The transition to Pediatric Hospital Medicine fellowship: A national survey-based needs assessment.

BACKGROUND: Each year, the number of fellows entering Pediatric Hospital Medicine (PHM) fellowship is increasing. Residency curricula do not always prepare trainees for all aspects of PHM as a specialty and gaps often exist in the transition to fellowship. OBJECTIVE: To explore the preparedness of PHM fellows for clinical, teaching, and scholarship tasks at the start of fellowship and to identify opportunities for residency and fellowship program development. DESIGN: Quantitative survey. SETTING AND PARTICIPANTS: Current and recently graduated PHM fellows (matriculation years 2019-2022). METHODS: We conducted a national cross-sectional survey from July 2022 to February 2023. We designed survey questions based on PHM fellowship core competencies. MAIN OUTCOME AND MEASURES: We asked participants to rate preparedness for tasks on a 5-point Likert scale (1 = very unprepared, 5 = very prepared). We analyzed numerical data using descriptive and comparative statistics and free-response data using inductive content analysis. RESULTS: We received 223 responses to our survey (response rate 74%). Of the respondents, 25% reported no PHM-specific orientation at their program (n = 55). Respondents reported lower median preparedness for research (3, interquartile range [IQR] [2,4]) and teaching tasks (4, IQR [4,4]) compared to clinical tasks (4, IQR [4,5]) at the start of fellowship (p < 0.01, p < 0.01). Content analysis revealed most fellows wished they had received more training around scholarship at the start of fellowship. CONCLUSIONS: Many PHM fellows enter fellowship feeling inadequately prepared, particularly in scholarship and teaching. Our findings suggest that residency and fellowship programs need to develop more robust curricula to better prepare trainees for successful PHM fellowship. This national survey-based needs assessment should serve as a guide for further program development.

Opportunities for Diagnostic Improvement Among Pediatric Hospital Readmissions.

OBJECTIVES: Diagnostic errors, termed "missed opportunities for improving diagnosis" (MOIDs), are known sources of harm in children but have not been well characterized in pediatric hospital medicine. Our objectives were to systematically identify and describe MOIDs among general pediatric patients who experienced hospital readmission, outline improvement opportunities, and explore factors associated with increased risk of MOID. PATIENTS AND METHODS: Our retrospective cohort study included unplanned readmissions within 15 days of discharge from a freestanding children's hospital (October 2018-September 2020). Health records from index admissions and readmissions were independently reviewed and discussed by practicing inpatient physicians to identify MOIDs using an established instrument, SaferDx. MOIDs were evaluated using a diagnostic-specific tool to identify improvement opportunities within the diagnostic process. RESULTS: MOIDs were identified in 22 (6.3%) of 348 readmissions. Opportunities for improvement included: delay in considering the correct diagnosis (n = 11, 50%) and failure to order needed test(s) (n = 10, 45%). Patients with MOIDs were older (median age: 3.8 [interquartile range 1.5-11.2] vs 1.0 [0.3-4.9] years) than patients without MOIDs but similar in sex, primary language, race, ethnicity, and insurance type. We did not identify conditions associated with higher risk of MOID. Lower respiratory tract infections accounted for 26% of admission diagnoses but only 1 (4.5%) case of MOID. CONCLUSIONS: Standardized review of pediatric readmissions identified MOIDs and opportunities for improvement within the diagnostic process, particularly in clinician decision-making. We identified conditions with low incidence of MOID. Further work is needed to better understand pediatric populations at highest risk for MOID.

Into the Unknown: Characterizing Fellow Uncertainty During the Transition to Unsupervised Practice.

Background: Helping fellows confront and manage uncertainty in the course of diagnosis and treatment of patients has been a growing focus of medical education. How these same fellows confront uncertainty as they make a transition in their professional development is less commonly a focus of training programs. Better understanding of how fellows experience these transitions will allow fellows, training programs, and hiring institutions to navigate transitions more easily. Objective: This study aimed to explore how fellows in the United States experience uncertainty during the transition to unsupervised practice. Methods: Using constructivist grounded theory, we invited participants to engage in semi-structured interviews exploring experiences with uncertainty as they navigate the transition to unsupervised practice. Between September 2020 and March 2021, we interviewed 18 physicians in their final year of fellowship training from 2 large academic institutions. Participants were recruited from adult and pediatric subspecialties. Data analysis was conducted using an inductive coding approach. Results: Experiences with uncertainty during the transition process were individualized and dynamic. Primary sources of uncertainty identified included clinical competence, employment prospects, and career vision. Participants discussed multiple strategies for mitigating uncertainty, including structured graduated autonomy, leveraging professional networks locally and non-locally, and utilizing established program and institutional supports. Conclusions: Fellows' experiences with uncertainty during their transitions to unsupervised practice are individualized, contextual, and dynamic with several shared overarching themes.

