Child Health Needs and the Pediatric Hospital Medicine Workforce: 2020-2040.

Pediatric hospital medicine (PHM) established a new model of care for hospitalized children in the United States nearly 3 decades ago. In that time, the field experienced rapid growth while distinguishing itself through contributions to medical education, quality improvement, clinical and health services research, patient safety, and health system leadership. Hospital systems have also invested in using in-house pediatricians to manage various inpatient care settings as patient acuity has accelerated. National PHM leaders advocated for board certification in 2014, and the first certification examination was administered by the American Board of Pediatrics in 2019. In this article, we describe the development of the subspecialty, including evolving definitions and responsibilities of pediatric hospitalists. Although PHM was not included in the model forecasting future pediatric subspecialties through 2040 in this supplement because of limited historical data, in this article, we consider the current and future states of the workforce in relation to children's health needs. Expected challenges include potential alterations to residency curriculum, changes in the number of fellowship positions, expanding professional roles, concerns related to job sustainability and burnout, and closures of pediatric inpatient units in community hospitals. We simultaneously forecast growing demand in the PHM workforce arising from the increasing prevalence of children with medical complexity and increasing comanagement of hospitalized children between pediatric hospitalists and other subspecialists. As such, our forecast incorporates a degree of uncertainty and points to the need for ongoing investments in future research to monitor and evaluate the size, scope, and needs of pediatric hospitalists and the PHM workforce.

Implementing a Family-Centered Rounds Intervention Using Novel Mentor-Trios.

BACKGROUND AND OBJECTIVES: Patient and Family Centered I-PASS (PFC I-PASS) emphasizes family and nurse engagement, health literacy, and structured communication on family-centered rounds organized around the I-PASS framework (Illness severity-Patient summary-Action items-Situational awareness-Synthesis by receiver). We assessed adherence, safety, and experience after implementing PFC I-PASS using a novel "Mentor-Trio" implementation approach with multidisciplinary parent-nurse-physician teams coaching sites. METHODS: Hybrid Type II effectiveness-implementation study from 2/29/19-3/13/22 with ≥3 months of baseline and 12 months of postimplementation data collection/site across 21 US community and tertiary pediatric teaching hospitals. We conducted rounds observations and surveyed nurses, physicians, and Arabic/Chinese/English/Spanish-speaking patients/parents. RESULTS: We conducted 4557 rounds observations and received 2285 patient/family, 1240 resident, 819 nurse, and 378 attending surveys. Adherence to all I-PASS components, bedside rounding, written rounds summaries, family and nurse engagement, and plain language improved post-implementation (13.0%-60.8% absolute increase by item), all P < .05. Except for written summary, improvements sustained 12 months post-implementation. Resident-reported harms/1000-resident-days were unchanged overall but decreased in larger hospitals (116.9 to 86.3 to 72.3 pre versus early- versus late-implementation, P = .006), hospitals with greater nurse engagement on rounds (110.6 to 73.3 to 65.3, P < .001), and greater adherence to I-PASS structure (95.3 to 73.6 to 72.3, P < .05). Twelve of 12 measures of staff safety climate improved (eg, "excellent"/"very good" safety grade improved from 80.4% to 86.3% to 88.0%), all P < .05. Patient/family experience and teaching were unchanged. CONCLUSIONS: Hospitals successfully used Mentor-Trios to implement PFC I-PASS. Family/nurse engagement, safety climate, and harms improved in larger hospitals and hospitals with better nurse engagement and intervention adherence. Patient/family experience and teaching were not affected.

Strategies to Counteract Impact of Harmful Bias in Selection of Medical Residents.

Human biases impact medical care in ways that perpetuate health disparities. Research has demonstrated that biases negatively affect patient outcomes and stifle diversity across the physician workforce, further compounding health disparities by worsening patient-physician concordance. Taken as one, the application, interview, recruitment, and selection processes employed by residency programs has been one of the critical junctures where bias has exacerbated inequities among future physicians. In this article, the authors define diversity and bias, review the history of bias in residency programs' processes for selecting residents, explore the impact of this history on workforce demographics, and discuss ways to optimize and work toward equity in the practices used by residency programs to select residents.

