Usability And Feasibility of an in-Home Remote Exam Device in Children with Medical Complexity During the COVID-19 Pandemic.

Background: Children with medical complexity (CMC) account for high health care utilization. Telemedicine holds significant potential in CMC, as it allows a provider to engage with CMC in their home environment and can alleviate both financial and transportation burdens. Remote exam devices that enable the performance of a physical exam could expand the ability of providers to clinically assess CMC during a telemedicine visit. In this pilot study, our goal was to develop a process for integrating an in-home remote exam device into a complex care clinic during the COVID-19 pandemic and evaluate the usability and feasibility of this device. Methods: The remote exam device was distributed to caregivers of CMC cared for at a complex care outpatient center. Using deliberate practice framework, our onboarding process provided opportunities for caregivers and providers to learn how to utilize the device. Surveys examining usability and feasibility were administered to both caregivers and providers after each telemedicine encounter. Results: A total of 43 caregivers participated in the onboarding process, which included a total of 83 practice visits. The remote exam device was rated as having excellent usability by caregivers; however, providers rated the device as having lower usability. Feasibility was notable for technology issues contributing to 15% of encounters being cancelled or ending early. Conclusions: The remote exam device was successfully integrated into a complex care clinic. Data from this pilot study supports the usability and feasibility of deploying a remote exam device across a telemedicine platform in a busy and complex outpatient academic practice.

Development and evaluation of a pediatric hospital medicine board review course.

BACKGROUND: The American Board of Medical Specialties recognized Pediatric Hospital Medicine (PHM) for subspecialty certification in 2016, with the first certification exam in 2019. To address the need for exam preparatory materials, we designed and evaluated a novel PHM board review course that was offered both in-person and online. METHODS: Course content was based on the American Board of Pediatrics (ABP) PHM certifying exam outline. Course objectives were developed from published PHM core competencies and the 2012 ABP general pediatrics content objectives. National experts served as faculty, presenting didactic sessions, and contributing to a question bank for high-yield review. For program evaluation, we applied the Kirkpatrick Model, evaluating estimated exam pass rates (Level 4), participant learning (Level 2) via post-presentation practice questions, and participants' ratings of presenters (via five-point Likert scale) and satisfaction (Level 1). RESULTS: There were 112 in-person and 144 online participants with estimated pass rates of 89 and 93%, respectively. The mean correct response for the post-presentation knowledge questions was 84%. Faculty effectiveness ratings ranged from 3.81 to 4.96 (median score 4.60). Strengths included the pace of the course, question bank, and printed syllabus. Suggestions for improvement included question bank expansion, focus on "testable" points rather than general information, and challenges with long days of didactic presentations. CONCLUSIONS: This novel PHM board review course demonstrated effectiveness. Hospitalists preferred focused "testable" information, an active learning environment, and a robust question bank. Future preparatory courses should consider including more opportunities for practice questions, focused content review, and learner engagement.

Closer to Home: A Quality Improvement Initiative to Optimize Satellite Site Bed Capacity.

BACKGROUND: The coronavirus disease 2019 pandemic resulted in the underutilization of inpatient beds at our satellite location. A lack of clarity and standardized admission criteria for the satellite led to frequent transfers to the main campus, resulting in patients traveling larger distances to receive inpatient care. We sought to optimize inpatient resource use at the satellite campus and keep patients "closer to home" by admitting eligible patients to that inpatient unit (LA4). Our aim was to increase bed capacity use at the satellite from 45% to 70% within 10 months. Our process measure was to increase the proportion of patients needing hospitalization who presented to the satellite emergency department (ED) and were then admitted to LA4 from 76% to 85%. METHODS: A multidisciplinary team used quality improvement methods to optimize bed capacity use. Interventions included (1) the revision and dissemination of satellite admission guidelines, (2) steps to create shared understanding of appropriate satellite admissions between ED and inpatient providers, (3) directed provider feedback on preventable main campus admissions, and (4) consistent patient and family messaging about the potential for transfer. Data were collected via chart review. Annotated run charts were used to assess the impact of interventions over time. RESULTS: Average LA4 bed capacity use increased from 45% to 69%, which was sustained for 1 year. The average percentage of patients admitted from the satellite ED to LA4 increased from 76% to 84%. CONCLUSIONS: We improved bed capacity use at our satellite campus through transparent admission criteria and shared mental models of patient care needs between ED and inpatient providers.

