Lack of standardization and faculty development in pediatric colonoscopy: A qualitative study.

A standard curriculum for pediatric colonoscopy training has neither been required nor universally implemented in North American fellowship programs. This qualitative study assessed the needs of colonoscopy training in pediatric gastroenterology to determine the standardized components of procedural teaching. Focus groups with pediatric gastroenterology attendings, fellows, procedural nurses, and interviews with advanced endoscopists, all practicing at a single institution, were conducted between March and June 2018. Data were analyzed using thematic analysis principles. Four themes emerged: (1) lack of standardization of colonoscopy performance, (2) lack of professional development of procedure teaching skills, (3) need for teaching behaviors that promote learner's performance, and (4) barriers to effective teaching and learning. A conceptual framework was created for developing a standardized "train-the-trainer" curriculum. Our needs assessment supports expansion of efforts to make this comprehensive training available to all pediatric gastroenterologists involved in procedure teaching.

Beyond the Workshop: Results From a Longitudinal, Interprofessional Teaching Certificate Program.

OBJECTIVES: While most hospital-based, healthcare professionals are expected to teach and supervise, few receive training in education. We designed, implemented, and evaluated an interprofessional, hospital-based teaching certificate program based on experiential learning and reflective practice for healthcare professionals with little or no formal training in education. METHODS: Participants attended educational seminars; incorporated new concepts, skills, and behaviors in their teaching; and submitted written reflections. Participants also met with an education coach, received feedback from a trained observer, and observed a "master teacher." We used descriptive statistics to analyze a survey distributed to the 2017-2019 cohort. We also analyzed written reflections to determine whether participants described a new teaching skill, concept, or behavior, and how they applied these to their teaching. RESULTS: Survey completion rate was 15/20 (75%). Participants described feeling connected to an educator community, establishing educational alliances with senior educators, and learning teaching strategies from other certificate members outside their own profession. Participants indicated they are more likely to pursue educational innovation, leadership, and scholarship. In the reflections, 88% described incorporating a new concept in their teaching. CONCLUSION: Participants in an interprofessional teaching certificate program engaged in a curriculum of professional development in education. Graduates of the program reported knowledge gain, behavior change, and establishment of educational alliances and a community of practice.

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.

Family-Educator Partnership in the Development of Entrustable Professional Activities in Complex Care.

PROBLEM: Incorporating patient and family voices in the development of entrustable professional activities (EPAs) is not standard practice. Care of children with medical complexity (CMC) is an area of pediatrics that relies on family partnership, and families of CMC are ideal partners in EPA development given their expertise in their child's care and experience interacting with the health care system. The authors describe their model for partnering with families to develop EPAs and reflect on the unique contributions of family leaders to the process. APPROACH: After recruitment of family leaders from a national organization of families and friends of children with special health care needs, the authors used a multistage process for EPA development from June 2019 to February 2021. Family leaders were integrated throughout the process, including creating EPA descriptions, revising content across all EPAs, appraising EPAs through virtual focus groups with other key stakeholders, and finalizing and publishing EPAs. The authors used content analysis to identify recommendations for patient- and family-integrated EPA development. OUTCOMES: Family leaders and educators partnered in every phase of developing EPAs for the care of CMC, including as content experts, editors, focus group facilitators, and coauthors. Family leaders recommended substantive changes to all EPAs, including revising language, augmenting content, and modifying scope of practice. In addition, content analysis of family leaders' revisions yielded 10 recommendations to ensure that written EPA descriptions are patient- and family-centered. NEXT STEPS: The described process of EPA development for the care of CMC models how families can be integrated into competency framework development and highlights their contributions. Family leader recommendations for embedding patient and family voices in EPA descriptions can serve as a guide for EPA development in other specialties.

Bridge Builders: A Qualitative Study of Fellows' Successful Supervision of Residents.

