Association Between Neighborhood Disadvantage and Pediatric Readmissions.

OBJECTIVE: Although individual-level social determinants of health (SDH) are known to influence 30-day readmission risk, contextual-level associations with readmission are poorly understood among children. This study explores associations between neighborhood disadvantage measured by Area Deprivation Index (ADI) and pediatric 30-day readmissions. METHODS: This retrospective cohort study included discharges of patients aged < 20 years from Maryland's 2013-2016 all-payer dataset. The ADI, which quantifies 17 indicators of neighborhood socioeconomic disadvantage within census block groups, is used as a proxy for contextual-level SDH. Readmissions were identified with the 30-day Pediatric All-Condition Readmissions measure. Associations between ADI and readmission were identified with generalized estimating equations adjusted for patient demographics and clinical severity (Chronic Condition Indicator [CCI], Pediatric Medical Complexity Algorithm [PMCA], Index Hospital All Patients Refined Diagnosis Related Groups [APR-DRG]), and hospital discharge volume. RESULTS: Discharges (n = 138,998) were mostly female (52.7%), publicly insured (55.1%), urban-dwelling (93.0%), with low clinical severity levels (0-1 CCIs [82.3%], minor APR-DRG severity [48.4%]). Overall readmission rate was 4.0%. Compared to the least disadvantaged ADI quartile, readmissions for the most disadvantaged quartile were significantly more likely (aOR 1.19, 95% CI 1.09-1.30). After adjustment, readmissions were associated with public insurance and indicators of medical complexity (higher number of CCIs, complex-chronic disease PMCA, and APR-DRG severity). CONCLUSION: In this all-payer, statewide sample, living in the most socioeconomically disadvantaged neighborhoods independently predicted pediatric readmission. While the relative magnitude of neighborhood disadvantage was modest compared to medical complexity, disadvantage is modifiable and thus represents an important consideration for prevention and risk stratification efforts.

Association of Patient Characteristics With Postoperative Mortality in Children Undergoing Tonsillectomy in 5 US States.

Importance: The rate of postoperative death in children undergoing tonsillectomy is uncertain. Mortality rates are not separately available for children at increased risk of complications, including young children (aged <3 y) and those with sleep-disordered breathing or complex chronic conditions. Objective: To estimate postoperative mortality following tonsillectomy in US children, both overall and in relation to recognized risk factors for complications. Design, Setting, and Participants: Retrospective cohort study based on longitudinal analysis of linked records in state ambulatory surgery, inpatient, and emergency department discharge data sets distributed by the Healthcare Cost and Utilization Project for 5 states covering 2005 to 2017. Participants included 504 262 persons younger than 21 years for whom discharge records were available to link outpatient or inpatient tonsillectomy with at least 90 days of follow-up. Exposures: Tonsillectomy with or without adenoidectomy. Main Outcome and Measures: Postoperative death within 30 days or during a surgical stay lasting more than 30 days. Modified Poisson regression with sample weighting was used to estimate postoperative mortality per 100 000 operations, both overall and in relation to age group, sleep-disordered breathing, and complex chronic conditions. Results: The 504 262 children in the cohort underwent a total of 505 182 tonsillectomies (median [IQR] patient age, 7 [4-12] years; 50.6% females), of which 10.1% were performed in young children, 28.9% in those with sleep-disordered breathing, and 2.8% in those with complex chronic conditions. There were 36 linked postoperative deaths, which occurred a median (IQR) of 4.5 (2-20.5) days after surgical admission, and most of which (19/36 [53%]) occurred after surgical discharge. The unadjusted mortality rate was 7.04 (95% CI, 4.97-9.98) deaths per 100 000 operations. In multivariable models, neither age younger than 3 years nor sleep-disordered breathing was significantly associated with mortality, but children with complex chronic conditions had significantly higher mortality (16 deaths/14 299 operations) than children without these conditions (20 deaths/490 883 operations) (117.22 vs 3.87 deaths per 100 000 operations; adjusted rate difference, 113.55 [95% CI, 51.45-175.64] deaths per 100 000 operations; adjusted rate ratio, 29.39 [95% CI, 13.37-64.62]). Children with complex chronic conditions accounted for 2.8% of tonsillectomies but 44% of postoperative deaths. Most deaths associated with complex chronic conditions occurred in children with neurologic/neuromuscular or congenital/genetic disorders. Conclusions and Relevance: Among children undergoing tonsillectomy, the rate of postoperative death was 7 per 100 000 operations overall and 117 per 100 000 operations among children with complex chronic conditions. These findings may inform decision-making for pediatric tonsillectomy.