Impact of a Remote Virtual Reality Curriculum Pilot on Clinician Conflict Communication Skills.

OBJECTIVES: Conflict management skills are essential for interprofessional team functioning, however existing trainings are time and resource intensive. We hypothesized that a curriculum incorporating virtual reality (VR) simulations would enhance providers' interprofessional conflict communication skills and increase self-efficacy. METHODS: We conducted a randomized controlled pilot study of the Conflict Instruction through Virtual Immersive Cases (CIVIC) curriculum among inpatient clinicians at a pediatric satellite campus. Participants viewed a 30-minute didactic presentation on conflict management and subsequently completed CIVIC (intervention group) or an alternative VR curriculum on vaccine counseling (control group), both of which allowed for verbal interactions with screen-based avatars. Three months following VR training, all clinicians participated in a unique VR simulation focused on conflict management that was recorded and scored using a rubric of observable conflict management behaviors and a Global Entrustment Scale (GES). Differences between groups were evaluated using generalized linear models. Self-efficacy was also assessed immediately pre, post, and 3 months postcurriculum. Differences within and between groups were assessed with paired independent and 2-sample t-tests, respectively. RESULTS: Forty of 51 participants (78%) completed this study. The intervention group (n = 17) demonstrated better performance on the GES (P = .003) and specific evidence-based conflict management behaviors, including summarizing team member's concerns (P = .02) and checking for acceptance of the plan (P = .02), as well as statistical improvements in 5 self-efficacy measures compared with controls. CONCLUSIONS: Participants exposed to CIVIC demonstrated enhanced conflict communication skills and reported increased self-efficacy compared with controls. VR may be an effective method of conflict communication training.

Qualitative Analysis of a Virtual Near-Peer Pediatric Boot Camp Elective.

Objective: To explore fourth-year medical students' experience with a virtual, near-peer facilitated pediatric boot camp through the lens of self-determination theory (SDT). Methods: We developed a virtual pediatric boot camp elective for fourth-year medical students pursuing pediatric residency using Kern's six steps of curriculum development. The two-week virtual elective consisted of facilitated video conferences and small group discussions led by two senior pediatric residents. Semi-structured focus groups were conducted after elective completion. Using SDT as our conceptual framework, we explored participants' experience with the near-peer facilitation of the boot camp. Focus group recordings were transcribed and thematically analyzed using deductive coding for SDT, with inductive coding for themes outside the theory's scope. Saturation was reached after three focus groups. The codebook was iteratively revised through peer debriefing between coders and reviewed by other authors. Credibility was established through member checking. Results: Ninety-two percent of eligible medical students (n = 23/25) participated in the boot camp with attendance ranging from 18-21 students per session. Twelve students (52%) participated in three focus groups. Qualitative analysis identified five major themes. Four themes consistent with SDT emerged: competence, autonomy, relatedness to near-peers, and relatedness to specialty/institution. The learning environment, including the virtual setting, emerged as an additional, non-SDT-related theme. Conclusions: Medical students' experience with our virtual boot camp closely aligned with SDT. Near-peer relatedness emerged as a unique theme which could be further investigated in other aspects of medical student education. Future research could evaluate higher-level learning outcomes from near-peer educational opportunities. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-021-01466-w.

Building a doctor, one skill at a time: Rethinking clinical training through a new skills-based feedback modality.

The Accreditation Council for Graduate Medical Education milestones and entrustable professional activities (EPAs) are important assessment approaches but may lack specificity for learners seeking improvement through daily feedback. As in other professions, clinicians grow best when they engage in deliberate practice of well-defined skills in familiar contexts. This growth is augmented by specific, actionable coaching from supervisors. This article proposes a new feedback modality called microskills, which are derived from the psychology, negotiation, and business literature, and are unique in their ability to elicit targeted feedback for trainee development. These microskills are grounded in both clinical and situational contexts, thereby mirroring learners' cognitive schemas and allowing for more natural skill selection and adoption. When taken as a whole, microskills are granular actions that map to larger milestones, competencies, and EPAs. This article outlines the theoretical justification for this new skills-based feedback modality, the methodology behind the creation of clinical microskills, and provides a worked example of microskills for a pediatric resident on a hospital medicine rotation. Ultimately, microskills have the potential to complement milestones and EPAs and inform feedback that is specific, actionable, and relevant to medical learners.

