"Do No Harm": Promoting Anti-Racist Policing in Pediatric Emergency Departments Through 20 Practice Change Considerations.

Children represent some of the most vulnerable and most valuable members of society. When acutely ill or injured, pediatric emergency departments (EDs) provide first line, specialized care for children and adolescents. Unique and unpredictable, the pediatric ED environment requires a wide range of health care professionals to care for children and their families and often includes hospital-employed security professionals and local law enforcement personnel to ensure safe and protective spaces paramount for optimal patient care. However, an active policing presence within environments designed to promote healing can paradoxically contribute to harm, particularly for Black and Brown patients. As health care systems pledge to dismantle structural racism and achieve health equity, efforts must include anti-racist reforms of threat management systems within clinical environments. We propose assessment and evaluation of current security and police encounters within pediatric EDs. We call for institution of policies that mitigate biases, address medical mistrust, distinguish clinical from criminal aggression, and minimize punitive contact with police. We outline a multitiered, patient-centered approach to disruptive and violent acts that prioritizes prevention, early intervention, and de-escalation strategies with a goal of reducing the perceived need for policing presence in pediatric EDs.

Mitigating Misogynoir: Inclusive Professionalism as a Health Equity Strategy.

As Obstetrics and Gynecology begins to recognize how structural racism drives inequitable health outcomes, it must also acknowledge the effects of structural racism on its workforce and culture. Black physicians comprise ~5% of the United States physician population. Unique adversities affect Black women physicians, particularly during residency training, and contribute to the lack of equitable workforce representation. Eliminating racialized inequities in clinical care requires addressing these concerns. By applying historical context to present-day realities and harms experienced by Black women (ie, misogynoir), Obstetrics and Gynecology can identify interventions, such as equity-focused recruitment and retention strategies, that transform the profession.

Improving Patient Experience Scores Using Simultaneous Interpretation on Family-Centered Rounds.

OBJECTIVES: Patients speaking a primary language other than English face barriers to equitable care, particularly patient-provider communications. There is no gold standard for providing inpatient medical interpretation on family-centered rounds (FCR). We aimed to implement simultaneous, in-person interpretation of FCR for Spanish-speaking families and hypothesized improved satisfaction in care. METHODS: In-person, Spanish Equipment-Assisted Simultaneous Medical Interpretation (EASMI) was implemented in March 2018 on FCR. Child Hospital Consumer Assessment of Healthcare Providers and Systems (Child HCAHPS) experience scores on communication domains were analyzed for Spanish and English-speaking families pre- (n = 118) and postimplementation (n = 552). Postimplementation, we conducted medical team surveys (n = 104) and semistructured interviews with Spanish-speaking families (n = 25) to determine satisfaction with interpretation modalities (phone, video, and EASMI). RESULTS: Spanish-speaking families exhibited statistically significant improvements in Child HCAHPS top box scores compared to English-speaking families in multiple communication and informed care-related domains. For example, "How often did your child's doctors explain things to you in a way that was easy to understand?" top box scores improved from 58% to 95% for Spanish-speaking families, compared to 85% to 83% for English speakers, with the differential effect of the intervention showing statistical significance (P = .001). Medical team surveys demonstrated high satisfaction with EASMI. Qualitative themes from interviews and open-ended survey responses emphasized multiple care benefits with EASMI, including a perceived reduction of communication errors and increased family participation. CONCLUSIONS: EASMI was associated with significant improvements in Child HCAHPS scores in communication domains and increased medical team and family members' satisfaction with interpretation. EASMI presents a novel method for equitable FCR for Spanish-speaking families.

Barely Tweeting and Rarely About Racism: Assessing US State Health Department Twitter Use During the COVID-19 Vaccine Rollout.

