Brief Resolved Unexplained Events Symptoms Frequently Result in Inappropriate Gastrointestinal Diagnoses and Treatment.

OBJECTIVE: To determine associations between presenting symptoms and oropharyngeal dysphagia diagnoses, gastroesophageal reflux disease (GERD) diagnoses, and treatment with acid suppression medication in infants with brief resolved unexplained event (BRUE). STUDY DESIGN: We performed a prospective cohort study of infants with BRUE to review presenting symptoms and their potential impact on testing and treatment. Videofluoroscopic swallow study (VFSS) results and explanatory diagnoses were obtained from medical record review; acid suppression use was determined by parental survey. Binary and multivariable logistic regression models were used to evaluate associations between presenting symptoms and obtaining VFSS, VFSS results, GERD diagnoses, and acid suppression medication. RESULTS: Presenting symptoms were varied in 157 subjects enrolled at 51.0 ± 5.3 days of age, with many symptoms that may be related to GERD or dysphagia. Of these, 28% underwent VFSS with 71% abnormal. Overall, 42% had their BRUE attributed to GERD, and 33% were treated with acid suppression during follow-up. Presenting symptoms were significantly associated with the decision to obtain VFSS but not with abnormal VFSS results. Presenting symptoms were also associated with provision of GERD explanatory diagnoses. Both presenting symptoms and GERD explanatory diagnoses were associated with acid suppression use (aOR 2.3, 95% CI 1.03-5.3, P = .04). CONCLUSIONS: Presenting symptoms may play a role in clinicians' decisions on which BRUE patients undergo VFSS but are unreliable to make a diagnosis of oropharyngeal dysphagia. Presenting symptoms may also influence assignment of GERD explanatory diagnoses that is associated with increased acid suppression medication use.

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.

The Impact of the American Academy of Pediatrics Brief Resolved Unexplained Event Guidelines on Gastrointestinal Testing and Prescribing Practices.

OBJECTIVES: To determine if hospitalization, testing, diagnosis, and management of suspected gastroesophageal reflux, and follow-up visits decreased since introduction of American Academy of Pediatrics guidelines for brief resolved unexplained events (BRUEs). STUDY DESIGN: We performed a retrospective cohort study of infants with BRUE evaluated at Boston Children's Hospital in the year before and after guideline implementation to determine if practice patterns have changed. Outcomes included hospitalization rates, frequency of swallow assessments, other diagnostic testing, and reflux diagnoses, cost of care, and number of repeat visits. Groups were compared based on whether they presented before or after guideline implementation. RESULTS: In total, 359 subjects (186 pre-, 173 post-guidelines) were identified. There were no significant differences in practice patterns or outcomes before or after guideline implementation. Subjects had mean age 2.53 ± 0.15 months, and 80% were hospitalized for 2.49 ± 0.26 days. Each subject had 2.47 diagnostic tests performed, and 89% were noncontributory. Despite only 13% having videofluoroscopic swallow study performed, 72% showed aspiration/penetration. No subject had gastroesophageal reflux testing, yet reflux was implicated as the cause for admission in 40% of subjects, resulting in increased odds of discharge on acid suppressing medications (OR 2.88, 95% CI 1.68-4.92, P = .0001). In follow-up, 28% of subjects had repeat hospitalizations or emergency department visits for persistent symptoms. CONCLUSIONS: Infants with BRUE continue to undergo low-yield diagnostic testing and after admission remain symptomatic and frequently re-present to medical care. Swallow testing remains infrequent despite its high-yield, reflux continues to be implicated and children are still being discharged on acid suppression despite lack of efficacy.

Development and psychometric characteristics of the pediatric inpatient experience survey (PIES).