Implementation of the I-PASS handoff program in diverse clinical environments: A multicenter prospective effectiveness implementation study.

BACKGROUND: Handoff miscommunications are a leading source of medical errors. Harmful medical errors decreased in pediatric academic hospitals following implementation of the I-PASS handoff improvement program. However, implementation across specialties has not been assessed. OBJECTIVE: To determine if I-PASS implementation across diverse settings would be associated with improvements in patient safety and communication. DESIGN: Prospective Type 2 Hybrid effectiveness implementation study. SETTINGS AND PARTICIPANTS: Residents from diverse specialties across 32 hospitals (12 community, 20 academic). INTERVENTION: External teams provided longitudinal coaching over 18 months to facilitate implementation of an enhanced I-PASS program and monthly metric reviews. MAIN OUTCOME AND MEASURES: Systematic surveillance surveys assessed rates of resident-reported adverse events. Validated direct observation tools measured verbal and written handoff quality. RESULTS: 2735 resident physicians and 760 faculty champions from multiple specialties (16 internal medicine, 13 pediatric, 3 other) participated. 1942 error surveillance reports were collected. Major and minor handoff-related reported adverse events decreased 47% following implementation, from 1.7 to 0.9 major events/person-year (p < .05) and 17.5 to 9.3 minor events/person-year (p < .001). Implementation was associated with increased inclusion of all five key handoff data elements in verbal (20% vs. 66%, p < .001, n = 4812) and written (10% vs. 74%, p < .001, n = 1787) handoffs, as well as increased frequency of handoffs with high quality verbal (39% vs. 81% p < .001) and written (29% vs. 78%, p < .001) patient summaries, verbal (29% vs. 78%, p < .001) and written (24% vs. 73%, p < .001) contingency plans, and verbal receiver syntheses (31% vs. 83%, p < .001). Improvement was similar across provider types (adult vs. pediatric) and settings (community vs. academic).

Family, nurse, and physician beliefs on family-centered rounds: A 21-site study.

BACKGROUND: Variation exists in family-centered rounds (FCR). OBJECTIVE: We sought to understand patient/family and clinician FCR beliefs/attitudes and practices to support implementation efforts. DESIGNS, SETTINGS AND PARTICIPANTS: Patients/families and clinicians at 21 geographically diverse US community/academic pediatric teaching hospitals participated in a prospective cohort dissemination and implementation study. INTERVENTION: We inquired about rounding beliefs/attitudes, practices, and demographics using a 26-question survey coproduced with family/nurse/attending-physician collaborators, informed by prior research and the Consolidated Framework for Implementation Research. MAIN OUTCOME AND MEASURES: Out of 2578 individuals, 1647 (64%) responded to the survey; of these, 1313 respondents participated in FCR and were included in analyses (616 patients/families, 243 nurses, 285 resident physicians, and 169 attending physicians). Beliefs/attitudes regarding the importance of FCR elements varied by role, with resident physicians rating the importance of several FCR elements lower than others. For example, on adjusted multivariable analysis, attending physicians (odds ratio [OR] 3.0, 95% confidence interval [95% CI] 1.2-7.8) and nurses (OR 3.1, 95% CI 1.3-7.4) were much more likely than resident physicians to report family participation on rounds as very/extremely important. Clinician support for key FCR elements was higher than self-reported practice (e.g., 88% believed family participation was important on rounds; 68% reported it often/always occurred). In practice, key elements of FCR were reported to often/always occur only 23%-70% of the time. RESULT: Support for nurse and family participation in FCR is high among clinicians but varies by role. Physicians, particularly resident physicians, endorse several FCR elements as less important than nurses and patients/families. The gap between attitudes and practice and between clinician types suggests that attitudinal, structural, and cultural barriers impede FCR.

Patient and Family-Centered I-PASS SCORE Program: Resident and Advanced Care Provider Training Materials.