Nurse/Resident Reciprocal Shadowing to Improve Interprofessional Communication.

OBJECTIVES: Poor communication is a major contributor to sentinel events in hospitals. Suboptimal communication between physicians and nurses may be due to poor understanding of team members' roles. We sought to evaluate the impact of a shadowing experience on nurse-resident interprofessional collaboration, bidirectional communication, and role perceptions. METHODS: This mixed-methods study took place at 2 large academic children's hospitals with pediatric residency programs during the 2018-2019 academic year. First-year residents and nurses participated in a reciprocal, structured 4-hour shadowing experience. Participants were surveyed before, immediately after, and 6 months after their shadowing experience by using an anonymous web-based platform containing the 20-item Interprofessional Collaborative Competency Attainment Survey, as well as open-ended qualitative questions. Quantitative data were analyzed via linear mixed models. Qualitative data were thematically analyzed. RESULTS: Participants included 33 nurses and 53 residents from the 2 study sites. The immediate postshadowing survey results revealed statistically significant improvements in 12 Interprofessional Collaborative Competency Attainment Survey question responses for nurses and 19 for residents (P ≤ .01). Subsequently, 6 questions for nurses and 17 for residents revealed sustained improvements 6 months after the intervention. Qualitative analysis identified 5 major themes related to optimal nurse-resident engagement: effective communication, collaboration, role understanding, team process, and patient-centered. CONCLUSIONS: The reciprocal shadowing experience was associated with an increase in participant understanding of contributions from all interprofessional team members. This improved awareness may improve patient care. Future work may be conducted to assess the impact of spread to different clinical areas and elucidate patient outcomes that may be associated with this intervention.

Screening for Social Determinants of Health in Hospitalized Children.

OBJECTIVES: Outpatient screening for social determinants of health (SDH) improves patient access to resources. However, no studies have examined if and how inpatient pediatric providers perform SDH screening. We aimed to identify inpatient pediatric provider screening practices for SDH, barriers to screening, and the acceptability of screening for hospitalized patients. METHODS: We conducted a multicenter descriptive study at 4 children's hospitals surveying inpatient hospitalists and nurses on the general wards about their SDH screening practices. A survey instrument was developed on the basis of literature pertaining to SDH, content expert review, cognitive interviews, and survey piloting. Descriptive statistics and logistic regression analyses are reported. RESULTS: Results from 146 hospitalists and 227 nurses were analyzed (58% and 26% response rate, respectively). Twenty-nine percent of hospitalists and 41% of nurses reported screening for ≥1 SDH frequently or with every hospitalized patient. Only 26% of hospitalists reported consistently communicating SDH needs with primary care providers. Most respondents (97% of hospitalists and 65% of nurses) reported they do not use a specific screening tool, and only 34% of hospitalists and 32% of nurses reported feeling competent screening for SDH. Lack of time, resources, and a standardized inpatient screening tool were reported as barriers to screening. CONCLUSIONS: Hospitalization provides an opportunity for SDH screening and connecting patients to resources; however, a minority of pediatric providers currently report screening. Professional development activities training inpatient providers in SDH screening, using a screening instrument, and communicating identified needs to primary care providers may improve the effectiveness of SDH screening in the hospital.

Challenges Following Hospital Discharge for Children With Medical Complexity.

OBJECTIVES: The transition from hospital to home is a period of risk, particularly for children with medical complexity. Our aim was to identify and address discharge challenges through execution of postdischarge phone calls. METHODS: In this prospective study, we designed and executed a postdischarge phone call for patients discharged from an inpatient complex care team between May and November 2018. The call included dichotomous and open-ended questions to identify challenges regarding health status, follow-up appointments, medications, home nursing, medical supplies and/or equipment, and discharge instructions. These were recorded in the electronic health record. Details regarding identified challenges and corrective actions were categorized by 2 reviewers and adjudicated by a third reviewer if disagreement occurred. RESULTS: Descriptive statistics were used to summarize these findings. Sixty-seven phone calls were completed within 1 week of discharge. Two-thirds of calls identified at least 1 challenge, and more than one-third of calls identified 2 or more challenges for a total of 90 challenges. The most common challenges involved health status (26.7%), follow-up appointments (21.1%), and medications (20%). The majority of challenges were addressed by either caregivers or the multidisciplinary team, with the exception of home nursing challenges. CONCLUSIONS: Discharge challenges were commonly identified by caregivers of children with medical complexity. The majority of postdischarge challenges were addressed, with some addressed by families themselves. These results can inform health care providers about challenges to anticipate and suggest future interventions to mitigate anticipated challenges for a safe discharge and transition of care for these at-risk patients.