OBJECTIVE: To study the psychometric properties of the Pediatric Inpatient Experience Survey (PIES), a mail and phone survey for parent reporting of family-centered aspects of inpatient care experiences. DESIGN: Two waves of cross-sectional survey data were collected by mail and phone in 2009 to design a measurement instrument with good psychometric characteristics. Additional cross-sectional data from a mail administration in 2011 confirmed the measurement domains. SETTING: Free-standing pediatric hospital in the northeastern USA. PARTICIPANTS: A convenience sample of English-speaking parents of hospitalized children, stratified by patient type (medical versus surgical) and previous stays at this hospital (yes versus no), constituted the instrument design phase. Four hundred and seventy-nine (63%) of those approached agreed to participate and were randomly assigned to mail or phone survey administration. Four hundred and one of these respondents completed the first wave of the survey and 354 respondents completed the second wave. A shortened instrument was mailed to parents randomly selected from patient discharge records. Data from 929 parents (response rate: 36.2%) were used for confirmatory analysis of the created measurement domains. MAIN OUTCOME MEASURES: The main outcome measures of this psychometric validation study were individual item performance, test-retest reliability, internal consistency, and construct validity. RESULTS: The resulting survey includes 61 items with 35 rating items with satisfactory test-retest reliability loading on eight domains. The factor structure was supported by Cronbach's alpha and confirmatory factor analysis. The survey supported construct validity in distinguishing between medical versus surgical and first time versus previous hospital stay groups known to differ with regard to satisfaction. Comparing mail and phone administrations, differences in scores were exacerbated in domain scores and showed the need for mode adjustment. CONCLUSION: PIES shows satisfactory test-retest reliability, internal consistency, and construct validity. A new domain measuring emotional connectedness to staff and the hospital is highly correlated with overall satisfaction.

A Prospective Study of Brief Resolved Unexplained Events: Risk Factors for Persistent Symptoms.

OBJECTIVE: The risk of persistent symptoms after a brief resolved unexplained event (BRUE) is not known. Our objective was to determine the frequency and risk factors for persistent symptoms after BRUE hospitalizations. METHODS: We conducted a prospective longitudinal cohort study of infants hospitalized with an admitting diagnosis of BRUE. Caregiver-reported symptoms, anxiety levels, and management changes were obtained by questionnaires during the 2-month follow-up period. Clinical data including repeat hospitalizations were obtained from a medical record review. Multivariable analyses with generalized estimating equations were conducted to determine the risk of persistent symptoms. RESULTS: Of 124 subjects enrolled at 51.6 ± 5.9 days of age, 86% reported symptoms on at least 1 questionnaire after discharge; 65% of patients had choking episodes, 12% had BRUE spells, and 15% required a repeat hospital visit. High anxiety levels were reported by 31% of caregivers. Management changes were common during the follow-up period and included 30% receiving acid suppression and 27% receiving thickened feedings. Only 19% of patients had a videofluoroscopic swallow study while admitted, yet 67% of these studies revealed aspiration/penetration. CONCLUSIONS: Many infants admitted with BRUE have persistent symptoms and continue to access medical care, suggesting current management strategies insufficiently address persistent symptoms. Future randomized trials will be needed to evaluate the potential efficacy of therapies commonly recommended after BRUE.

Sacral Myeloradiculitis: An Uncommon Complication of Genital Herpes Infection.

Herpes simplex virus 1 and 2 infections affect up to 50 million people in the United States, with a natural history of recurrent viral shedding with or without recurrence of symptoms. Although many patients remain asymptomatic or with mild symptoms, a spectrum of rare but significant nervous system complications have been reported. Although urinary retention and constipation associated with genital herpesvirus infections is often attributed to painful genital ulcerations, herpesvirus-associated lumbosacral myeloradiculitis has been reported in adults. Here, we report an 18-year-old man with constipation, urinary retention, perineal paresthesias, and erectile dysfunction in the setting of a genital herpes infection. His workup was notable for a cerebrospinal fluid pleocytosis and MRI with enhancement of the cauda equina and nerve roots, all of which are consistent with sacral myeloradiculitis. The patient was treated with a 3-week course of intravenous acyclovir with complete resolution of symptoms. Pediatric practitioners should be aware of this complication of anogenital herpes simplex virus infection because appropriate diagnosis has implications for treatment delivery and duration.

