Implementation of a tier system for IVIG indications to address IVIG shortage at a tertiary care pediatric medical center.

BACKGROUND: Drug shortages are a common issue that healthcare systems face and can result in adverse health outcomes for patients requiring inferior alternate treatment. The United States recently experienced a national drug shortage of intravenous immunoglobulin (IVIG). Several reported strategies to address the IVIG and other drug shortages have been proposed; however, there is a lack of evidence-based methods for protocol development and implementation. OBJECTIVE: To evaluate the efficacy of introducing a multidisciplinary task force and tier system of indications and to minimize adverse effects during a shortage of IVIG. METHODS: Faculty members across disciplines with expertise in IVIG use were invited to participate in a task force to address the shortage and ensure adequate supply for emergent indications. A tier system of IVIG indications was established according to the severity of diagnosis, urgency of indication, and quality of supporting evidence. Based on inventory, indications in selected tiers were auto-approved. Orders that could not be automatically approved were escalated for task force review. RESULTS: Overall, there were 342 distinct requests for IVIG during the study period (August 1, 2019 to December 31, 2019). All Tier 1 indications were approved. Of all requests, only 2.6% (9) of requests were denied, none of which resulted in adverse effects based on retrospective chart review. Seven patients who regularly receive IVIG had possible adverse effects due to dose reduction or spacing of treatment; however, each complication was multifactorial and not attributed to the shortage or tier system implementation alone. CONCLUSION: Implementation of a multidisciplinary task force and tier system to appropriately triage high-priority indications for limited pharmaceutical agents should be considered in health institutions faced with a drug shortage.

Evolution of conflict management style during first year of paediatric residency.

BACKGROUND: First-year residents frequently encounter conflict during their training. Residents' conflict management strategies can influence patient safety, quality of care and perceptions of performance on competency evaluations. Existing literature inadequately describes how first-year resident conflict management styles evolve over time. OBJECTIVE: The objective of this study is to assess if and how conflict management styles change during first year of paediatric residency in the United States. METHODS: In 2021-2022, we conducted a non-experimental, longitudinal, survey study of first-year residents from 16 US-based paediatric residency programmes. Using the Thomas-Kilmann Conflict Mode Instrument, we scored first-year residents' use of five conflict management modes twice, 6 months apart. We calculated the percentage of first-year residents who experienced a change in predominant conflict management mode and assessed for changes in score and variance for each conflict management mode. RESULTS: Fifty-seven (18%) first-year residents participated in the first survey. Of those, 45 (14%) also completed the follow-up survey. Nonresponse bias analysis showed no significant difference in scores for early and late respondents or for second-survey respondents and non-respondents. Half of respondents experienced a change in predominant conflict management mode, but the distribution of predominant modes remained largely unchanged. When residents changed modes, they typically moved from one low-assertiveness mode, such as avoiding or accommodating, to the other. Only the use of the compromising conflict management mode significantly decreased. Variance did not significantly change. CONCLUSIONS: The overall lack of change in conflict management style may suggest the need for specific and focused educational interventions to help residents adjust their conflict handling strategies.

The 21st century water quality challenges for managed aquifer recharge: towards a risk-based regulatory approach.

Sustained environmental and human health protection is threatened by ~350,000 chemicals available in global markets, plus new biological entities including coronaviruses. These water-quality hazards challenge the proponents of managed aquifer recharge (MAR) who seek to ensure the integrity of groundwater. A risk-based regulatory framework accounting for groundwater quality changes, adoption in subsurface attenuation zones, and use of advanced monitoring methods is required to support confidence in the sustainability of MAR.

La protection durable de l'environnement et de la santé humaine est menacée par ~350,000 substances chimiques disponibles sur les marchés mondiaux, à quoi s'ajoutent de nouvelles entités biologiques, incluant les coronavirus. Ces risques sur la qualité de l'eau sont un défi pour les partisans de la recharge raisonnée des aquifères (RRA) qui cherchent à assurer l'intégrité des eaux souterraines. Un cadre réglementaire basé sur les risques, tenant compte des changements de qualité des eaux souterraines, de l'adoption de zones d'atténuation souterraine, de l'utilisation de méthodes de contrôle avancées, est nécessaire pour soutenir la confiance dans la durabilité de la RRA.