Trends in Hospital Treatment of Empyema in Children in the United States.

OBJECTIVE: To evaluate trends in procedures used to treat children hospitalized in the US with empyema during a period that included the release of guidelines endorsing chest tube placement as an acceptable first-line alternative to video-assisted thoracoscopic surgery. STUDY DESIGN: We used National Inpatient Samples to describe empyema-related discharges of children ages 0-17 years during 2008-2014. We evaluated trends using inverse variance weighted linear regression and characterized treatment failure using multivariable logistic regression to identify factors associated with having more than 1 procedure. RESULTS: Empyema-related discharges declined from 3 in 100 000 children to 2 in 100 000 during 2008-2014 (P = .04, linear trend). There was no significant change in the proportion of discharges having 1 procedure (66.1% to 64.1%) or in the proportion having 2 or more procedures (22.1% to 21.6%). The proportion coded for video-assisted thoracoscopic surgery as the only procedure declined (41.4% to 36.2%; P = .03), and the proportions coded for 1 chest tube (14.6% to 20.9%; P = .04) and 2 chest tube procedures (0.9% to 3.5%; P < .01) both increased. The median length of stay for empyema-related discharges remained unchanged (9.3 days to 9.8 days; P = .053). Having more than 1 procedure was associated with continuous mechanical ventilation (adjusted OR, 2.7; 95% CI, 1.8-4.1) but not with age, sex, payer, chronic conditions, transfer admission, hospital size, or census region. CONCLUSIONS: The use of video-assisted thoracoscopic surgery to treat children in the US hospitalized with empyema seems to be decreasing without associated increases in length of stay or need for additional drainage procedures.

Thresholds and interpretations: How clinical competency committees identify pediatric residents with performance concerns.

BACKGROUND: Clinical competency committee (CCC) identification of residents with performance concerns is critical for early intervention. METHODS: Program directors and 94 CCC members at 14 pediatric residency programs responded to a written survey prompt asking them to describe how they identify residents with performance concerns. Data was analyzed using thematic analysis. RESULTS: Six themes emerged from analysis and were grouped into two domains. The first domain included four themes, each describing a path through which residents could meet or exceed a concern threshold:1) written comments from rotation assessments are foundational in identifying residents with performance concerns, 2) concerning performance extremes stand out, 3) isolated data points may accumulate to raise concern, and 4) developmental trajectory matters. The second domain focused on how CCC members and program directors interpret data to make decisions about residents with concerns and contained 2 themes: 1) using norm- and/or criterion-referenced interpretation, and 2) assessing the quality of the data that is reviewed. CONCLUSIONS: Identifying residents with performance concerns is important for their education and the care they provide. This study delineates strategies used by CCC members across several programs for identifying these residents, which may be helpful for other CCCs to consider in their efforts.

Disparities in COVID-19 vaccine intentions, testing and trusted sources by household language for children with medical complexity.