Improving the Transition of Intravenous to Enteral Antibiotics in Pediatric Patients with Pneumonia or Skin and Soft Tissue Infections.

BACKGROUND: Despite national recommendations for early transition to enteral antimicrobials, practice variability has existed at our hospital. OBJECTIVE: The aim of this study was to increase the proportion of enterally administered antibiotic doses for Pediatric Hospital Medicine patients aged >60 days admitted for uncomplicated community-acquired pneumonia or skin and soft tissue infections from 44% to 75% in eight months. METHODS: This quality improvement study was conducted at a large, urban, academic children's hospital. The study population included Hospital Medicine patients aged >60 days with diagnoses of pneumonia or skin and soft tissue infections. Interventions included education on intravenous and enteral antibiotic charge differentials, documentation of transition plan, structured discussions of transition criteria, and real-time identification of failures with feedback. Our process measure was the total number of enteral antibiotic doses divided by all antibiotic doses in patients receiving enteral medications on the same day. An annotated statistical process control chart tracked the impact of interventions on the administration route of antibiotic doses over time. Additional outcome measures included antimicrobial costs per patient encounter using average wholesale prices and length of stay. RESULTS: The percentage of enterally administered antibiotic doses increased from 44% to 80% within eight months. Antimicrobial costs per patient encounter and the associated standard deviation of costs for our target diagnoses decreased by 70% and 84%, respectively. Average length of stay did not change. CONCLUSIONS: Standardized communication about criteria for transition from intravenous to enteral antibiotics can lead to earlier transitions for patients with pneumonia or skin and soft tissue infections, subsequently reducing costs and prescribing variability.

Pathways to Publication in Pediatric Hospital Medicine Educational Research.

OBJECTIVES: Dissemination of rigorous, innovative educational research is key to inform best practices among the global medical education community. Although abstract presentation at professional conferences is often the first step, journal publication maximizes impact. The current state of pediatric hospital medicine (PHM) educational scholarship dissemination via journal publication has not been well described. To describe educational research dissemination after PHM conference abstract submission, we identified the publication rate, median time to publication, and median publishing journal impact factor of abstracts submitted over 4 years. METHODS: Abstract data were obtained from the 2014-2017 PHM conferences and organized by presentation type (oral, poster, rejected). PubMed, MedEdPORTAL, and Google Scholar were queried for abstract publication evidence. We used logistic regression models, Kaplan-Meier survival curves and Kruskal-Wallis tests to determine the association of presentation type with the odds of publication, time to publication, and publishing journal impact factors. RESULTS: Of 173 submitted educational research abstracts, 56 (32%) were published. Oral abstracts had threefold greater and fivefold greater odds of publication compared to poster and rejected abstracts, respectively (odds ratio 3.2; 95% confidence interval 1.3-8.0; P = .011; odds ratio 5.2; 95% confidence interval 1.6-16.7; P = .003). Median time to publication did not differ between presentation types. The median journal impact factor was >2 times higher for published oral and poster abstracts than published rejected abstracts. CONCLUSIONS: Because abstract acceptance and presentation type may be early indicators of publication success, abstract submission to the PHM conference is a reasonable first step in disseminating educational scholarship.

Promoting interdisciplinary shared mental models.