Discharge Day: A Case-Based Interprofessional Exercise About Team Collaboration in Pediatrics.

Introduction: Interprofessional education, which gives medical students the opportunity to learn from, with, and about other health professionals, is an essential component of the undergraduate medical education curriculum. Nonetheless, deliberate and sustained integration of interprofessional education into the undergraduate medical learning experience can be challenging, especially within the clinical setting. Methods: We implemented a 75-minute, interactive, collaborative, case-based conference focusing on an interprofessional clinical challenge in a pediatric setting. Medical students on their pediatrics core rotation and trainees within social work, nursing, pharmacy, and nutrition explored the concept of a team, reflected on roles, and considered how interprofessional collaboration could influence patient outcomes. Results: One hundred ninety-two health professions students participated in 15 sessions at three sites over a 10-month period (September 2017-July 2018). After each session, participants completed a session evaluation. They gave high ratings to the effectiveness and relevance of the experience and the case vignette. Responses to open-ended questions revealed that students had learned the importance of leveraging the expertise of team members and had resolved to speak up when faced with an interprofessional challenge in the future. Discussion: This case-based session is a logistically feasible and positively received opportunity for health professions students to discuss interprofessional collaboration. It could be adapted for a variety of learner populations and academic environments and could be incorporated into existing curricula.

Assessment of Hospitalist-Subspecialist Agreement About Who Should Be in Charge and Comparison With Actual Assignment Practices.

BACKGROUND: A key juncture in patient hospitalization is determining which type of physician should be primarily responsible for directing treatment. We (1) examine the frequency hospitalists and subspecialists agree on preferred assignments and (2) compare preferred assignment with actual assignment. METHODS: Using a mixed methods approach, we first surveyed 66 physicians in 8 specialties about hospitalist assignments versus subspecialist assignments for 176 diagnoses at an academic children's hospital. Agreement was calculated by using the interrater reliability coefficient, Pi . We subsequently compared survey responses to actual hospitalization data from January 2009 to August 2015. RESULTS: Specialty and physician response rates were 100% and 44%, respectively. For preferred assignment among hospitalists and specialists, some diagnoses (eg, gastroesophageal reflux, syncope) experienced high agreement (π = 0.714-1.000); other diagnoses (eg, Guillain-Barre, encephalopathy) had less agreement (π = 0.000-0.600). Hematologists and oncologists agreed among themselves most frequently (73%); endocrinologists agreed among themselves least frequently (9%). Perceptions of agreement were often higher than actual survey results. Of the 25 highest volume diagnoses, 7 were conditions with consensus (Pi ≥ 0.6) about assignment, and of those conditions, 6 were assigned to a subspecialist at least 50% of the time, although consensus indicated a hospitalist should have been assigned (1597 hospitalizations). CONCLUSIONS: This is the first study used to analyze preferences of hospitalist-subspecialist assignment and show variation from actual practice. Although physicians assessed the same patient information, agreement on preferred assignment varied noticeably across diagnoses and subspecialties. With our results, we reveal potential challenges in integrating hospitalists with other specialists and provide evidence for standardizing certain aspects of physician roles.

Families as Partners in Hospital Error and Adverse Event Surveillance.