La sostenibilidad del medio ambiente y la protección de la salud humana se ve amenazada por unas 350,000 sustancias químicas disponibles en los mercados mundiales, además de nuevas entidades biológicas como el coronavirus. Estos peligros para la calidad del agua suponen un desafío para los defensores de la recarga gestionada de acuíferos (MAR), que pretenden garantizar la integridad de las aguas subterráneas. Se necesita un marco normativo basado en el riesgo que tenga en cuenta los cambios en la calidad de las aguas subterráneas, la incorporación a las zonas de atenuación del subsuelo y el uso de métodos avanzados de control para respaldar la confianza en la sostenibilidad de la recarga acuífera gestionada.

A proteção sustentável do meio ambiente e da saúde humana está ameaçada por cerca de 350,000 produtos químicos disponíveis nos mercados globais, além de novas entidades biológicas, incluindo coronavírus. Esses riscos de qualidade da água desafiam os proponentes da recarga gerenciada de aquíferos (RGA) que buscam garantir a integridade das águas subterrâneas. Uma estrutura regulatória baseada em risco que considere as mudanças na qualidade das águas subterrâneas, a adoção em zonas de atenuação do subsolo e o uso de métodos avançados de monitoramento são necessários para apoiar a confiança na sustentabilidade da RGA.

Increasing Pediatric Residency Class Diversity to Improve Patient Outcomes and Address Structural Racism.

PROBLEM: The racial and ethnic makeup of physicians in the United States does not reflect that of the communities they serve. Addressing this disparity may improve patient outcomes and combat structural racism. APPROACH: Starting in 2014, the pediatric residency program at Children's National Hospital deliberately worked to assemble residency classes with racial and ethnic diversity that was similar to that of the Washington, DC, community it served. This work consisted of 3 initiatives: the Minority Senior Scholarship Program (MSSP), a pipeline program for rising fourth-year underrepresented in medicine (UIM) medical students to expose them to careers in academic pediatrics; an enhanced applicant recruitment process for UIM applicants; and mechanisms like a diversity dinner series for UIM residents to find the support they need to succeed. OUTCOMES: Since its inception in 2015, 73 participants have completed the MSSP, with 26% (19/73) going on to match at Children's National Hospital. An additional 12 participants are completing the program during the 2022 Match cycle. The MSSP has also increased participants' self-reported interest in pursuing a career in academic pediatrics, from 70% (14/20) before participation to 95% (19/20) after participation. In addition, the enhanced recruitment efforts have proven fruitful. The percentage of UIM interns at Children's National Hospital has increased from 5% (2/40) in 2014 to 51% (21/41) in 2021. NEXT STEPS: The dimensions of diversity included in these initiatives will be expanded to include individuals from other marginalized populations, such as certain individuals of Southeast Asian descent, those who identify as LGBTQ+, and those with disabilities. An antiracism initiative has also been implemented in the residency program in collaboration with the hospital and partner medical schools.

Flying Solo: Effectiveness of Attendingless Family-Centered Rounds on Improving Resident Autonomy.

BACKGROUND AND OBJECTIVES: The Accreditation Council for Graduate Medical Education requires that residents demonstrate increasing autonomy during their training. Although residents report a better educational environment with hospitalists present during family-centered rounds (FCRs), there is a concern that attending presence may reduce resident autonomy. We aim to determine the effect of FCRs without an attending during rounds on senior residents' sense of autonomy. METHODS: We conducted a multicenter, retrospective, preintervention-postintervention study at 5 children's hospitals to evaluate the effect of rounding without an attending on senior residents' self-efficacy, using a questionnaire developed by using Bandura's principles of self-efficacy and Accreditation Council for Graduate Medical Education milestones. Questions addressed skills of diagnosis and/or management, communication, teaching, and team management. We compared preintervention and postintervention results using paired t tests and Wilcoxon rank tests. One-way analysis of variance tests were used to compare means among >2 groups. RESULTS: 116 (82% response rate) of 142 eligible senior residents completed the questionnaire, which yielded a high reliability (α = 0.80) with a 1-factor score. The average composite score of self-efficacy significantly improved after intervention compared with the preintervention score (66.71 ± 6.95 vs 60.91 ± 6.82; P < .001). Additional analyses revealed meaningful improvement of each individual item postintervention. The highest gain was reported in directing bedside teaching (71.8% vs 42.5%; P < .001) and answering learner questions on rounds (70.7% vs 47.0%; P < .001). CONCLUSIONS: Conducting FCRs without an attending increases resident reported self-efficacy regarding core elements of patient care and team leadership. In future studies, researchers should examine the impact of rounding without the attending on other stakeholders, such as students, interns, patients and/or families.