OBJECTIVES: Children with medical complexity experienced health disparities during the coronavirus disease 2019 (COVID-19) pandemic. Language may compound these disparities since people speaking languages other than English (LOE) also experienced worse COVID-19 outcomes. Our objective was to investigate associations between household language for children with medical complexity and caregiver COVID-19 vaccine intentions, testing knowledge, and trusted sources of information. METHODS: This cross-sectional survey of caregivers of children with medical complexity ages 5 to 17 years was conducted from April-June 2022. Children with medical complexity had at least 1 Complex Chronic Condition. Households were considered LOE if they reported speaking any language other than English. Multivariable logistic regression examined associations between LOE and COVID-19 vaccine intentions, interpretation of COVID-19 test results, and trusted sources of information. RESULTS: We included 1,338 caregivers of children with medical complexity (49% response rate), of which 133 (10%) had household LOE (31 total languages, 58% being Spanish). There was no association between household LOE and caregiver COVID-19 vaccine intentions. Caregivers in households with LOE had similar interpretations of positive COVID-19 test results, but significantly different interpretations of negative results. Odds of interpreting a negative test as expected (meaning the child does not have COVID-19 now or can still get the virus from others) were lower in LOE households (aOR [95% CI]: 0.56 [0.34-0.95]). Households with LOE were more likely to report trusting the US government to provide COVID-19 information (aOR [95% CI]: 1.86 [1.24-2.81]). CONCLUSION: Differences in COVID-19 test interpretations based on household language for children with medical complexity were observed and could contribute to disparities in outcomes. Opportunities for more inclusive public health messaging likely exist.

Perception of Physicians' Notes Among Parents of Different Health Literacy Levels.

OBJECTIVES: To explore the benefits and challenges of accessing physicians' notes during pediatric hospitalization across parents of different health literacy levels. METHODS: For this secondary analysis, we used semi-structured interviews conducted with 28 parents on their impressions of having access to their child's care team notes on a bedside table. Three researchers used thematic analysis to develop a codebook, coded interview data, and identified themes. Parent interviews and respective themes were then dichotomized into proficient or limited health literacy groups and compared. RESULTS: Nine themes were identified in this secondary analysis: 6 benefits and 3 challenges. All parents identified more benefits than challenges, including that the notes served as a recap of information and memory aid and increased autonomy, empowerment, and advocacy for their child. Both groups disliked receiving bad news in notes before face-to-face communication. Parents with proficient literacy reported that notes allowed them to check information accuracy, but that notes may not be as beneficial for parents with lower health literacy. Parents with limited literacy uniquely identified limited comprehension of medical terms but indicated that notes facilitated their understanding of their child's condition, increased their appreciation for their health care team, and decreased their anxiety, stress, and worry. CONCLUSIONS: Parents with limited health literacy uniquely reported that notes improved their understanding of their child's care and decreased (rather than increased) worry. Reducing medical terminology may be one equitable way to increase note accessibility for parents across the health literacy spectrum.

Parent Perceptions of Trainees in Pediatric Care: Cross-Sectional Study.

BACKGROUND: Clinical experience and progressive autonomy are essential components of medical education and must be balanced with patient comfort. While previous studies have suggested that most patients accept trainee involvement in their care, few studies have focused specifically on the views of parents of pediatric patients or examined groups who may not report acceptance. OBJECTIVE: This study aims to understand parental profiles of resident and medical student involvement in pediatric care and to use latent class analysis (LCA) methodology to identify classes of responses associated with parent demographic characteristics. METHODS: We used data from a national cross-sectional web-based survey of 3000 parents. The survey used a 5-point Likert scale to assess 8 measures of parent perceptions of residents and medical students. We included participants who indicated prior experience with residents or medical students. We compared responses about resident involvement in pediatric care with responses about student involvement, used LCA to identify latent classes of parent responses, and compared demographic features between the latent classes. RESULTS: Of the 3000 parents who completed the survey, 1543 met the inclusion criteria for our study. Participants reported higher mean scores for residents than for medical students for perceived quality of care, comfort with autonomously performing an examination, and comfort with autonomously giving medical advice. LCA identified 3 latent classes of parent responses: Trainee-Hesitant, Trainee-Neutral, and Trainee-Supportive. Compared with the Trainee-Supportive and Trainee-Neutral classes, the Trainee-Hesitant class had significantly more members reporting age <30 years, household income < US $50,000, no college degree, and lesser desire to receive future care at a teaching hospital (all P<.05). CONCLUSIONS: Parents may prefer greater clinical autonomy for residents than medical students. Importantly, views associated with the Trainee-Hesitant class may be held disproportionately by members of historically and currently socially marginalized demographic groups. Future studies should investigate underlying reasons for trainee hesitancy in these groups, including the possibility of mistrust in medicine.