Introduction: The general public was discussing racism and potential inequities in COVID-19 vaccinations among African Americans on Twitter before the first COVID-19 vaccine received emergency use authorization, but it is unclear how US state health departments (SHDs) were using Twitter to address the inequities. This study examines the frequency, content and timing of SHD tweets during the US rollout of the first SARS Co-V2 vaccine. Methods: This was a prospective study of tweets posted from the official Twitter accounts of each of the 50 US SHDs and the DC health department from October 19, 2020 to February 28, 2021. We retrieved the content and metadata of 100% of their tweets; calculated frequencies and proportions of tweets containing key terms related to COVID-19 vaccines, equity and racism; stratified the data by region; and charted longitudinal trends. Results: Overall, SHDs tweeted infrequently, and rarely tweeted about inequities, mistrust or racism. Though 55.48% of all SHD tweets were about COVID-19, hardly any tweets contained the terms: race/ethnicity (1.20%); equity (1.09); mistrust (.59%); or racism (.06%). Similar patterns existed among vaccination-related tweets, which accounted for 24.38% of all tweets. Only 21.64% of vaccination-related tweets containing any race/ethnicity, equity, mistrust, or racism terms were posted prior to the first Emergency Use Authorization (EUA). Those about African Americans (70.45%) were posted ≥8 weeks after EUA. Conclusions: Concerns about racism and inequities in COVID-19 vaccination continue on Twitter, but SHDs rarely tweet about them. This strikes a worrisome chord of disconnection from the science linking health inequities to racism.

Association of Racial Disparities With In-Hospital Outcomes in Severe Bronchopulmonary Dysplasia.

Importance: Bronchopulmonary dysplasia (BPD) is the most common serious morbidity of preterm birth. Short-term respiratory outcomes for infants with the most severe forms of BPD are highly variable. The mechanisms that explain this variability remain unknown and may be mediated by racial disparities. Objective: To determine the association of maternal race with death and length of hospital stay in a multicenter cohort of infants with severe BPD. Design, Setting, and Participants: This multicenter cohort study included preterm infants enrolled in the BPD Collaborative registry from January 1, 2015, to July 19, 2021, involving 8 BPD Collaborative centers located in the US. Included patients were born at less than 32 weeks' gestation, had a diagnosis of severe BPD as defined by the 2001 National Institutes of Health Consensus Criteria, and were born to Black or White mothers. Exposures: Maternal race: Black vs White. Main Outcomes and Measures: Death and length of hospital stay. Results: Among 834 registry infants (median [IQR] gestational age, 25 [24-27] weeks; 492 male infants [59%]) meeting inclusion criteria, the majority were born to White mothers (558 [67%]). Death was observed infrequently in the study cohort (32 [4%]), but Black maternal race was associated with an increased odds of death (adjusted odds ratio, 2.1; 95% CI, 1.2-3.5) after adjusting for center. Black maternal race was also significantly associated with length of hospital stay (adjusted between-group difference, 10 days; 95% CI, 3-17 days). Conclusions and Relevance: In a multicenter severe BPD cohort, study results suggest that infants born to Black mothers had increased likelihood of death and increased length of hospital stay compared with infants born to White mothers. Prospective studies are needed to define the sociodemographic mechanisms underlying disparate health outcomes for Black infants with severe BPD.

Restitution Through Equity-Focused Mentoring: A Solution to Diversify the Physician Workforce.

Minoritized and marginalized physicians who identify as Black, Latino/a/x and Native American (BLNA) remain unacceptably underrepresented in medicine. Multiple studies provide a compelling argument for prioritizing racial/ethnic diversification of the physician workforce to improve racial/ethnic physician-patient concordance and assist in achieving more equitable health outcomes. Despite a growing awareness for the tangible benefits of a diversified physician workforce, the number of physicians from minoritized and marginalized groups remains relatively stagnant or worsening in certain demographics. The 5:1 ratio of Black students and trainees to Black faculty exemplifies and exacerbates the increased risk for harmful isolation particularly experienced by many BLNA mentees. They too need and deserve the benefits produced by concordant racial/ethnic faculty mentoring and support. However, these demands on time, resources and bandwidth can lead to negative consequences for BLNA faculty engaged in these efforts by contributing to their emotional, mental and physical exhaustion. Given the perpetual paucity of BLNA physicians in academic medicine, immediate interventions to prevent attrition of BLNA faculty, trainees and students journeying along the physician career pathway are urgently needed. Requiring the implementation of mentoring programs explicitly focused on increasing the number of physicians from groups underrepresented in medicine must happen at every point of the education and training process.