BACKGROUND: Emergency Medicine (EM) and Hospital Medicine (HM) providers frequently interact when transitioning patients from the emergency department (ED) to the inpatient unit; however, there is infrequent collaboration between these subspecialties, and effective communication in EM-HM provider handover is an area for improvement. Shared mental models can enhance communication and safety. The purpose of this article is to describe the implementation of an interdisciplinary conference to allow providers to create shared mental models, and to assess the impact on attitudes and behaviours towards communication and collaboration outside the competing attentions of patient care environments. METHODS: The authors instituted a quarterly interactive case-based conference at an academic tertiary care children's hospital in which EM and HM subspecialty trainees co-facilitate evidence-based interactive presentations of clinical, diagnostic or management dilemmas. The conferences were evaluated via repeated cross-sectional surveys of EM and HM providers, as well as session evaluations. Surveys included multiple-choice, Likert-scale and free-text responses to assess the degree of interaction and collaboration between the divisions and provider attitudes toward changes in clinical practice. RESULTS: Assessment of the EM-HM collaborative conferences demonstrated trends towards increased interaction between divisions and increased discussion about management decisions among colleagues. Two-thirds of individuals who attended at least one conference felt that having attended an interdisciplinary conference influenced future management decisions. Effective communication in EM-HM provider handover is an area for improvement CONCLUSIONS: Interdisciplinary conferences provide a forum for cross-specialty communication to discuss management differences in a low-stress educational environment, and allow providers to develop shared mental models for effective, safe patient care.

Improving Efficiency of Pediatric Hospital Medicine Team Daily Workflow.

BACKGROUND AND OBJECTIVES: Workflow inefficiencies by medical teams caring for hospitalized patients may affect patient care and team experience. At our institution, complexity and clinical volume of the pediatric hospital medicine (HM) service have increased over time; however, efficient workflow expectations were lacking. We aimed to increase the percentage of HM teams meeting 3 efficiency criteria (70% nurses present for rounds, rounds completed by 11:30 am, and HM attending notes completed by 5 pm) from 28% to 80% within 1 year. METHODS: Improvement efforts targeted 5 HM teams at a large academic hospital. Our multidisciplinary team, including HM attending physicians, pediatric residents, and nurses, focused on several key drivers: shared expectations, enhanced physician and nursing buy-in and communication, streamlined rounding process, and data transparency. Interventions included (1) daily rounding expectations with prerounds huddle, (2) visible reminders, (3) complex care team scheduled rounds, (4) real-time nurse notification of rounds via electronic platform, (5) workflow redesign, (6) attending feedback and data transparency, and (7) resource attending implementation. Attending physicians entered efficiency data each day through a Research Electronic Data Capture survey. Annotated control charts were used to assess the impact of interventions over time. RESULTS: Through sequential interventions, the percentage of HM teams meeting all 3 efficiency criteria increased from 28% to 61%. Nursing presence on rounds improved, and rounds end time compliance remained high, whereas attending note completion time remained variable. CONCLUSIONS: Inpatient workflow for pediatric providers was improved by setting clear expectations and enhancing team communication; competing demands while on service contributed to difficulty in improving timely attending note completion.

A Faculty Development Workshop for High-Value Care Education Across Clinical Settings.

Introduction: Despite rising health care costs, trainees frequently do not receive formal high-value care (HVC) training. As medical education often occurs through informal learning, it is imperative that medical educators be prepared to teach HVC concepts across clinical settings. Methods: This workshop was created to provide frameworks for teaching HVC across four pediatric educational settings: (1) case-based conferences, (2) inpatient rounding, (3) ambulatory visits, and (4) conversations with patients and families. Frameworks were developed based on literature review, content experts' knowledge, and internal assessment and feedback. The workshop was divided into two sections: a didactic overview of HVC education and interactive small-group sessions to practice application of the Toolkit for Teaching High-Value Care. At the end of the workshop, participants completed the Prescription for High-Value Care to create a personal action plan. Results: This workshop has been presented at both national and local pediatric conferences. From over 89 evaluations (83% response rate), participants felt the workshop met objectives, served as a valuable use of their time, and provided useful resources. Evaluations elicited specific actions that participants gleaned from workshop content along with proposed behavior changes, such as creating HVC case-based conferences at their home institution and initiating more value-based discussions. Discussion: This workshop has been successfully presented in both national and local settings and has been well received by participants. The workshop is targeted for clinical educators and aims to address the gap in faculty development for HVC education.

Teaching High-Value Care: Case Vignettes for Pediatric Practice.

