAP), the Academic Pediatric Association (APA) and the Society of Hospital Medicine (SHM). Pediatric hospitalists are fulfilling both clinical and system improvement roles within varied hospital systems. Defined expectations and competencies for pediatric hospitalists are needed. METHODS: In 2005, SHM's Pediatric Core Curriculum Task Force initiated the project and formed the editorial board. Over the subsequent four years, multiple pediatric hospitalists belonging to the AAP, APA, or SHM contributed to the content of and guided the development of the project. Editors and collaborators created a framework for identifying appropriate competency content areas. Content experts from both within and outside of pediatric hospital medicine participated as contributors. A number of selected national organizations and societies provided valuable feedback on chapters. The final product was validated by formal review from the AAP, APA, and SHM. RESULTS: The Pediatric Hospital Medicine Core Competencies were created. They include 54 chapters divided into four sections: Common Clinical Diagnoses and Conditions, Core Skills, Specialized Clinical Services, and Healthcare Systems: Supporting and Advancing Child Health. Each chapter can be used independently of the others. Chapters follow the knowledge, skills, and attitudes educational curriculum format, and have an additional section on systems organization and improvement to reflect the pediatric hospitalist's responsibility to advance systems of care. CONCLUSION: These competencies provide a foundation for the creation of pediatric hospital medicine curricula and serve to standardize and improve inpatient training practices.

Intern to attending: assessing stress among physicians.

PURPOSE: Organizations have raised concerns regarding stress in the medical work environment and effects on health care worker performance. This study's objective was to assess workplace stress among interns, residents, and attending physicians using Ecological Momentary Assessment technology, the gold-standard method for real-time measurement of psychological characteristics. METHOD: The authors deployed handheld computers with customized software to 185 physicians on the medicine and pediatric wards of four major teaching hospitals. The physicians contemporaneously recorded multiple dimensions of physician work (e.g., type of call day), emotional stress (e.g., worry, stress, fatigue), and perceived workload (e.g., patient volume). The authors performed descriptive statistics and t test and linear regression analyses. RESULTS: Participants completed 5,673 prompts during an 18-month period from 2004 to 2005. Parameters associated with higher emotional stress in linear regression models included male gender (t = -2.5, P = .01), total patient load (t = 4.2, P < .001), and sleep quality (t = -2.8, P = .006). Stress levels reported by attendings (t = -3.3, P = .001) were lower than levels reported by residents (t = -2.6, P = .009), and emotional stress levels of attendings and residents were both lower compared with interns. CONCLUSIONS: On inpatient wards, after recent resident duty hours changes, physician trainees continue to show wide-ranging evidence of workplace stress and poor sleep quality. This is among the first studies of medical workplace stress in real time. These results can help residency programs target education in stress and sleep and readdress workload distribution by training level. Further research is needed to clarify behavioral factors underlying variability in housestaff stress responses.

Results of a medication reconciliation survey from the 2006 Society of Hospital Medicine national meeting.

BACKGROUND: The status of implementation of medication reconciliation across hospitals is variable to date; the degree to which hospitalists are involved is not known. METHODS: To better describe the current state of medication reconciliation implementation, we conducted a survey of attendees of the 2006 Society of Hospital Medicine national meeting. RESULTS: We identified a lack of uniformity across hospitals with respect to the degree of process implementation. Hospitalists were involved in design and implementation in a majority of cases, and felt that medication reconciliation would likely have a positive impact on patient safety. Tertiary care academic centers were more likely to use physicians to perform medication reconciliation, whereas community hospitals were more likely to involve nurses as well. Pharmacist participation in the medication reconciliation process was found to be quite low. Process and outcome measures were used infrequently. Patients' lack of medication knowledge and absence of preadmission medication information were cited most frequently as barriers to implementation of medication reconciliation. CONCLUSIONS: Implementation of medication reconciliation is complex and challenging. Medication information is often incomplete, and elements of the medication reconciliation process result in increased time demands on providers. Current implementation efforts often have physicians and nurses "share" responsibility for compliance, and pharmacists are underutilized in medication reconciliation processes. Hospitalists have thus far played a substantial role in process design and implementation, and should continue to lead the way in advancing efforts to successfully implement medication reconciliation.