Introduction: Patient and family-centered rounds (PFCRs) are an important element of family-centered care often used in the inpatient pediatric setting. However, techniques and best practices vary, and faculty, trainees, nurses, and advanced care providers may not receive formal education in strategies that specifically enhance communication on PFCRs. Methods: Harnessing the use of structured communication, we developed the Patient and Family-Centered I-PASS Safer Communication on Rounds Every Time (SCORE) Program. The program uses a standardized framework for rounds communication via the I-PASS mnemonic, principles of health literacy, and techniques for patient/family engagement and bidirectional communication. The resident and advanced care provider training materials, a component of the larger SCORE Program, incorporate a flipped classroom approach as well as interactive exercises, simulations, and virtual learning options to optimize learning and retention via a 90-minute workshop. Results: Two hundred forty-six residents completed the training and were evaluated on their knowledge and confidence regarding key elements of the curriculum. Eighty-eight percent of residents agreed/strongly agreed that after training they could activate and engage families and all members of the interprofessional team to create a shared mental model; 90% agreed/strongly agreed that they could discuss the roles/responsibilities of various team members during PFCRs. Discussion: The Patient and Family-Centered I-PASS SCORE Program provides a structured framework for teaching advanced communication techniques that can improve provider knowledge of and confidence with engaging and communicating with patients/families and other members of the interprofessional team during PFCRs.

Intervention, individual, and contextual determinants to high adherence to structured family-centered rounds: a national multi-site mixed methods study.

BACKGROUND: Effective communication in transitions between healthcare team members is associated with improved patient safety and experience through a clinically meaningful reduction in serious safety events. Family-centered rounds (FCR) can serve a critical role in interprofessional and patient-family communication. Despite widespread support, FCRs are not utilized consistently in many institutions. Structured FCR approaches may prove beneficial in increasing FCR use but should address organizational challenges. The purpose of this study was to identify intervention, individual, and contextual determinants of high adherence to common elements of structured FCR in pediatric inpatient units during the implementation phase of a large multi-site study implementing a structured FCR approach. METHODS: We performed an explanatory sequential mixed methods study from September 2019 to October 2020 to evaluate the variation in structured FCR adherence across 21 pediatric inpatient units. We analyzed 24 key informant interviews of supervising physician faculty, physician learners, nurses, site administrators, and project leaders at 3 sites using a qualitative content analysis paradigm to investigate site variation in FCR use. We classified implementation determinants based on the Consolidated Framework for Implementation Research. RESULTS: Provisional measurements of adherence demonstrated considerable variation in structured FCR use across sites at a median time of 5 months into the implementation. Consistent findings across all three sites included generally positive clinician beliefs regarding the use of FCR and structured rounding approaches, benefits to learner self-efficacy, and potential efficiency gains derived through greater rounds standardization, as well as persistent challenges with nurse engagement and interaction on rounds and coordination and use of resources for families with limited English proficiency. CONCLUSIONS: Studies during implementation to identify determinants to high adherence can provide generalizable knowledge regarding implementation determinants that may be difficult to predict prior to implementation, guide adaptation during the implementation, and inform sustainment strategies.

Association of Patient and Family Reports of Hospital Safety Climate With Language Proficiency in the US.