Gender Difference in Teaching Evaluation Scores of Pediatric Faculty.

OBJECTIVE: To evaluate associations between faculty gender and milestone-based teaching assessment scores assigned by residents. METHODS: We performed a retrospective cohort study of milestone-based clinical teaching assessments of pediatric faculty completed by pediatric residents at a mid-sized residency program from July 2016 to June 2019. Assessments included 3 domains (Clinical Interactions, Teaching Skills, Role Modeling/Professionalism) comprised of a total of 11 sub-competency items. We used multilevel logistic regression accounting for repeat measures and clustering to evaluate associations between faculty gender and assessment scores in the 1) top quartile, 2) bottom quartile, or 3) top-box (highest score). Findings were adjusted for faculty rank and academic track, and resident year and gender. RESULTS: Over 3 years, 2889 assessments of 104 faculty were performed by 91 residents. Between assessments of women and men faculty, there were no significant differences in the odds of receiving a score in the top quartile for the 3 domains (Clinical aOR 0.99, P = .86; Teaching aOR 0.99, P = .93; Role Modeling aOR 0.87, P = .089). However, assessments of women were more likely to receive a score in the bottom quartile in both Teaching (aOR 1.23, P = .019) and Role Modeling (aOR 1.26, P = .008). Assessments of women also had lower odds of receiving the highest score in 6 of 11 sub-competencies. CONCLUSION: Results suggest that gender bias may play a role in resident assessments of pediatric faculty. Future studies are needed to determine if findings are replicated in other settings and to identify opportunities to reduce the gender gap in pediatric academic medicine.

Parent Perspectives on Sharing Pediatric Hospitalization Clinical Notes.

BACKGROUND AND OBJECTIVES: Federal guidelines mandate that hospitals provide patients and caregivers with free, online access to their physician's clinical notes. This study sought to identify parent perceptions of the benefits and challenges of real-time note access during their child's hospitalization and strategies to optimize note-sharing at the bedside. METHODS: This qualitative study was conducted with parents of children aged <12 years admitted to a pediatric hospitalist service in April 2019. Parents were given access to their child's admission and daily progress notes on a bedside tablet (iPad), and interviewed upon discharge. In-depth, 60-minute interviews were audio-recorded and transcribed. Two researchers developed and refined a codebook and coded data inductively and deductively with validation by a third researcher. Thematic analysis was used to identify emergent themes. RESULTS: The 28 interviewed parents described 6 benefits of having note access, which: provided a recap and improved their knowledge about their child's care plan, enhanced communication, facilitated empowerment, increased autonomy, and incited positive emotions. Potential challenges included that notes: caused confusion, hindered communication with the health care team, highlighted problems with note content, and could incite negative emotions. Parents recommended 4 strategies to support sharing: provide preemptive communication about expectations, optimize the note release process, consider parent-friendly note template modifications, and offer informational resources for parents. CONCLUSIONS: Findings provide a framework for operationalizing note-sharing with parents during hospitalization. These results have important implications for hospitals working to comply with federal regulations and researchers assessing the effects of increased information transparency in the inpatient setting.

Transaminase Elevation in Nutritional Infantile Failure to Thrive.

INTRODUCTION: Laboratory investigations pursued for infants with failure to thrive (FTT) often show mild transaminase elevations, the incidence and significance of which are unknown. METHODS: This retrospective chart review included infants diagnosed with simple nutritional FTT at a single academic tertiary care system. Comparisons of diagnostic studies and outcomes between children with and without transaminase elevation were performed using chi-square and Wilcoxon rank sum tests. RESULTS: None of the infants with abnormal transaminases required additional follow-up or developed alternative diagnoses in the following year. DISCUSSION: Transaminase elevation may be common in infants with FTT and may not warrant further investigation if the history indicates an isolated etiology of insufficient nutrition.

US Hospital Stays in Children and Adolescents With Acetaminophen Poisoning.

