Smoking Cessation Counseling in the Inpatient Unit: A Survey of Pediatric Hospitalists.

OBJECTIVES: To determine practices and beliefs of pediatric hospitalists regarding smoking cessation counseling for caregivers of hospitalized children. METHODS: An electronic survey was distributed to 249 members of the Pediatric Research in Inpatient Settings Network over 6 weeks in 2017 (83 responses [33%]). Questions explored beliefs regarding the impact of tobacco smoke exposure (TSE) and practices in TSE screening, provision of counseling, resources, and pharmacotherapy. Nonparametric tests were used to compare groups on numeric variables, χ2 tests were used to compare groups on nominal variables, and McNemar's test was used to compare dichotomous responses within subjects. RESULTS: All respondents were familiar with the term "secondhand smoke," and >75% were familiar with "thirdhand smoke" (THS). Familiarity with THS was associated with more recent completion of training (P = .04). Former smokers (7%) were less likely to agree that THS has a significant impact on a child's health (P = .04). Hospitalists ask about TSE more often than they provide counseling, resources, or pharmacotherapy to caregivers who want to quit smoking. Hospitalists are more likely to ask about TSE and provide cessation counseling when patients have asthma as opposed to other diseases. Time was identified by 41% of respondents as a barrier for providing counseling and by 26% of respondents as a barrier for providing resources. Most respondents never prescribe pharmacotherapy (72%), nor do they follow-up with caregivers after hospitalization regarding cessation (87%). CONCLUSIONS: Although most respondents ask about TSE, opportunities are missed for counseling and providing support to caregivers who want to quit smoking. Providers should be educated about THS, and systems should be streamlined to facilitate brief counseling sessions.

Patient safety after implementation of a coproduced family centered communication programme: multicenter before and after intervention study

OBJECTIVE: To determine whether medical errors, family experience, and communication processes improved after implementation of an intervention to standardize the structure of healthcare provider-family communication on family centered rounds. DESIGN: Prospective, multicenter before and after intervention study. SETTING: Pediatric inpatient units in seven North American hospitals, 17 December 2014 to 3 January 2017. PARTICIPANTS: All patients admitted to study units (3106 admissions, 13171 patient days); 2148 parents or caregivers, 435 nurses, 203 medical students, and 586 residents. INTERVENTION: Families, nurses, and physicians coproduced an intervention to standardize healthcare provider-family communication on ward rounds ("family centered rounds"), which included structured, high reliability communication on bedside rounds emphasizing health literacy, family engagement, and bidirectional communication; structured, written real-time summaries of rounds; a formal training programme for healthcare providers; and strategies to support teamwork, implementation, and process improvement. MAIN OUTCOME MEASURES: Medical errors (primary outcome), including harmful errors (preventable adverse events) and non-harmful errors, modeled using Poisson regression and generalized estimating equations clustered by site; family experience; and communication processes (eg, family engagement on rounds). Errors were measured via an established systematic surveillance methodology including family safety reporting. RESULTS: The overall rate of medical errors (per 1000 patient days) was unchanged (41.2 (95% confidence interval 31.2 to 54.5) pre-intervention v 35.8 (26.9 to 47.7) post-intervention, P=0.21), but harmful errors (preventable adverse events) decreased by 37.9% (20.7 (15.3 to 28.1) v 12.9 (8.9 to 18.6), P=0.01) post-intervention. Non-preventable adverse events also decreased (12.6 (8.9 to 17.9) v 5.2 (3.1 to 8.8), P=0.003). Top box (eg, "excellent") ratings for six of 25 components of family reported experience improved; none worsened. Family centered rounds occurred more frequently (72.2% (53.5% to 85.4%) v 82.8% (64.9% to 92.6%), P=0.02). Family engagement 55.6% (32.9% to 76.2%) v 66.7% (43.0% to 84.1%), P=0.04) and nurse engagement (20.4% (7.0% to 46.6%) v 35.5% (17.0% to 59.6%), P=0.03) on rounds improved. Families expressing concerns at the start of rounds (18.2% (5.6% to 45.3%) v 37.7% (17.6% to 63.3%), P=0.03) and reading back plans (4.7% (0.7% to 25.2%) v 26.5% (12.7% to 7.3%), P=0.02) increased. Trainee teaching and the duration of rounds did not change significantly. CONCLUSIONS: Although overall errors were unchanged, harmful medical errors decreased and family experience and communication processes improved after implementation of a structured communication intervention for family centered rounds coproduced by families, nurses, and physicians. Family centered care processes may improve safety and quality of care without negatively impacting teaching or duration of rounds. TRIAL REGISTRATION: ClinicalTrials.gov NCT02320175.

The use of evidence-based medicine in pediatrics: past, present and future.

PURPOSE OF REVIEW: Evidence-based medicine is a process that seeks to integrate the best research evidence with clinical expertise and patient values in order to optimize clinical outcomes for our patients. This article will review the benefits of and barriers to the use of evidence-based medicine in pediatrics in the twenty-first century, discuss various implementation strategies and outline the resources that pediatricians could use to increase their knowledge and skills and apply them to their clinical practice. RECENT FINDINGS: Although physicians have generally welcomed evidence-based medicine, the benefits and limitations are often debated, and studies reveal that physicians feel that practicing evidence-based medicine could be difficult in a busy clinical practice because they lack the time, knowledge and resources. There have been many recent developments to help pediatricians overcome these barriers and to use best evidence in their practice. SUMMARY: Pediatricians must be able to use the evidence-based medicine process to identify, access, apply and integrate new knowledge into their practice to provide high-quality care for their patients. The resources discussed in this review will help pediatricians make clinical decisions about patient care that are based on the best, most current, valid, and relevant evidence available.