PURPOSE: Clinical fellows, those training to become subspecialists in a program certified by the Accreditation Council for Graduate Medical Education, supervise residents on inpatient subspecialty rotations. Unlike for supervising residents or for faculty, there is a paucity of literature describing fellows' supervision of residents. The aim of this study was to understand residents' and fellows' perception of successful supervision of residents by fellows on inpatient subspecialty rotations to inform the development of curricula to support fellows as supervisors. METHOD: Using grounded theory methodology, the authors held focus groups in May 2020 of pediatric residents and pediatric subspecialty fellows at Boston Children's Hospital, Boston, Massachusetts. Focus groups were conducted until thematic saturation was achieved. Deidentified transcripts were independently coded by 2 authors. The author team consolidated the codes into themes and developed an interpretive model for fellows' successful supervision of residents. Key results were confirmed via member checking. RESULTS: The authors conducted 4 resident focus groups, composed of 16 pediatric residents, and 4 fellow focus groups, composed of 13 pediatric subspecialty fellows. Participants perceived that fellows who provided successful resident supervision advanced residents' professional growth and supported residents' development along 5 "bridges": (1) generalist to subspecialist, (2) trainee to autonomous practitioner, (3) individual to member of the interprofessional team, (4) emerging physician to patient-facing care provider, and (5) newcomer to engaged clinical learner. Fellows can further residents' growth in these areas by demonstrating approachability, empathy, appreciation, and kindness. CONCLUSIONS: As newcomers on inpatient subspecialty rotations, residents engage in legitimate peripheral participation. Fellows who are successful supervisors move residents toward full participation in their profession via the bridge model. The fellow-resident dynamic carries advantages of near-peer learning. Fellows can harness their role, subspecialty knowledge, and familiarity with the training environment to enhance resident supervision.

Perspectives on Complex Care Training in a Large Academic Pediatric Training Program.

OBJECTIVE: To identify gaps and opportunities in complex care training for pediatric residents. METHODS: Residents in an academic pediatric residency program were surveyed about: training experiences in complex care; self-entrustment in key clinical activities in complex care; educational strategies that would increase preparedness; and recommendations for curriculum development. We used descriptive statistics for quantitative data and content analysis for free-text responses. RESULTS: Of the 160 residents surveyed, 110 (69%) participated. Most participants reported prior clinical exposure to children with medical complexity (CMC; 106, 96%) during both inpatient (82, 75%) and outpatient (88, 80%) clinical rotations. Mean self-entrustment was at or below "somewhat confident" for all clinical activities in complex care, for residents in all postgraduate years. Clinical activities with highest reported self-entrustment included evaluating aspiration into the airway, nutritional issues, care coordination, and evaluating pain. Lowest self-entrustment was reported for facilitating transition to adult care, managing medical technologies, and safety/emergency planning. In terms of educational strategies, participants recommended inpatient encounters with an expert preceptor teaching about evaluating aspiration, pain/irritability and dysmotility (>50%); discussions with patients/families for advocacy, difficult discussions, and transition to adult care (>40%); and hands-on practice for medical technology care (>40%). CONCLUSIONS: Pediatric residents report limited self-entrustment in performing key clinical activities in complex care, including for residents at the end of their last postgraduate year. Future curriculum development should prioritize direct observation of clinical encounters with CMC by expert preceptors, partnership with patients and families of CMC, and hands-on simulation.

Mendelian etiologies identified with whole exome sequencing in cerebral palsy.

OBJECTIVES: Cerebral palsy (CP) is the most common childhood motor disability, yet its link to single-gene disorders is under-characterized. To explore the genetic landscape of CP, we conducted whole exome sequencing (WES) in a cohort of patients with CP. METHODS: We performed comprehensive phenotyping and WES on a prospective cohort of individuals with cryptogenic CP (who meet criteria for CP; have no risk factors), non-cryptogenic CP (who meet criteria for CP; have at least one risk factor), and CP masqueraders (who could be diagnosed with CP, but have regression/progressive symptoms). We characterized motor phenotypes, ascertained medical comorbidities, and classified brain MRIs. We analyzed WES data using an institutional pipeline. RESULTS: We included 50 probands in this analysis (20 females, 30 males). Twenty-four had cryptogenic CP, 20 had non-cryptogenic CP, five had CP masquerader classification, and one had unknown classification. Hypotonic-ataxic subtype showed a difference in prevalence across the classification groups (p = 0.01). Twenty-six percent of participants (13/50) had a pathogenic/likely pathogenic variant in 13 unique genes (ECHS1, SATB2, ZMYM2, ADAT3, COL4A1, THOC2, SLC16A2, SPAST, POLR2A, GNAO1, PDHX, ACADM, ATL1), including one patient with two genetic disorders (ACADM, PDHX) and two patients with a SPAST-related disorder. The CP masquerader category had the highest diagnostic yield (n = 3/5, 60%), followed by the cryptogenic CP category (n = 7/24, 29%). Fifteen percent of patients with non-cryptogenic CP (n = 3/20) had a Mendelian disorder on WES. INTERPRETATION: WES demonstrated a significant prevalence of Mendelian disorders in individuals clinically diagnosed with CP, including in individuals with known CP risk factors.