OBJECTIVES: Acetaminophen poisoning occurs in all age groups; however, hospital-based outcomes of children with these poisonings were not well characterized. Our objectives were to describe the incidence, characteristics, and outcomes of hospital stays in children with acetaminophen poisoning and evaluate the contribution of intentionality. METHODS: We used the 2016 Kids' Inpatient Database and validated International Classification of Diseases, 10th Revision diagnostic codes to identify hospitalizations of children aged 0 to 19 years for acetaminophen poisoning. We used standard survey methods to generate weighted population estimates and describe characteristics and outcomes, both overall and stratified by intentionality. RESULTS: There were 9935 (95% confidence interval [CI], 9252-10 619) discharges from acute care hospitals for acetaminophen poisoning in U.S. children aged 0 to 19 years during 2016, corresponding to a population rate of 12.1 (95% CI, 11.3-12.9) hospitalizations per 100 000 children. Most hospitalizations for both intentional and unintentional acetaminophen poisoning occurred in females, with a strongly age-related sex distribution. Median length of stay was 2 days (interquartile range, 1-4 days); however, nearly half of discharges were subsequently transferred to another type of facility (eg, psychiatric hospital). Median hospital charges for acute care were $14 379 (interquartile range, $9162-$23 114), totaling $204.7 million (95% CI, $187.4-$221.9) in aggregate. Of 31 632 hospital discharges associated with self-harm medication poisoning in children aged 0 to 19 years, acetaminophen was the single most commonly implicated agent. CONCLUSIONS: Acetaminophen poisoning was the most common cause of U.S. hospital stays associated with medication self-harm poisoning. More effective acetaminophen poisoning prevention strategies are needed, which may reduce the burden of this common adolescent malady.

COVID-19 Vaccination Intentions for Children With Medical Complexity.

OBJECTIVES: The chronic conditions and functional limitations experienced by children with medical complexity (CMC) place them at disproportionate risk for COVID-19 transmission and poor outcomes. To promote robust vaccination uptake, specific constructs associated with vaccine hesitancy must be understood. Our objective was to describe demographic, clinical, and vaccine perception variables associated with CMC parents' intention to vaccinate their child against COVID-19. METHODS: We conducted a cross-sectional survey (June-August 2021) for primary caregivers of CMC between ages 5 to 17 at an academic medical center in the Midwest. Multivariable logistic regression examined associations between vaccination intent and selected covariates. RESULTS: Among 1330 families, 65.8% indicated vaccination intent. In multivariable models, demographics had minimal associations with vaccination intent; however, parents of younger children (<12 years) had significantly lower adjusted odds of vaccination intent (adjusted odds ratio [95% confidence interval]: 0.26 [0.17-0.3]) compared to parents of older children (≥12 years). CMC with higher severity of illness, ie, those with ≥1 hospitalization in the previous year (versus none) or >1 complex chronic condition (vs 1), had higher adjusted odds of vaccination intent (1.82 [1.14-2.92] and 1.77 [1.16-2.71], respectively). Vaccine perceptions associated with vaccine intention included "My doctor told me to get my child a COVID-19 vaccine" (2.82 [1.74-4.55]); and "I'm concerned about my child's side effects from the vaccine" (0.18 [0.12-0.26]). CONCLUSIONS: One-third of CMC families expressed vaccine hesitation; however, constructs strongly associated with vaccination intent are potentially modifiable. Pediatrician endorsement of COVID-19 vaccination and careful counseling on side effects might be promising strategies to encourage uptake.

The Association of Antibiotic Duration With Successful Treatment of Community-Acquired Pneumonia in Children.