Introduction: As health care systems recognize the importance of high-value care (HVC), physicians must focus on individualized patient outcomes using economically responsible and evidence-based medicine. The best ways to teach medical trainees HVC principles that can result in meaningful practice and behavior changes are unknown. Methods: We designed a case-based curriculum mapping six common pediatric clinical scenarios to HVC principles. Each scenario included learning objectives, small-group activities, educational resources, a facilitator guide, and participant evaluations. After internal and external review, the scenarios were piloted at four teaching institutions (Children's Hospital Los Angeles, Johns Hopkins All Children's Hospital, Seattle Children's Hospital, and Texas Children's Hospital). Facilitators were encouraged to adapt each vignette to learner needs and site-specific conference characteristics. All participants were asked to complete anonymous case-specific evaluations at the end of each session. Results: Approximately 331 individuals (students, residents, attendings) participated, with an evaluation response rate of 76% (n = 253). Participants across all sites acknowledged the sessions as a valuable use of time (range: 4.2-4.6 on a 5-point Likert scale) and identified HVC principles that could be applied daily in clinical practice (range: 4.4-4.6). Discussion: Implementation of six case-based HVC vignettes at four pilot institutions was both feasible and well received by a diverse group of learners. The curriculum was perceived as valuable and applicable to learners' clinical practice. Next steps include longitudinal assessments of learners and the development of tools measuring HVC-related behaviors to understand better the impact of the curriculum on clinical practice.

Development and Evaluation of High-Value Pediatrics: A High-Value Care Pediatric Resident Curriculum.

Low-value health care is pervasive in the United States, and clinicians need to be trained to be stewards of health care resources. Despite a mandate by the Accreditation Council for Graduate Medical Education to educate trainee physicians on cost awareness, only 10% of pediatric residency programs have a high-value care (HVC) curriculum. To meet this need, we set out to develop and evaluate the impact of High-Value Pediatrics, an open-access HVC curriculum. High-Value Pediatrics is a 3-part curriculum that includes 4 standardized didactics, monthly interactive morning reports, and an embedded HVC improvement project. Curriculum evaluation through an anonymous, voluntary survey revealed an improvement in the self-reported knowledge of health care costs, charges, reimbursement, and value (P < .05). Qualitative results revealed self-reported behavior changes, and HVC improvement projects resulted in higher-value patient care. The implementation of High-Value Pediatrics is feasible and reveals improved knowledge and attitudes about HVC. HVC improvement projects augmented curricular knowledge gains and revealed behavior changes. It is imperative that formal high-value education be taught to every pediatric trainee to lead the culture change that is necessary to turn the tide against low-value health care. In addition, simultaneous work on faculty education and attention to the hidden curriculum of low-value care is needed for sustained and long-term improvements.

The Pipeline From Abstract Presentation to Publication in Pediatric Hospital Medicine.

BACKGROUND: The annual Pediatric Hospital Medicine (PHM) conference serves as a venue for the dissemination of research in this rapidly growing discipline. A measure of research validity is subsequent publication in peer-reviewed journals. OBJECTIVE: To identify the publication rate of abstracts submitted to the 2014 PHM conference and determine whether presentation format was associated with subsequent journal publication or time to publication. METHODS: We identified abstracts submitted to the 2014 PHM conference. Presentation formats included rejected abstracts and poster and oral presentations. Abstracts subsequently published in journals were identified by searching the author and abstract title in PubMed, MedEdPORTAL, and Google Scholar. We used logistic regression and Cox proportional hazards models to determine if presentation format was associated with publication, time to publication, and publishing journal impact factor. RESULTS: Of 226 submitted abstracts, 19.0% were rejected, 68.0% were selected for posters, and 12.8% were selected for oral presentations; 36.3% were subsequently published within 30 months after the conference. Abstracts accepted for oral presentation had more than 7-fold greater odds of publication (adjusted odds ratio 7.8; 95% confidence interval [CI], 2.6-23.5) and a 4-fold greater likelihood of publication at each month (adjusted hazard ratio 4.5; 95% CI, 2.1-9.7) compared with rejected abstracts. Median journal impact factor was significantly higher for oral presentations than other presentation formats (P < 0.01). CONCLUSIONS: Abstract reviewers may be able to identify methodologically sound studies for presentation; however, the low overall publication rate may indicate that presented results are preliminary or signify a need for increased mentorship and resources for research development in PHM.