Importance: Patients with language barriers have a higher risk of experiencing hospital safety events. This study hypothesized that language barriers would be associated with poorer perceptions of hospital safety climate relating to communication openness. Objective: To examine disparities in reported hospital safety climate by language proficiency in a cohort of hospitalized children and their families. Design, Setting, and Participants: This cohort study conducted from April 29, 2019, through March 1, 2020, included pediatric patients and parents or caregivers of hospitalized children at general and subspecialty units at 21 US hospitals. Randomly selected Arabic-, Chinese-, English-, and Spanish-speaking hospitalized patients and families were approached before hospital discharge and were included in the analysis if they provided both language proficiency and health literacy data. Participants self-rated language proficiency via surveys. Limited English proficiency was defined as an answer of anything other than "very well" to the question "how well do you speak English?" Main Outcomes and Measures: Primary outcomes were top-box (top most; eg, strongly agree) 5-point Likert scale ratings for 3 Children's Hospital Safety Climate Questionnaire communication openness items: (1) freely speaking up if you see something that may negatively affect care (top-box response: strongly agree), (2) questioning decisions or actions of health care providers (top-box response: strongly agree), and (3) being afraid to ask questions when something does not seem right (top-box response: strongly disagree [reverse-coded item]). Covariates included health literacy and sociodemographic characteristics. Logistic regression was used with generalized estimating equations to control for clustering by site to model associations between openness items and language proficiency, adjusting for health literacy and sociodemographic characteristics. Results: Of 813 patients, parents, and caregivers who were approached to participate in the study, 608 completed surveys (74.8% response rate). A total of 87.7% (533 of 608) of participants (434 [82.0%] female individuals) completed language proficiency and health literacy items and were included in the analyses; of these, 14.1% (75) had limited English proficiency. Participants with limited English proficiency had lower odds of freely speaking up if they see something that may negatively affect care (adjusted odds ratio [aOR], 0.26; 95% CI, 0.15-0.43), questioning decisions or actions of health care providers (aOR, 0.19; 95% CI, 0.09-0.41), and being unafraid to ask questions when something does not seem right (aOR, 0.44; 95% CI, 0.27-0.71). Individuals with limited health literacy (aOR, 0.66; 95% CI, 0.48-0.91) and a lower level of educational attainment (aOR, 0.59; 95% CI, 0.36-0.95) were also less likely to question decisions or actions. Conclusions and Relevance: This cohort study found that limited English proficiency was associated with lower odds of speaking up, questioning decisions or actions of providers, and being unafraid to ask questions when something does not seem right. This disparity may contribute to higher hospital safety risk for patients with limited English proficiency. Dedicated efforts to improve communication with patients and families with limited English proficiency are necessary to improve hospital safety and reduce disparities.

Improving trainee clinical documentation through a novel curriculum in internal medicine.

BACKGROUND: Clinical documentation is a key component of practice. Trainees rarely receive formal training in documentation or assessment of their documentation. Effective methods of improving documentation remain unknown. OBJECTIVE: The objective of this study was to determine if the implementation of a documentation curriculum led to improvement in admission note quality. DESIGNS: Admission notes written prior to implementation of the curriculum and after the curriculum intervention were assessed. Notes were assessed from two-time frames for both years to account for improvement with time not associated with the intervention. SETTINGS AND PARTICIPANTS: Admission notes written by University of Cincinnati interns were assessed. INTERVENTIONS: The documentation curriculum consisted of educational sessions and routine admission note assessments with feedback. MAIN OUTCOMES AND MEASURES: Admission notes were assessed via the 16 checklist items and two global assessment items of the Admission Note Assessment Tool (ANAT). RESULTS: Six ANAT items showed statistically significant differences. The review of systems item improved with the intervention only (odds ratio: 3.61, p < .001) while the assessment and plan item 1 and global assessment item 2 improved with time only (ß = .08, p = .03 and ß = .25, p = .02, respectively) in univariate models. In univariate models the physical exam item, diagnostic data item 2, and global assessment item 1 showed improvement with both intervention and time, respectively, with additive effects seen in models with both intervention and time. CONCLUSION: Several aspects of documentation can improve with a formal documentation curriculum which includes a routine assessment with feedback, and some aspects of documentation improve with time.

I-PASS Mentored Implementation Handoff Curriculum: Frontline Provider Training Materials.

Introduction: The I-PASS Handoff Program is a comprehensive handoff curriculum that has been shown to decrease rates of medical errors and adverse events during patient handoffs. Frontline providers are the key individuals participating in handoffs of patient care. It is important they receive robust handoff training. Methods: The I-PASS Mentored Implementation Handoff Curriculum frontline provider training materials were created as part of the original I-PASS Study and adapted for the Society of Hospital Medicine (SHM) I-PASS Mentored Implementation Program. The adapted materials embrace a flipped classroom approach with an emphasis on adult learning theory principles. The training includes an overview of I-PASS handoff techniques, TeamSTEPPS team communication strategies, verbal handoff simulation scenarios, and a printed handoff document exercise. Results: As part of the SHM I-PASS Mentored Implementation Program, 2,735 frontline providers were trained at 32 study sites (16 adult and 16 pediatric) across North America. At the end of their training, 1,762 frontline providers completed the workshop evaluation form (64% response rate). After receiving the training, over 90% agreed/strongly agreed that they were able to distinguish a good- from a poor-quality handoff, articulate the elements of the I-PASS mnemonic, construct a high-quality patient summary, advocate for an appropriate environment for handoffs, and participate in handoff simulations. Universally, the training provided them with knowledge and skills relevant to their patient care activities. Discussion: The I-PASS frontline training materials were rated highly by those trained and are an integral part of a successful I-PASS Handoff Program implementation.