Variation in pediatric hospitalists' use of proven and unproven therapies: a study from the Pediatric Research in Inpatient Settings (PRIS) network.

BACKGROUND: Undesirable practice variation remains a major concern with the quality of the healthcare system. While care in pediatric hospitalist systems has been demonstrated to be efficient, neither the quality of care nor determinants of variation in pediatric hospitalist systems are well understood. OBJECTIVE: To measure variation in pediatric hospitalists' reported use of common inpatient therapies, and to test the hypothesis that variation in reported use of proven therapies is lower than variation in reported use of unproven therapies. DESIGN AND MEASUREMENTS: We conducted a survey of pediatric hospitalists in the US and Canada. Respondents reported their frequency of using 14 therapies in the management of common conditions. Each therapy was determined to be of proven or unproven effectiveness using published critical appraisals. Variation in reported use of proven and unproven therapies was compared. RESULTS: 67% (213/320) of surveyed individuals participated. Little variability existed in reported use of albuterol and corticosteroids in asthma (4-6% of respondents reported not often using them) and systemic dexamethasone in bronchiolitis (12% of respondents reported using it more than rarely). Moderate to high variation existed in reported use of all other therapies studied. Variation in reported use of proven therapies was significantly less than variation in reported use of unproven therapies (15.5 +/- 12.5% vs. 44.6 +/- 20.5%). CONCLUSIONS: Substantial variation exists in hospitalists' reported management of common pediatric conditions. Variation is significantly lower for strongly evidence-based therapies. To decrease undesirable variation in care, a stronger evidence base for inpatient pediatric care must be built.

Variations in management of common inpatient pediatric illnesses: hospitalists and community pediatricians.

OBJECTIVE: The goal was to test the hypothesis that pediatric hospitalists use evidence-based therapies and tests more consistently in the care of inpatients and use therapies and tests of unproven benefit less often, compared with community pediatricians. METHODS: A national survey was administered to hospitalists and a random sample of community pediatricians. Hospitalists and community pediatricians reported their frequency of use of diagnostic tests and therapies, on 5-point Likert scales (ranging from never to almost always), for common inpatient pediatric illnesses. Responses were compared in univariate and multivariable logistic regression analyses controlling for gender, race, years out of residency, days spent attending per year, hospital practice type, and completion of fellowship/postgraduate training. RESULTS: Two hundred thirteen pediatric hospitalists and 352 community pediatricians responded. In multivariable regression analyses, hospitalists were significantly more likely to report often or almost always using the following evidence-based therapies for asthma: albuterol and ipratropium in the first 24 hours of hospitalization. After the first urinary tract infection, hospitalists were more likely to report obtaining the recommended renal ultrasound and voiding cystourethrogram. Hospitalists were significantly more likely than community pediatricians to report rarely or never using the following therapies of unproven benefit: levalbuterol, inhaled steroid therapy, and oral steroid therapy for bronchiolitis; stool culture and rotavirus testing for gastroenteritis; and ipratropium after 24 hours of hospitalization for asthma. CONCLUSION: Overall, in comparison with community pediatricians, hospitalists reported greater adherence to evidence-based therapies and tests in the care of hospitalized patients and less use of therapies and tests of unproven benefit.

Prevention of medication errors in the pediatric inpatient setting.

Although medication errors in hospitals are common, medication errors that result in death or serious injury occur rarely. Even before the Institute of Medicine reported on medical errors in 1999, the American Academy of Pediatrics and its members had been committed to improving the health care system to provide the best and safest health care for infants, children, adolescents, and young adults. This commitment includes designing health care systems to prevent errors and emphasizing the pediatrician's role in this system. Human and device errors can lead to preventable morbidity and mortality. National and state legislative actions have heightened public awareness of these events. All involved persons, beginning with the physician and including every member of the health care team, must be better educated about and engaged in the several steps recommended to decrease these errors. The safe administration of medications to hospitalized infants and children requires additional specific safeguards that are above and beyond those for adult patients. Pediatricians should help hospitals develop effective programs for safely providing medications, reporting medication errors, and creating an environment of medication safety for all hospitalized pediatric patients.