The Rounds Efficiency Index: A Novel Physics-Based Construct for Patient- and Family-Centered Rounds.

BACKGROUND AND OBJECTIVES: Efficiently conducting patient- and family-centered rounds (PFCR) is challenging, particularly without a measure of efficiency. In physics, efficiency is the ratio of work output to work input. We sought to evaluate PFCR efficiency via a novel construct rooted in physics. Our objectives were to (1) Establish baseline work output for clinical work (CW), educational effectiveness (EE), and family experience (FE); (2) establish baseline work input for rounds length (RL); and (3) begin preliminary construction of a rounds efficiency index (REI) as a measure of PFCR efficiency. METHODS: Four components of rounds efficiency were collected on 5 inpatient acute care teams during a baseline period. CW consisted of the percentage of daily orders placed on rounds. EE was assessed via survey for trainees and FE by families. RL was recorded in minutes per patient. During an 8-week intensive period, the REI (reported as %) was calculated as a ratio of work output/work input using aggregate mean/median ratings for CW, EE, FE, and RL. RESULTS: Baseline data included 809 orders, 28 EE ratings, 21 FE ratings, and RL mean of 11.4 minutes per patient. During the intensive period, the median team-specific weekly REI for the end versus beginning of the academic year was 58% and 52.5% (P = .17), respectively. The median REI during the start and end of the block was 49% and 57% (P = .15), respectively. CONCLUSIONS: The study assessed 4 components of efficiency (CW, EE, FE, RL) and calculated REI allowing for a preliminary tool to measure rounding efficiency. With this, targeted interventions can improve PFCR efficiency.

Six Year Old With Chronic Headache: An Unexpected Meningitis Mimic.

The constellation of fevers accompanied by headache and vomiting is a red flag for clinicians that appropriately triggers evaluation for meningitis and other life-threatening diagnoses. When symptoms persist even after these conditions are ruled out, patient care becomes more challenging. We present the case of a 6-year-old male with a history of autism spectrum disorder who presented with 6 months of headaches and associated vomiting and intermittent fevers with negative infectious workup despite cerebrospinal fluid pleocytosis. Serial neuroimaging and laboratory evaluation ultimately led to a diagnosis of myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) presenting as aseptic meningitis. The clinical and radiographic findings of MOGAD are widely variable and overlap with several other inflammatory conditions, which makes diagnosis challenging. This case highlights the importance of recognizing this rare MOGAD presentation as an infectious meningitis mimic.

Imaging Practices and Implications in Young Infants With Urinary Tract Infection.

OBJECTIVES: Management of infants aged ≤60 days with urinary tract infections (UTI) is challenging. We examined renal imaging in infants aged ≤60 days with UTI at a tertiary care children's hospital to identify the impact of standardizing renal ultrasound (RUS) interpretation. METHODS: We retrospectively studied infants aged ≤60 days hospitalized for UTI or fever with urine culture and renal imaging obtained and final diagnosis of UTI. RUS initially had noncriterion-based (NCB) interpretation by experienced pediatric radiologists. For this study, a single pediatric radiologist used a criterion-based (CB) hydronephrosis grading system to reinterpret films initially classified as "abnormal" on the NCB reading. We compared final renal imaging results between NCB and CB groups. RESULTS: Of 193 infants, 180 (93%) had inpatient RUS with 114 (63%) abnormal NCB interpretation. Of those with initially abnormal NCB interpretation, 85 OF 114 (75%) had minor and 29 OF 114 (25%) had significant abnormality by CB reinterpretation. In follow-up, the CB "minor abnormality" group showed 25% abnormal renal imaging, whereas the "significant abnormality" group showed 77% abnormal renal imaging with 54% having high-grade reflux on a voiding cystourethrogram (VCUG). Patients with CB inpatient RUS minor abnormality showed 3% abnormal RUS at follow-up, but 13% showed high-grade reflux on VCUG. CONCLUSIONS: Standardized RUS interpretation in young infants with UTI improved the accuracy of identification of abnormalities on follow-up renal imaging. In patients with CB minor abnormality on inpatient RUS, our results suggest limited utility of follow-up RUS; however, follow-up VCUG remained useful to identify high-grade reflux.

Use of Peer- and Self-Evaluation to Improve Conversations with Interfacility Referring Clinicians.

INTRODUCTION: Pediatric hospital medicine physicians receive little formal training in communicating with interfacility referring clinicians. We sought to improve pediatric hospital medicine physician confidence and communication scores by 10% during patient triage calls from interfacility referring providers via a continuing professional development initiative. METHODS: We conducted a single-center 10-month quality improvement project. Confidence was assessed via survey before and after the initiative. A novel self- and peer-evaluation tool was used to assess accepting pediatric hospital medicine physician communication on recorded calls. Call assessment scores were measured at baseline, cycle 1, and cycle 2. Interventions included group discussion and development of a scripting flowsheet. RESULTS: Twenty pediatric hospital medicine physicians participated and completed a total of 203 call assessments. From baseline to post-initiative, general confidence communicating with referring clinicians increased by 13% (mean ranks 11.8, 16.8, respectively), and specific confidence communicating when there is a difference of opinion increased significantly by 37% (mean ranks 9.8, 19.2, P < 0.001). Interfacility transfer conversation evaluation scores increased by 11%. DISCUSSION: Our initiative improved accepting physician's confidence and communication evaluation scores using self- and peer-evaluation, group reflection, and a scripting flowsheet. Self- and peer-evaluation of recorded calls can be an effective intervention for building physician confidence in communicating with referring clinicians.