A Multistakeholder Approach to the Development of Entrustable Professional Activities in Complex Care.

BACKGROUND: Care of children with medical complexity (CMC) involves unique knowledge, skills, and attitudes. Previous work has identified curricular priorities in complex care for pediatricians yet there are no established competency frameworks to guide curriculum development. We aimed to develop and appraise Entrustable Professional Activities (EPAs) for the care of CMC with multistakeholder involvement. METHODS: We recruited complex care practitioners to develop EPAs using a template for elaborating descriptive elements. A team of clinicians, educators, trainees, and family leaders refined EPAs and mapped content to the Accreditation Council for Graduate Medical Education Milestones. We conducted virtual focus groups to assess whether EPAs represented the essential skills of pediatricians caring for CMC. Focus group data were analyzed using content analysis. RESULTS: Content experts developed 11 EPAs for the care of CMC describing knowledge, skills, and attitudes required for attaining competency. EPAs were mapped to 21 of the 21 (100%) reporting pediatric milestones. Focus group participants endorsed and refined EPA content. Categories of feedback included clarifying medical knowledge, expanding on interpersonal communication skills, emphasizing systems-based practice, and affirming family partnership. CONCLUSIONS: A systematic approach to developing EPAs for the care of CMC provides a guide for curriculum development and assessment in complex care.

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.

Establishing trust within interprofessional teams with a novel simulation activity in the pediatric clerkship.

Interprofessional trust is essential for effective team-based care. Medical students are transient members of clinical teams during clerkship rotations and there may be limited focus on developing competency in interprofessional collaboration. Within a pediatric clerkship rotation, we developed a novel simulation activity involving an interprofessional conflict, aiming to foster trusting interprofessional relationships. Active participants included a nurse educator and a medical student participant, with additional students using a checklist to actively observe. The debrief focused on teaching points related to interprofessional competencies and conflict resolution. Students completed a written evaluation immediately following the simulation. Descriptive statistics were used to analyze Likert-type scale questions. Conventional content analysis was used to analyze open-ended responses. Two hundred and fourteen students participated in the simulation between June 2018-June 2019. Most students indicated that the simulation was effective (86%) and improved their confidence to constructively manage disagreements about patient care (88%). Students described anticipated changes in practice including developing their role on the interprofessional team as a medical student, developing a shared mental model, and establishing a shared goal. Our findings suggest that simulation-based learning may present an opportunity for developing interprofessional trust in academic health centers.

L'utilisation sécuritaire des médicaments chez les enfants ayant des problèmes médicaux complexes.

Grâce aux progrès de la médecine et aux innovations en technologies de la santé, de nombreux enfants atteints d'affections au pronostic réservé vivent désormais plus longtemps. Ces enfants sont souvent qualifiés d'« enfants ayant des problèmes médicaux complexes ¼, parce qu'ils ont des affections chroniques, utilisent davantage les soins de santé et sont dépendants de la technologie. La complexité de leurs soins et leur fragilité intrinsèque entraînent des risques plus élevés d'erreurs de médication, autant dans un contexte ambulatoire qu'hospitalier. Le taux élevé de fragmentation des soins, de mauvaise communication et de polypharmacie chez les enfants ayant des problèmes médicaux complexes accroissent les possibilités d'erreurs, particulièrement au moment de changer de milieu de soins et de praticiens. Il n'existe pas de données sur les facteurs qui contribuent à un risque plus élevé d'erreurs de médication dans cette population et sur les meilleures mesures pour les éviter. Le présent point de pratique fournit des directives cliniques aux professionnels de la santé afin de s'assurer d'une utilisation sécuritaire des médicaments auprès des enfants ayant des problèmes médicaux complexes et s'attarde sur des stratégies pratiques applicables à la fois en soins ambulatoires et hospitaliers.

