"Can you help me think this through?" How pediatric hospitalists learn from informal peer consultation.

Informal peer consultation (IPC), also called curbside consultation, is a common practice in medicine. Research has shown that physicians use IPC but how this learning occurs during the process has not been studied. This basic qualitative study describes how pediatric hospitalists learn during IPC, framed by Kolb's (2015) Experiential Learning Theory of Growth and Development. Eleven pediatric hospitalists were interviewed. Deidentified transcripts were coded for key themes using inductive methods. The main prompt for informal peer consultation was the perception of uncertainty. Three themes describe the learning process: "Eliciting Perspectives," "Thinking Aloud Together," and "Experiencing Validation. A fourth theme, "Acknowledging Value," described the importance of IPC for modeling how to manage uncertainty with patients' caregivers and medical trainees. By describing the learning process, the results have implications for physicians who engage in IPC and may inform faculty-level professional development initiatives to improve the IPC process.

Multidisciplinary Initiative to Increase Guideline-concordant Antibiotic Prescription at Discharge for Hospitalized Children with Uncomplicated Community-acquired Pneumonia.

Background: Clinical practice guidelines recommend using narrow-spectrum antibiotics to treat uncomplicated pneumonia in children. This quality improvement (QI) project aimed to evaluate if QI methods could improve guideline-concordant antibiotic prescribing at hospital discharge for children with uncomplicated pneumonia. Methods: For this single-center QI project, we implemented QI interventions in serial plan-do-study-act cycles, focusing on the key drivers targeting general pediatric inpatient resident teams. Interventions included: (1)Small bimonthly group didactic sessions, (2)Visual job aids posted in resident work areas, and (3) A noon conference session. Balancing measures included postdischarge emergency room visits, readmission and adverse drug reactions. Results: To establish a baseline rate, we conducted a chart review of 112 children diagnosed with uncomplicated community-acquired pneumonia during hospitalization from July 2017 through January 2019. The average monthly percentage of children discharged with guideline-concordant antibiotics was 67%. The intervention period was from February 2019 through February 2020, with 118 children meeting the criteria after a review of 262 charts. After our interventions, the average monthly percentage of children discharged with guideline-concordant antibiotics increased to 87%, with the increase persisting for at least 12 months. There were no significant differences in balancing measures pre- and post-interventions. Conclusions: Our QI initiative sustained increased rates of uncomplicated community-acquired pneumonia guideline-concordant antibiotic prescribing at discharge over 12 months without an increase in balancing measures. The enduring changes in prescribing behavior suggest a lasting impact of our interventions.

Development and Implementation of a Peer Curbside Consult Service for Pediatric Hospitalists.

OBJECTIVE: To describe the development and implementation of a Peer Curbside Consult Service (PCCS) for a pediatric hospital medicine (PHM) division. METHODS: We developed a pilot intervention with hospitalists at a freestanding children's hospital to provide peer consultation services for challenging clinical cases. Postconsultation surveys collected from both the requesting and consulting hospitalists provided feedback about the program. The 12-point Template for Intervention Description and Replication (TIDieR) checklist is used to describe the process for program creation and implementation. RESULTS: The PCCS has provided 60 consultations in the first 2 years since implementation in April 2020 and supports a large PHM division with >75 members who practice at a tertiary care, freestanding children's hospital and 7 affiliate sites. Hospitalists request peer consultation for challenging clinical cases. The consultations were typically conducted in person or via telephone. Currently, 11 PHM faculty members within the division volunteer as consultants, with 2 assigned per week. Electronic postconsultation experience surveys were received from 70% of requesting and 89% of consultant hospitalists. We also provide preliminary data from this pilot intervention in the Supplemental Information. CONCLUSIONS: We successfully established a peer consult service that provided just-in-time clinical decision support across the various practice sites. Through transparent reporting using the TIDieR checklist, other divisions may be able to replicate and adapt their own peer consult program.

"Sick or not sick?" A mixed methods study evaluating the rapid determination of illness severity in a pediatric emergency department.

OBJECTIVES: Experienced physicians must rapidly identify ill pediatric patients. We evaluated the ability of an illness rating score (IRS) to predict admission to a pediatric hospital and explored the underlying clinical reasoning of the gestalt assessment of illness. METHODS: We used mixed-methods to study pediatric emergency medicine physicians at an academic children's hospital emergency department (ED). Physicians rated patients' illness severity with the IRS, anchored by 0 (totally well) and 10 (critically ill), and shared their rationale with concurrent think-aloud responses. The association between IRS and need for hospitalization, respiratory support, parenteral antibiotics, and resuscitative intravenous (IV) fluids were analyzed with mixed effects linear regression. Area under the curve (AUC) receiver operator characteristic (ROC) curve and test characteristics at different cut-points were calculated for IRS as a predictor of admission. Think-aloud responses were qualitatively analyzed via inductive process. RESULTS: A total of 141 IRS were analyzed (mean 3.56, SD 2.30, range 0-9). Mean IRS were significantly higher for patients requiring admission (4.32 vs. 3.13, p<0.001), respiratory support (6.15 vs. 3.98, p = 0.033), IV fluids (4.53 vs. 3.14, p < 0.001), and parenteral antibiotics (4.68 vs. 3.32, p = 0.009). AUC for IRS as a predictor of admission was 0.635 (95% CI: 0.534-0.737). Analysis of 95 think-aloud responses yielded eight categories that describe the underlying clinical reasoning. CONCLUSIONS: Rapid assessments as captured by the IRS differentiated pediatric patients who required admission and medical interventions. Think-aloud responses for the rationale for rapid assessments may form the basis for teaching the skill of identifying ill pediatric patients.