BACKGROUND: National guidelines recommend 10 days of antibiotics for children with community-acquired pneumonia (CAP), acknowledging that the outcomes of children hospitalized with CAP who receive shorter durations of therapy have not been evaluated. METHODS: We conducted a comparative effectiveness study of children aged ≥6 months hospitalized at The Johns Hopkins Hospital who received short-course (5-7 days) vs prolonged-course (8-14 days) antibiotic therapy for uncomplicated CAP between 2012 and 2018 using an inverse probability of treatment weighted propensity score analysis. Inclusion was limited to children with clinical and radiographic criteria consistent with CAP, as adjudicated by 2 infectious diseases physicians. Children with tracheostomies; healthcare-associated, hospital-acquired, or ventilator-associated pneumonia; loculated or moderate to large pleural effusion or pulmonary abscess; intensive care unit stay >48 hours; cystic fibrosis/bronchiectasis; severe immunosuppression; or unusual pathogens were excluded. The primary outcome was treatment failure, a composite of unanticipated emergency department visits, outpatient visits, hospital readmissions, or death (all determined to be likely attributable to bacterial pneumonia) within 30 days after completing antibiotic therapy. RESULTS: Four hundred and thirty-nine patients met eligibility criteria; 168 (38%) patients received short-course therapy (median, 6 days) and 271 (62%) received prolonged-course therapy (median, 10 days). Four percent of children experienced treatment failure, with no differences observed between patients who received short-course vs prolonged-course antibiotic therapy (odds ratio, 0.48; 95% confidence interval, .18-1.30). CONCLUSIONS: A short course of antibiotic therapy (approximately 5 days) does not increase the odds of 30-day treatment failure compared with longer courses for hospitalized children with uncomplicated CAP.

Reducing Delays in a Pediatric Procedural Unit With Ultrasound-Guided Intravenous Line Insertion.

OBJECTIVES: Delay in vascular access is a leading cause of procedure delay in our pediatric procedure and infusion center. Use of ultrasound decreases time to peripheral intravenous catheter (PIV) insertion; however, ultrasound availability in our center was limited to an external venous access team (VAT). The objective of this project was to reduce PIV-related delays by 25%. METHODS: Stakeholders convened and theorized that creating a unit-based nurse team specializing in ultrasound-guided peripheral intravenous catheter (USgPIV) insertion would facilitate faster access and a reduction in delayed procedures. An initial plan-do-study-act cycle was performed, training 2 nurses in USgPIV placement. Subsequent cycles were focused on increasing availability of USgPIV-trained nurses. The outcome measure was the rate of procedures delayed by PIV placement, analyzed on a statistical process control U-chart. The process measure was the percentage of USgPIV placements requiring consultations to the VAT, analyzed on a statistical process control P-chart. The balancing measure was the success rate per method of insertion. Comparisons of success rates were conducted by using a χ2 test and Fisher's exact test. RESULTS: The mean rate of procedures delayed because of vascular access fell by special cause variation from 10.8% to 6.4%. The mean VAT consultation rate fell from 86.4% to 32.0%. The VAT had higher rates of overall success (100% vs 87%; P = .01) and first-attempt success (93% vs 77%; P = .03) compared with unit nurse USgPIV placement. CONCLUSIONS: Unit-based USgPIV placement in a pediatric procedural center was successfully implemented, with a significant decline in procedures delayed by PIV access.

Faculty and Peer Support During Pediatric Residency: Association With Performance Outcomes, Race, and Gender.

PURPOSE: To examine the association of resident perception of colleague and faculty support with performance, as measured by milestones-based competency scores, exploring associations between race and gender and perception of support and milestone scoring. METHODS: Resident satisfaction was measured using an annual survey of residents at 49 pediatric residency programs in 2016, 2017, and 2018. Satisfaction with colleague and faculty support was measured using Likert scale survey questions. Pediatric Milestone Competency scores were obtained from the Association of Pediatric Program Directors' Longitudinal Educational Assessment Research Network. Analysis included linear fixed-effects models to examine the relationship between support satisfaction, race, gender, and spring milestone scores. RESULTS: Over 60% of eligible residents responded to the survey. The majority of residents were satisfied with colleague and faculty support, with those identifying as Asian or underrepresented in medicine (URM) reporting lower rates of satisfaction than White peers. Residents satisfied with colleague support had higher milestone scores compared to those with a neutral degree of satisfaction. Residents reporting dissatisfaction with colleague and faculty support had lower milestone scores in most competency domains. Residents identifying as URM had lower milestone scores than White residents, which was partially mediated by lower rates of support satisfaction. CONCLUSIONS: Resident satisfaction with colleague and faculty support correlates with milestone performance. In particular, dissatisfied residents have lower scores than those who are neutral or satisfied. Racial inequities in resident milestone scores may be partially driven by lower rates of support satisfaction among underrepresented residents.