Importance: Medical errors and adverse events (AEs) are common among hospitalized children. While clinician reports are the foundation of operational hospital safety surveillance and a key component of multifaceted research surveillance, patient and family reports are not routinely gathered. We hypothesized that a novel family-reporting mechanism would improve incident detection. Objective: To compare error and AE rates (1) gathered systematically with vs without family reporting, (2) reported by families vs clinicians, and (3) reported by families vs hospital incident reports. Design, Setting, and Participants: We conducted a prospective cohort study including the parents/caregivers of 989 hospitalized patients 17 years and younger (total 3902 patient-days) and their clinicians from December 2014 to July 2015 in 4 US pediatric centers. Clinician abstractors identified potential errors and AEs by reviewing medical records, hospital incident reports, and clinician reports as well as weekly and discharge Family Safety Interviews (FSIs). Two physicians reviewed and independently categorized all incidents, rating severity and preventability (agreement, 68%-90%; κ, 0.50-0.68). Discordant categorizations were reconciled. Rates were generated using Poisson regression estimated via generalized estimating equations to account for repeated measures on the same patient. Main Outcomes and Measures: Error and AE rates. Results: Overall, 746 parents/caregivers consented for the study. Of these, 717 completed FSIs. Their median (interquartile range) age was 32.5 (26-40) years; 380 (53.0%) were nonwhite, 566 (78.9%) were female, 603 (84.1%) were English speaking, and 380 (53.0%) had attended college. Of 717 parents/caregivers completing FSIs, 185 (25.8%) reported a total of 255 incidents, which were classified as 132 safety concerns (51.8%), 102 nonsafety-related quality concerns (40.0%), and 21 other concerns (8.2%). These included 22 preventable AEs (8.6%), 17 nonharmful medical errors (6.7%), and 11 nonpreventable AEs (4.3%) on the study unit. In total, 179 errors and 113 AEs were identified from all sources. Family reports included 8 otherwise unidentified AEs, including 7 preventable AEs. Error rates with family reporting (45.9 per 1000 patient-days) were 1.2-fold (95% CI, 1.1-1.2) higher than rates without family reporting (39.7 per 1000 patient-days). Adverse event rates with family reporting (28.7 per 1000 patient-days) were 1.1-fold (95% CI, 1.0-1.2; P = .006) higher than rates without (26.1 per 1000 patient-days). Families and clinicians reported similar rates of errors (10.0 vs 12.8 per 1000 patient-days; relative rate, 0.8; 95% CI, .5-1.2) and AEs (8.5 vs 6.2 per 1000 patient-days; relative rate, 1.4; 95% CI, 0.8-2.2). Family-reported error rates were 5.0-fold (95% CI, 1.9-13.0) higher and AE rates 2.9-fold (95% CI, 1.2-6.7) higher than hospital incident report rates. Conclusions and Relevance: Families provide unique information about hospital safety and should be included in hospital safety surveillance in order to facilitate better design and assessment of interventions to improve safety.

Serum 25-hydroxyvitamin D levels among Boston trainee doctors in winter.

As indoor workers, trainee doctors may be at risk for inadequate vitamin D. All trainee doctors (residents) in a Boston pediatric training program (residency) were invited to complete a survey, and undergo testing for serum 25-hydroxyvitamin D [25(OH)D], PTH, and calcium during a 3-week period in March 2010. We examined the association between resident characteristics and serum 25(OH)D using Chi2 and Kruskal-Wallis test and multivariable linear and logistic regression. Of the 119 residents, 102 (86%) participated. Although the mean serum 25(OH)D level was 67 nmol/L (±26), 25 (25%) had a level <50 nmol/L and 3 (3%) residents had levels <25 nmol/L. In the multivariable model, factors associated with 25(OH)D levels were: female sex (ß 12.7, 95% CI 3.6, 21.7), white race (ß 21.7, 95% CI 11.7, 31.7), travel to more equatorial latitudes during the past 3 months (ß 6.3, 95% CI 2.0, 10.5) and higher daily intake of vitamin D (ß 1.1, 95% CI 0.04, 2.1). Although one in four residents in our study had a serum 25(OH)D <50 nmol/L, all of them would have been missed using current Centers for Medicare and Medicaid Services (CMS) screening guidelines. The use of traditional risk factors appears insufficient to identify low vitamin D in indoor workers at northern latitudes.