Addressing bias and knowledge gaps regarding race and ethnicity in neonatology manuscript review.

A recent shift in public attention to racism, racial disparities, and health equity have resulted in an abundance of calls for relevant papers and publications in academic journals. Peer-review for such articles may be susceptible to bias, as subject matter expertise in the evaluation of social constructs, like race, is variable. From the perspective of researchers focused on neonatal health equity, we share our positive and negative experiences in peer-review, provide relevant publicly available data regarding addressing bias in peer-review from 12 neonatology-focused journals, and give recommendations to address bias and knowledge gaps in the peer review process of health equity research.

Taking the VITALS to Interrupt Microaggressions.

INTRODUCTION: Microaggressions are subtle statements or actions that reinforce stereotypes. Medical students, residents, and faculty report experiences of microaggressions, with higher incidences among women and marginalized groups. An educational tool utilizing the acronym VITALS (validate, inquire, take time, assume, leave opportunities, speak up) provided a framework for processing and addressing microaggressions encountered in the academic health center environment. METHODS: We developed a 60-minute workshop designed to raise awareness of microaggressions encountered by medical students and trainees. The workshop consisted of a didactic presentation and multiple interactive exercises shared in small- and large-group formats. Participants also completed pre- and postsurvey instruments to assess changes in their knowledge and attitudes about promoting an environment that prevents microaggressions from occurring. RESULTS: There were 176 participants who completed our workshop. In comparing anonymized pre- and postworkshop responses submitted by attendees, an increase in recognition of one's own potential stereotypical beliefs about social identity groups was observed. Participants also expressed a greater sense of empowerment to foster mutual respect in health care settings. After completing the workshop, attendees indicated a greater likelihood to engage in difficult conversations, including responding to microaggressions, which both peers and superiors encountered in both academic and clinical environments. DISCUSSION: The workshop provided an interactive format for medical students and trainees to gain awareness, knowledge, and tools for addressing microaggressions encountered in health care settings.

Addressing bias and disparities in periviable counseling and care.

Addressing bias and disparities in counseling and care requires that we contend with dehumanizing attitudes, stereotypes, and beliefs that our society and profession holds towards people of color, broadly, and Black birthing people in particular. It also necessitates an accounting of the historically informed, racist ideologies that shape present-day implicit biases. These biases operate in a distinctly complex and damaging manner in the context of end-of-life care, which centers around questions related to human pain, suffering, and value. Therefore, this paper aims to trace biases and disparities that operate in periviable care, where end-of-life decisions are made at the very beginning of life. We start from a historical context to situate racist ideologies into present day stereotypes and tropes that dehumanize and disadvantage Black birthing people and Black neonates in perinatal care. Here, we review the literature, address historical incidents and consider their impact on our ability to deliver patient-centered periviable care.

What Will You Protect? Redefining Professionalism Through the Lens of Diverse Personal Identities.

INTRODUCTION: Professional identity formation (PIF) encapsulates the process of incorporating a physician's professional identity into existing personal identity. Medical schools shape PIF by reinforcing professional norms defined by a historical physician phenotype. Increasingly, medical students who are underrepresented in medicine must confront the apparent contradictions between personal identities and the often-subjective definitions of professionalism endorsed by faculty, patients, and peers. The lack of a framework for negotiating these conflicts can create barriers to achieving full academic and professional potential. METHODS: We designed a 2-hour professionalism module during the first-year medical student orientation at one medical school. Participating students listened to a physician discuss a defining career moment that required reconciliation of personal and professional identities. Afterwards, students broke into small groups and discussed vignettes illustrating personal identities challenged by professionalism norms. Students then anonymously wrote a reflection about one aspect of their identity they intended to protect during their PIF process. An overwhelming majority of students posted their anonymous reflections on a wall for other students, staff, and faculty to view. RESULTS: We analyzed the written reflective responses to the module. Several broad-ranging themes, including Mission, Identity, and Relationships, were identified. Both participant and facilitator evaluations were analyzed to determine the module's success. DISCUSSION: This module provides a framework for faculty and administrators to create other curricular and pericurricular experiences that positively shape PIF. The session format utilized may generate greater interest in proactively supporting medical students as they navigate formation of their professional identities.