Medication safety for children with medical complexity.

Due to advances in medical care and innovations in health technology, many children with life-limiting conditions are now living longer. These children are often referred to as 'children with medical complexity (CMC)', and they are characterized by chronic conditions, increased health care utilization, and technology dependence. Their complexity of care and inherent fragility lead to higher risk for medication errors, both in-community and in-hospital. High rates of care fragmentation, miscommunication, and polypharmacy in CMC increase opportunities for error, particularly as children transition between health care settings and practitioners. Data on the factors contributing to higher risk of medication errors in this population and how they can be effectively addressed are lacking. This practice point provides clinical guidance for health care professionals to ensure medication safety when caring for CMC, with focus on practical strategies for outpatient and inpatient care.

Visiting Jack: Mixed Methods Evaluation of a Virtual Home Visit Curriculum With a Child With Medical Complexity.

BACKGROUND: There are limited training opportunities for pediatricians in caring for children with medical complexity (CMC) in the home and community. Prior studies have described a lack of comfort caring for CMC among pediatric residents. OBJECTIVE: 1) To evaluate the impact of participation in a virtual home visit curriculum on pediatric residents' confidence, knowledge, and application of knowledge in complex care; 2) to explore changes in perspectives relating to the care of CMC after participation in the curriculum. METHODS: This was a prospective pre-post intervention study in 2019 with first-year pediatric residents, using quantitative and qualitative methods. The intervention, co-created with a family partner, was an online video-based curriculum followed by an in-person seminar. Pre- and postassessments were compared using paired t tests. Follow-up interviews and focus groups were performed 5 to 8 weeks after training. Transcripts were analyzed using inductive thematic analysis. RESULTS: Twenty-four residents (100%) participated. Residents reported increased confidence in all aspects of complex care presented in the curriculum, with significant increase in knowledge and application of knowledge (all P < .001). Twelve residents (50%) participated in a follow-up interview or focus group. Four themes were identified: 1) recognizing prior attitudes toward complexity, 2) new mental framework for complex care at home, 3) drivers of behavior change, and 4) commitment to change practice. CONCLUSIONS: Participation in this curriculum was associated with increased confidence, knowledge, and application of knowledge in complex care outside of the hospital. Qualitative findings align with transformative learning theory, lending insight into effective approaches to complex care training.

Encouraging Entrustment: A Qualitative Study of Resident Behaviors That Promote Entrustment.

PURPOSE: To explore resident and attending physician perceptions of resident behaviors and skills that demonstrate trustworthiness and promote entrustment by supervisors. METHOD: Using grounded theory methodology, the authors conducted 3 focus groups with pediatric residents from the Boston Combined Residency Program and 3 focus groups with attending physicians who were either general pediatric hospitalists or other pediatric subspecialists at Boston Children's Hospital and Boston Medical Center in Boston, Massachusetts, from May to December 2018. Data were collected and analyzed iteratively until theoretical saturation was achieved. Three independent reviewers coded each transcript. Codes were grouped into dominant themes to develop a conceptual model. RESULTS: Twelve residents and 18 attending physicians participated in the focus groups. Participants described actions that they felt actively demonstrated residents' trustworthiness within previously described domains of trustworthiness. Four modifiers emerged that affect a resident's progression from trustworthiness to entrustment: (1) self-management, (2) relationships, (3) self-advocacy, and (4) patient-centeredness. Findings were synthesized into a conceptual model depicting how trainees can promote their own entrustment by supervisors. CONCLUSIONS: Trainees must actively demonstrate their trustworthiness to be entrusted. This study proposes that trainees can further gain entrustment through self-management, relationships, self-advocacy, and patient-centeredness. When they understand the actions and behaviors that promote entrustment, trainees may be better able to foster autonomy and progress toward more independent clinical practice. These findings add to existing evidence regarding entrustment and provide a novel, actionable framework for trainees to increase their own entrustment.