Complex Care Program Enrollment and Change in ED and Hospital Visits from Medical Device Complications.

INTRODUCTION: Medical device-related complications often lead to emergency department (ED) visits and hospitalizations for children with medical complexity (CMC), and pediatric complex care programs may be one way to decrease unnecessary encounters. METHODS: A retrospective cohort study comparing ED and inpatient encounters due to device complications of 2 cohorts of CMC at a single children's hospital during 2014-2016; 99 enrolled in a complex care program and 244 in a propensity-matched comparison group. Structured chart reviews identified ED and inpatient encounters due to device complications. The outcome was a change in the frequency of these encounters from the year before to the year after enrollment in the hospital's complex care program. Program effects were estimated with weighted difference-in-differences (DiDs), comparing the change in mean encounter frequency for CMC enrolled in the program with change for propensity-matched children not enrolled in the program. RESULTS: Mean encounters related to device complications decreased for both groups. Complication-related ED encounters per year decreased from a weighted mean (SD) of 0.74 (0.85) to 0.30 (0.44) in enrolled children and 0.26 (0.89) to 0.12 (0.56) in comparison children, a DiD of 0.30 fewer [95% confidence interval (CI) -0.01 to 0.60]. The largest reductions in device complication ED visits were among those with enteral tubes [0.36 fewer (95% CI 0.04-0.68)]. Hospitalizations decreased over time, but DiDs were not significantly different between groups. CONCLUSIONS: Acute care use from device complications decreased with time. Complex care program enrollment may be associated with more substantial reductions in device complication ED visits, and effects may be most pronounced for CMC with enteral tubes.

Stakeholder Perspectives in Anticipation of Sharing Physicians' Notes With Parents of Hospitalized Children.

OBJECTIVE: Elicit stakeholder perspectives on the anticipated benefits and challenges of sharing hospital physicians' admission and daily progress notes with parents at the bedside during their child's hospitalization and identify strategies to aid implementation of inpatient note sharing. METHODS: Five semistructured focus groups were conducted with 34 stakeholders (8 parents, 8 nurses, 5 residents, 7 hospitalists, 6 administrators) at a tertiary children's hospital from October to November 2018 to identify anticipated benefits, challenges, and implementation strategies prior to sharing inpatient physicians' notes. A facilitator guide elicited participants' perspectives about the idea of sharing notes with parents during their child's hospitalization. Three researchers used content analysis to analyze qualitative data inductively. RESULTS: Anticipated benefits of sharing inpatient notes included: Reinforcement of information, improved parental knowledge and empowerment, enhanced parent communication and partnership with providers, and increased provider accountability and documentation quality. Expected challenges included: Increased provider workload, heightened parental confusion, distress or anxiety, impaired parent relationship with providers, and compromised note quality and purpose. Suggested implementation strategies included: Setting staff and parent expectations upfront, providing tools to support parent education, and limiting shared note content and family eligibility. CONCLUSIONS: Stakeholders anticipated multiple benefits and drawbacks of sharing notes with parents during their child's hospital stay and made practical suggestions for ways to implement inpatient note sharing to promote these benefits and mitigate challenges. Findings will inform the design and implementation of an intervention to share notes using an inpatient portal and evaluation of its effect on child, parent, and healthcare team outcomes.

Evaluation and Improvement of Intern Progress Note Assessments and Plans.