Characteristics of Emergency Room and Hospital Encounters Resulting From Consumer Home Monitors.

BACKGROUND AND OBJECTIVES: Consumer home monitors (CHM), which measure vital signs, are popular products marketed to detect airway obstruction and arrhythmia. Yet, they lack evidence of infant death prevention, demonstrate suboptimal accuracy, and may result in false alarms that prompt unnecessary acute care visits. To better understand the hospital utilization and costs of CHM, we characterized emergency department (ED) and hospital encounters associated with CHM use at a children's hospital. METHODS: We used structured query language to search the free text of all ED and admission notes between January 2013 and December 2019 to identify clinical documentation discussing CHM use. Two physicians independently reviewed the presence of CHM use and categorized encounter characteristics. RESULTS: Evidence of CHM use contributed to the presentation of 36 encounters in a sample of over 300 000 encounters, with nearly half occurring in 2019. The leading discharge diagnoses were viral infection (13, 36%), gastroesophageal reflux (8, 22%) and false positive alarm (6, 17%). Median encounter duration was 20 hours (interquartile range: 3 hours to 2 days; max 10.5 days) and median cost of encounters was $2188 (interquartile range: $255 to $7632; max $84 928). CONCLUSIONS: Although the annual rate of CHM-related encounters was low and did not indicate a major public health burden, for individual families who present to the ED or hospital for concerns related to CHMs, there may be important adverse financial and emotional consequences.

A Quality Improvement Initiative to Improve Patient Safety Event Reporting by Residents.

INTRODUCTION: Residents play a key role in patient care at academic medical centers and have unique insights into safety improvement opportunities. At our institution, <1% of safety events were reported by resident trainees. The primary objective of this quality improvement (QI) initiative was to increase the monthly incidence of event reporting by pediatric residents by 20% from baseline within 12 months. METHODS: A QI team used the model for improvement to identify barriers to submitting safety event reports. The team used multiple intervention cycles to increase knowledge and promote engagement in event reporting. Interventions included educational tip sheets, a hospital-wide Morbidity and Mortality (M&M) conference, peer recognition and acknowledgment by senior leadership for report submission, and an interactive reporting activity. The outcome measure was monthly number of reports filed by residents. The process measure was the number of unique residents submitting a report each month. Time to complete a report was a balancing measure. RESULTS: The number of reports placed by residents increased significantly, with a centerline shift from 15 to 29 reports per month (statistical process control chart-Fig. 3). The number of unique residents submitting reports increased from 10 to 22 per month. The time to complete a report was unchanged. CONCLUSIONS: Engaging residents in patient safety initiatives through education, experiential learning, and recognition can increase safety event reporting by residents. Future planned interventions include enhancing safety event reporting technology, developing patient safety faculty and resident champions, and increasing transparency regarding outcomes of safety event reports.

Impact of hospitalists' social identities on perceptions of teamwork.

Interprofessional teamwork provides unique opportunities for improving patient care. This study used Social Identity Theory as a conceptual framework to characterize the relationships between the social identities of pediatric hospitalists and their perceptions of interprofessional teamwork. We used qualitative methods including free-listing and semi-structured interviews to examine these relationships. We identified five key themes: (a) Pediatric hospitalists' identities fall along a spectrum ranging from profession-centered to team-centered; (b) Familiarity is conducive to formation of team identity; (c) Co-creation of a shared vision and practice of creating shared mental models strengthens sense of team; (d) Institutional culture acts as both a facilitator for and barrier to formation of team identity; (e) High-functioning teams often epitomize the concept of "flexible leadership." We conclude that Social Identity Theory can be a useful theoretical lens for examining interprofessional teamwork in healthcare settings, including among pediatric hospitalists.