Developing Validity Evidence for a Patient- and Family-Centered Rounds Presenter Empowerment Action Rating Tool.

BACKGROUND: Training in patient- and family-centered care is endorsed by the American Academy of Pediatrics (AAP) and the Accreditation Council for Graduate Medical Education (ACGME) for learners. The AAP recommends patient- and family-centered rounds (PFCR) during inpatient care. The PEA-21 (21-item Presenter Empowerment Action checklist) was developed to evaluate presenter behavior during PFCR. OBJECTIVE: To gather validity evidence for the PEA-21 in evaluating third year medical student and intern presentations during PFCR in the domains of Data Accuracy, Communication Skills, Assessment and Plan Formation, and Family Interaction. METHODS: A 24-month prospective cohort study of students and interns presenting on PFCR. Content, response process, internal structure, and relationship with other variables were assessed. RESULTS: Data were collected from 101 rounds (758 individual patient encounters), both on pediatric subspecialty and hospital medicine teams. Presenters included third- and fourth-year medical students and interns in pediatrics, internal medicine-pediatrics, and family-medicine. Intraclass correlations between observers ranged from 0.5 to 0.72. Internal consistency showed α >0.7 for 3 of 4 domains. Interns scored higher than students across domains (P< .01), but students' scores improved throughout their rotations (d = 0.2-0.8). Both groups performed lowest in the Family Interaction Domain. CONCLUSIONS: The PEA-21 showed strong validity properties including content, response process, internal structure, and relationship with other variables and can be used by educators to assess learners' skill levels and provide formative feedback to both medical students and interns. Targeted efforts are needed to improve skills within the Family Interaction Domain for both medical students and interns.

Urinary Tract Infection in Young Infants: Practice Patterns in Evaluation and Treatment.

OBJECTIVES: No clear guidelines exist for the management of infants ≤60 days old with urinary tract infection (UTI), although this condition represents a significant percentage of serious bacterial infection in this age group. We examined patterns of UTI management in infants ≤60 days at a tertiary care children's hospital and hypothesized that younger infants would be hospitalized longer. METHODS: We reviewed electronic health records of infants age ≤60 days with diagnostic codes of UTI or fever hospitalized from January 2013 to January 2017 with urine culture obtained and UTI diagnosis documented. Outcomes were duration of parenteral antibiotic therapy, length of stay (LOS), and hospital readmission. RESULTS: One hundred ninety-three infants met criteria. Median age at admission was 37 days (interquartile range [IQR]: 22-48). Median duration of parenteral antibiotics was 59 hours (IQR 43-114) and median LOS was 71 hours (IQR 57 127). Infants age ≤28 days, with fever duration ≥24 hours, irritability or lethargy on initial examination, and bacteremia received longer parenteral therapy and had longer LOS. In multivariate analysis, age, irritability or lethargy, and presence of bacteremia remained independently related to parenteral therapy duration and LOS. CONCLUSIONS: In young infants with UTI, patients aged ≤28 days had longer duration of IV antibiotic therapy and LOS, independent of other clinical characteristics of their illness. The duration of parenteral therapy and LOS was relatively short, although significant variability still existed.

Factors Associated With HSV PCR CSF Testing and Empiric Acyclovir Therapy in Young Febrile Infants.

Herpes simplex virus (HSV) infection in infants is a devastating disease with an often subtle presentation. We examined cerebrospinal fluid (CSF) HSV PCR (polymerase chain reaction) testing and empiric acyclovir therapy in young febrile infants. Chart review identified hospitalized infants aged ≤60 days with fever ≥38°C who had undergone lumbar puncture. Previously published criteria were used to define patients at high risk for HSV. Primary outcomes were CSF HSV PCR testing and empiric acyclovir therapy. Of 536 febrile infants, 23% had HSV testing; empiric acyclovir was started in 15%. HSV testing and therapy were associated with younger age, seizure, maternal vaginal lesions, postnatal HSV contact, vesicles, poor tone, CSF pleocytosis, and enteroviral testing. Sixty-two percent of high-risk infants did not undergo HSV testing, and 75% did not receive acyclovir. High-risk infants were untested and untreated at relatively high rates. Evidence-based criteria to guide HSV testing and treatment are needed.

Teaching Inpatient Bedside Presenter Empowerment Actions During an Interactive Workshop.

Introduction: Medical students and interns are the principal communicators during inpatient bedside patient- and family-centered rounds. Excellent presenters are able to share information during rounds in a manner that is accurate, effective, and easy for all to understand. We previously identified the behaviors of excellent presenters and developed a term for them: presenter empowerment actions. Methods: To promote the use of presenter empowerment actions, an interactive workshop was created to teach them to medical students and interns. This educational summary contains information on how to facilitate a workshop to promote presenter empowerment actions, which includes both a didactic presentation and an interactive game. Results: Interns reported increases in confidence and knowledge of empowerment actions, as well as strong intent to incorporate presenter empowerment actions during inpatient rounds. Discussion: A workshop with an interactive game is an effective way to teach empowerment actions to learners. To reinforce presenter empowerment action use after the workshop, we recommend direct observation using the Suspected Observable Presenter Empowerment Action Checklist to provide formative feedback to the presenters.