Developing Content for Pediatric Hospital Medicine Certification Examination Using Practice Analysis.

OBJECTIVES: The American Board of Pediatrics (ABP) and the Pediatric Hospital Medicine (PHM) subboard developed a content outline to serve as a blueprint for the inaugural certification examination through practice analysis. The systematic approach of practice analyses process is described in the study. METHODS: A diverse, representative panel of 12 pediatric hospitalists developed the draft content outline using multiple resources (publications, textbooks, PHM Core Competencies, PHM fellow's curriculum, etc). The panel categorized practice knowledge into 13 domains and 202 subdomains. By using the ABP database self-defined practicing pediatric hospitalists were identified. Participants rated the frequency and criticality of content domains and subdomains along with providing open-ended comments. RESULTS: In total, 1449 (12.1%) generalists in the ABP database self-identified as pediatric hospitalists, and 800 full-time pediatric hospitalists responded. The content domains that were rated as highly critical and frequently required in practice were weighted more heavily (ie, the percentage of examination questions associated with a domain) than the less critical and less frequently rated. Both community and noncommunity pediatric hospitalists rated domains similarly (P = .943). Subdomain and preliminary weights were rated with similar means and SDs in the majority of topics. CONCLUSIONS: There was concordance in the rating of domain and universal tasks among both community and noncommunity hospitalists. The areas of significant differences, although minor, could be explained by difference in practice settings. The practice analysis approach was structured, engaged the PHM community, reflected the breadth and depth of knowledge required for PHM practice, and used an iterative process to refine the final product.

Development and Establishment of Initial Validity Evidence for a Novel Tool for Assessing Trainee Admission Notes.

BACKGROUND: Documentation is a key component of practice, yet few curricula have been published to teach trainees proper note construction. Additionally, a gold standard for assessing note quality does not exist, and no documentation assessment tools integrate with established competency-based frameworks. OBJECTIVE: To develop and establish initial validity evidence for a novel tool that assesses key components of trainee admission notes and maps to the Accreditation Council for Graduate Medical Education (ACGME) milestone framework. DESIGN: Using an iterative, consensus building process we developed the Admission Note Assessment Tool (ANAT). Pilot testing was performed with both the supervising attending and study team raters not involved in care of the patients. The finalized tool was piloted with attendings from other institutions. PARTICIPANTS: Local experts participated in tool development and pilot testing. Additional attending physicians participated in pilot testing. MAIN MEASURES: Content, response process, and internal structure validity evidence was gathered using Messick's framework. Inter-rater reliability was assessed using percent agreement. KEY RESULTS: The final tool consists of 16 checklist items and two global assessment items. Pilot testing demonstrated rater agreement of 72% to 100% for checklist items and 63% to 70% for global assessment items. Note assessment required an average of 12.3 min (SD 3.7). The study generated validity evidence in the domains of content, response process, and internal structure for use of the tool in rating admission notes. CONCLUSIONS: The ANAT assesses individual components of a note, incorporates billing criteria, targets note "bloat," allows for narrative feedback, and provides global assessments mapped to the ACGME milestone framework. The ANAT can be used to assess admission notes by any attending and at any time after note completion with minimal rater training. The ANAT allows programs to implement routine note assessment for multiple functions with the use of a single tool.

Risk Factors for the Development of Hospital-Associated Venous Thromboembolism in Adult Patients Admitted to a Children's Hospital.

