Effects of an Experiential Learning Curriculum on Systems-Thinking.

Introduction: Though health systems science (HSS) is referred to as the third pillar of medical education along with the pillars of basic science and clinical care, the effects of learning theories used to teach components of HSS including quality improvement/ patient safety (QI/PS), are poorly understood. Experiential learning theory is often referenced in QI/ PS education but its effects on QI/PS education are not well-described. Objective: To examine the effects of teaching QI using experiential learning theory on resident systems-thinking. Methods: Data was gathered from 30 resident participants in a 3-h QI workshop designed using experiential learning theory. Using a mixed-methods design, aspects of learner systems-thinking were analyzed both before and after the workshop. Learners were asked about their confidence in systems-thinking behaviors, and their QI plans were evaluated qualitatively for themes as well as quantitatively via the QIKAT-R. Results: There was a significant increase in self-reported confidence in systems-thinking behaviors post-workshop. Odds ratio of the QI aim statement focusing on the systems-level of the problem after the workshop was 41.4 with a 95% CI of 8.9142 to 192.2721, p-value .0001. Thematic analysis of QI plans revealed a change in residents' thinking about healthcare problems. They shifted from attributing problems to individual actors to thinking about the problem as lying in the interaction between systems. Conclusion: Experiential learning theory can be an effective framework for QI to transform learners into systems-thinkers.

Supporting Breastfeeding in Infants Hospitalized for Jaundice.

BACKGROUND: Infants readmitted for neonatal hyperbilirubinemia requiring phototherapy are less likely to exclusively breastfeed than infants who are not readmitted for phototherapy. Our aim for this study was to increase breastfeeding exclusivity for infants admitted for neonatal hyperbilirubinemia. METHODS: Using the Model for Improvement, we conducted 3 plan-do-study-act cycles to improve exclusive breastfeeding (EB). Our outcome measure was to increase the percentage of EB for infants hospitalized for phototherapy from 30% to 80% in 12 months. Our process measure was to increase lactation consultations from 60% to 80%. Balancing measures included the development of >10% weight loss, acute bilirubin encephalopathy, readmissions, and length of stay. Interventions involved staff breastfeeding education, automated orders for lactation consultations, and use of bilirubin blankets during breastfeeding. Data were analyzed by using run charts and statistical process control. RESULTS: A total of 92 infants with neonatal hyperbilirubinemia were admitted from December 2016 to August 2019, with 61 in the postintervention period. After implementation of an automated order for lactation consultation, EB improved from 30% to 60% and completed lactation consultations increased from 60% to 90%. Infants who received a lactation consultation within the first shift during their hospitalization were 4 times more likely to have EB during hospitalization than infants who did not (odds ratio 3.8; confidence interval: 1.17-12.39.) No infant experienced >10% weight loss, acute bilirubin encephalopathy, or a readmission, and length of stay did not significantly change. CONCLUSIONS: Early involvement of trained lactation consultants safely improves rates of EB for infants hospitalized with neonatal hyperbilirubinemia.

Up-regulation of the progesterone receptor (PR)-C isoform in laboring myometrium by activation of nuclear factor-kappaB may contribute to the onset of labor through inhibition of PR function.

Progesterone acting via the progesterone receptor (PR) plays a critical role in maintaining uterine quiescence during pregnancy. In the present study, we tested the hypothesis that the transactivating capability of the PR is down-regulated in the myometrium at term by a change in uterine PR isoform ratio resulting from local activation of the nuclear factor (NF)-kappaB pathway. Overexpression of the truncated PR-C isoform in human myometrial cells inhibited PR-B transactivation. Expression of PR isoforms, PR-A, PR-B, and PR-C, was characterized by immunoblotting and quantitative PCR (Q-PCR) in fundal and lower uterine segment myometrium from pregnant women in labor and not in labor and in the pregnant mouse uterus during late gestation. We observed a marked increase in levels of PR-C and transcriptionally active PR-B specifically in fundal myometrium of women in labor. In pregnant mouse uterus, levels of PR-B and PR-C also increased between 15 days post coitum and term, whereas expression of PR-A was dramatically up-regulated at 19 days post coitum. In studies of uterine tissues of mice injected intraamniotically with surfactant protein A and of human myometrial and T47D breast cancer cells in culture, up-regulation of PR isoform expression was observed in response to activation of the NF-kappaB pathway. Chromatin immunoprecipitation analysis revealed IL-1beta induced binding of NF-kappaB to the PR promoter. Collectively, these findings suggest that up-regulation of inhibitory PR isoform expression by NF-kappaB activation in both laboring human fundus and pregnant mouse uterus near term may inhibit PR transactivation and thereby lead to a loss of uterine quiescence and the onset of labor.