Prognostic factors for discharge to home and residing at home 12 months after hip fracture: an Anoia hip study.

OBJECTIVES: Hip fracture is often associated with loss of physical function and institutionalization. The aim of this study is to describe the prognostic factors for discharge to home and residing there 12 months after a hip fracture. METHODS: A prospective study that includes patients aged ≥ 69 years that live at home before the fracture, admitted from June 1st, 2010, to May 31st, 2013. We registered the demographic data, presurgical function and cognitive assessment, surgical waiting time, type of fracture and complications during hospitalization. RESULTS: We included 273 patients (mean age 84.8 ± 6.1 years; 80% women), 130 (47.6%) were discharged directly to their own home. The predictors of discharge to home were a lower Geriatrics Dementia Scale score (OR 1.42; 95% CI 1.17-1.71; p < 0.001), a higher Barthel Index score at discharge (OR 1.07; 95% CI 1.05-1.10; p < 0.001) and a longer hospital stay (OR 1.14; 95% CI 1.02-1.27; p = 0.019). At 12 months, 169 (63.5%) were still residing at home. Predictors of residing at home 12 months after the hip fracture were age (OR 1.07; 95% CI 1.02-1.12; p = 0.010), the discharge Barthel Index score (OR 0.96; 95% CI 0.94-0.98; p < 0.001), the Geriatrics Dementia Scale score (OR 1.27; 95% CI 1.05-1.52; p = 0.013), the surgical waiting time (OR 3.42; 95% CI 1.077-10.89; p = 0.037) and Charlson comorbidity index (OR 1.27; 95% CI 1.05-1.55; p = 0.016). CONCLUSION: Prognostic factors for discharging to home and remaining there 12 months after a hip fracture are those that reflect a better health condition prior to the fracture and better functionality at the hospital discharge for hip fracture.

Advantages of care for patients with hip fractures in the acute geriatric unit: Hip study Anoia.

AIM: Hip fracture as a result of bone fragility is characterized by poor health outcomes in the medium and long term. Our goal was to compare a new orthogeriatric model with the old trauma model and evaluate improvements in clinical management. METHODS: We carried out a comparative unicentric study, a historical sample (trauma model) collected from 1 June 2007 to 31 May 2010, versus a prospective sample (orthogeriatric model) collected from 1 June 2010 until 31 May 2013. We included all patients aged >69 years with hip fracture as a result of bone fragility. RESULTS: A total of 792 patients were evaluated (mean age 84.3 years). The surgical waiting period went from 2.70 days in the trauma model to 1.86 days in the orthogeriatric model (P < 0.001); the average stay was 15.76 days in the trauma model, and for the orthogeriatric model was reduced to 5.90 days (P < 0.001); mortality went from 4.5% to 1.3% (P ≤ 0.010); 1 month readmission for hip dislocation was reduced from 2.3% to 0.5% (P = 0.032). After a 6-month follow up, we had 302 trauma model patients and 287 orthogeriatric model patients. After 1 year, we had 288 patients in the trauma model and 264 patients in the orthogeriatric model. The main cause of abandonment was death, 108 patients (27.3%) in the trauma model and 100 patients (27.5%) in the orthogeriatric model (P = 0.951). CONCLUSIONS: When we compared the two models, we found statistically significant better results in the preoperative waiting period, average stay, hospital mortality and 1 month readmission as a result of hip prosthesis luxation in favor of the orthogeriatric model. Geriatr Gerontol Int 2018; 18: 407-414.