BACKGROUND AND OBJECTIVES: Hospital-associated venous thromboembolism (HA-VTE) is a leading cause of preventable in-hospital mortality in adults. Our objective was to describe HA-VTE and evaluate risk factors for its development in adults admitted to a children's hospital, which has not been previously studied. We also evaluated the performance of commonly used risk assessment tools for HA-VTE. METHODS: A case-control study was performed at a freestanding children's hospital. Cases of HA-VTE in patients ≥18 years old (2013-2017) and age-matched controls were identified. We extracted patient and HA-VTE characteristics and HA-VTE risk factors on the basis of previous literature. Thrombosis risk assessment was performed retrospectively by using established prospective adult tools (Caprini and Padua scores). RESULTS: Thirty-nine cases and 78 controls were identified. Upper extremities were the most common site of thrombosis (62%). Comorbid conditions were common (91.5%), and malignancy was more common among case patients than controls (P = .04). The presence of a central venous catheter (P < .01), longer length of stay (P < .01), ICU admission (P = .005), and previous admission within 30 days (P = .01) were more common among case patients when compared with controls. Median Caprini score was higher for case patients (P < .01), whereas median Padua score was similar between groups (P = .08). CONCLUSIONS: HA-VTE in adults admitted to children's hospitals is an important consideration in a growing high-risk patient population. HA-VTE characteristics in our study were more similar to published data in pediatrics.

I-PASS Adherence and Implications for Future Handoff Training.

BACKGROUND: A formal handoff process, such as the I-PASS handoff program, can improve communication about patients among residents. Faculty observation of resident handoffs has served as the primary method for documenting adherence to I-PASS, and little is known about residents' use when they are not being observed. OBJECTIVE: We determined how frequently pediatric residents use I-PASS when not being observed. METHODS: We implemented I-PASS in the 2016-2017 academic year and anonymously surveyed residents (December 2016 and June 2017), asking them how they perceive the effectiveness of I-PASS at enhancing patient safety, their frequency of I-PASS use when not observed, co-residents' frequency of use, and open-ended questions regarding factors affecting use. RESULTS: Fifty-one (52%) and 50 (51%) of 99 eligible residents completed the December and June surveys, respectively. All respondents thought I-PASS had some effectiveness in enhancing patient safety. In December, only 6 (12%) residents stated they used I-PASS more than 75% of the time and reported providing a synthesis statement during handoffs more than 75% of the time. The results were similar for both surveys. Commonly cited reasons for not using I-PASS included time (n = 30), prior knowledge of patients (n = 20), and patients with limited complexity (n = 9). CONCLUSIONS: While most residents thought I-PASS was effective at enhancing patient safety, many reported that they do not use all 5 elements in most of their handoffs when not being observed. Barriers reported included time, familiarity with patients, and limited patient complexity.

Communication with Diverse Patients: Addressing Culture and Language.

Effective communication is key when providing quality health care. The dynamics of communication within the health care team and with the patient and family can be challenging. These challenges stem from the sharing of complex information, highly emotional topics, and health literacy barriers. Linguistic and cultural barriers can further aggravate these challenges. This section provides an overview of linguistic and cultural challenges related to patient-provider communication, strategies for effective communication with patients with limited English Proficiency via the use of interpreter services, and tips for how to teach these skills to health care providers.

I-PASS Mentored Implementation Handoff Curriculum: Champion Training Materials.

Introduction: The I-PASS Handoff Program is a comprehensive handoff curriculum that has been shown to decrease rates of medical errors and adverse events during patient handoffs. I-PASS champions are a critical part of the implementation and sustainment of this curriculum, and therefore, a rigorous program to support their training is necessary. Methods: The I-PASS Handoff champion training materials were created for the original I-PASS Study and adapted for the Society of Hospital Medicine (SHM) I-PASS Mentored Implementation Program. The adapted materials embrace a flipped classroom approach and adult learning theory. The training includes an overview of I-PASS handoff techniques, an opportunity to practice evaluating handoffs with the I-PASS observation tools using a handoff video vignette, and other key implementation principles. Results: As part of the SHM I-PASS Mentored Implementation Program, 366 champions were trained at 32 sites across North America and participated in a total of 3,491 handoff observations. A total of 346 champions completed the I-PASS Champion Workshop evaluation form at the end of their training (response rate: 94.5%). After receiving the training, over 90% agreed/strongly agreed that it provided them with knowledge or skills critical to their patient care activities and that they were able to distinguish the difference between high- and poor-quality handoffs, competently use the I-PASS handoff assessment tools, and articulate the importance of handoff observations. Conclusion: The I-PASS champion training materials were rated highly by those trained and are an integral part of a successful I-PASS Handoff Program implementation.