OBJECTIVES: Progress notes communicate providers' assessments of patients' diagnoses, progress, and treatment plans; however, providers perceive that note quality has degraded since the introduction of electronic health records. In this study, we aimed to (1) develop a tool to evaluate progress note assessments and plans with high interrater reliability and (2) assess whether a bundled intervention was associated with improved intern note quality without delaying note file time. METHODS: An 8-member stakeholder team developed a 19-item progress note assessment and plan evaluation (PNAPE) tool and bundled intervention consisting of a new note template and intern training curriculum. Interrater reliability was evaluated by calculating the intraclass correlation coefficient. Blinded assessors then used PNAPE to evaluate assessment and plan quality in pre- and postintervention notes (fall 2017 and 2018). RESULTS: PNAPE revealed high internal interrater reliability between assessors (intraclass correlation coefficient = 0.86; 95% confidence interval: 0.66-0.95). Total median PNAPE score increased from 13 (interquartile range [IQR]: 12-15) to 15 (IQR: 14-17; P = .008), and median file time decreased from 4:30 pm (IQR: 2:33 pm-6:20 pm) to 1:13 pm (IQR: 12:05 pm-3:59 pm; P < .001) in pre- and postintervention notes. In the postintervention period, a higher proportion of assessments and plans indicated the primary problem requiring ongoing hospitalization and progress of this problem (P = .0016 and P < .001, respectively). CONCLUSIONS: The PNAPE tool revealed high reliability between assessors, and the bundled intervention may be associated with improved intern note assessment and plan quality without delaying file time. Future studies are needed to evaluate whether these improvements can be sustained throughout residency and reproduced in future intern cohorts and other inpatient settings.

BedsideNotes: Sharing Physicians' Notes With Parents During Hospitalization.

OBJECTIVES: Physicians increasingly share ambulatory visit notes with patients to meet new federal requirements, and evidence suggests patient experiences improve without overburdening physicians. Whether sharing inpatient notes with parents of hospitalized children yields similar outcomes is unknown. In this pilot study, we evaluated parent and physician perceptions of sharing notes with parents during hospitalization. METHODS: Parents of children aged <12 years admitted to a hospitalist service at a tertiary children's hospital in April 2019 were offered real-time access to their child's admission and daily progress notes on a bedside inpatient portal (MyChart Bedside). Upon discharge, ambulatory OpenNotes survey items assessed parent and physician (attendings and interns) perceptions of note sharing. RESULTS: In all, 25 parents and their children's discharging attending and intern physicians participated. Parents agreed that the information in notes was useful and helped them remember their child's care plan (100%), prepare for rounds (96%), and feel in control (91%). Although many physicians (34%) expressed concern that notes would confuse parents, no parent reported that notes were confusing. Some physicians perceived that they spent more time writing and/or editing notes (28%) or that their job was more difficult (15%). Satisfaction with sharing was highest among parents (100%), followed by attendings (81%) and interns (35%). CONCLUSIONS: Parents all valued having access to physicians' notes during their child's hospital stay; however, some physicians remained concerned about the potential negative consequences of sharing. Comparative effectiveness studies are needed to evaluate the effect of note sharing on outcomes for hospitalized children, families, and staff.

Resident Workshop to Improve Inpatient Documentation Using the Progress Note Assessment and Plan Evaluation (PNAPE) Tool.

Introduction: Physicians enter residency with varied knowledge regarding the purpose of progress notes and proficiency writing them. The objective of this study was to test whether resident knowledge, beliefs, and confidence writing inpatient progress notes improved after a 2.5-hour workshop intervention. Methods: An educational workshop and note assessment tool was constructed by resident and faculty stakeholders based on a review of literature and institutional best practices. The Progress Note Assessment and Plan Evaluation (PNAPE) tool was designed to assess adherence to best practices in the assessment and plan section of progress notes. Thirty-four residents from a midsized pediatric residency program attended the workshop, which consisted of didactics and small-group work evaluating sample notes using the PNAPE tool. Participants completed a four-question online pre- and postworkshop survey to evaluate their knowledge of progress note components and attitudes regarding note importance. Pre-post analysis was performed with Chi-square testing for true/false questions, and Mann-Whitney testing for Likert scale questions and summative scores. Results: A majority of pediatric residents completed the preintervention (n = 26, 76% response rate) and postintervention (n = 23, 68% response rate) surveys. Accurate response rate improved in 15 of 20 of the true/false items, with a statistically significant improvement in five items. Resident perceptions of note importance and confidence in note writing also increased. Discussion: A workshop intervention may effectively educate pediatric residents about progress note best practices. Further studies should assess the impact of the intervention on sustained knowledge and beliefs about progress notes and subsequent note quality.