Umbilical cord blood bilirubins, gestational age, and maternal race predict neonatal hyperbilirubinemia.

OBJECTIVE: No validated biomarker at birth exists to predict which newborns will develop severe hyperbilirubinemia. This study's primary aim was to build and validate a prediction model for severe hyperbilirubinemia using umbilical cord blood bilirubins (CBB) and risk factors at birth in neonates at risk for maternal-fetal blood group incompatibility. This study's secondary aim was to compare the accuracy of CBB to the direct antigen titer. METHODS: Inclusion criteria for this prospective cohort study included: ≥35 weeks gestational age, mother with blood type O and/or Rh negative or positive antibody screen, and <24 hours of age. The primary outcome was severe hyperbilirubinemia, defined as phototherapy during the initial hospital stay. Secondary outcomes were a total serum bilirubin concentration >95th and >75th percentile during the initial hospital stay. The predictive performance and accuracy of the two tests (CBB and direct antigen titer) for each outcome was assessed using area under a receiver-operating characteristic curve (AUC), sensitivity, and specificity. RESULTS: When compared to neonates who did not receive phototherapy (n = 463), neonates who received phototherapy (n = 36) had a greater mean CBB ± standard deviation (2.5 ± 0.7 vs. 1.6 ± 0.4 mg/dL, p<0.001). For every 0.3 mg/dL increase in CBB, a neonate was 3.20 (95% confidence interval, 2.31-4.45), 2.10 (1.63-2.70), and 3.12 (2.44-3.99) times more likely to receive phototherapy or have a total serum bilirubin concentration >95th and >75th percentile, respectively. The AUC ± standard error (95% confidence interval) for CBB for phototherapy and a total serum bilirubin concentration >95th and >75th percentile was 0.89 ± 0.03 (0.82-0.95), 0.81 ± 0.04 (0.73-0.90), and 0.84 ± 0.02 (0.80-0.89), respectively. However, the AUC for gestational age and maternal Asian race for these outcomes was only 0.55 ± 0.05 (0.45-0.66), 0.66 ± 0.05 (0.56-0.76), and 0.57 ± 0.04 (0.05-0.64), respectively. When the CBB was combined with gestational age and maternal Asian race, the AUC for a total serum bilirubin concentration >95th percentile improved to 0.87 ± 0.03 (0.81-0.92) (p = 0.034 vs. the model with CBB only and p<0.001 vs. the model with clinical risk factors only). In a sub-group of subjects (n = 189), the AUC for the direct antigen titer for phototherapy was 0.64 ± 0.06 (0.52-0.77) with a 52% sensitivity and 77% specificity. In contrast, a CBB cut-point of 1.85 mg/dL was 92% sensitive and 70% specific for phototherapy with an AUC of 0.87 ± 0.04 (0.80-0.95). CONCLUSION: CBB, in combination with gestational age and maternal race, may be a useful, non-invasive test to predict shortly after birth which neonates will develop severe hyperbilirubinemia.

Cord blood vitamin D status impacts innate immune responses.

OBJECTIVES: Our objectives were to 1) assess cord blood vitamin D concentrations from healthy term newborns, 2) ascertain whether cord blood vitamin D insufficiency precludes optimal induction of the Toll-like receptor (TLR) antimicrobial pathway in monocytes, and 3) determine whether in vitro supplementation with 25-hydroxyvitamin D(3) [25(OH)D(3)] and/or 1,25-dihydroxyvitamin D(3) [1,25(OH)(2)D(3)] restores TLR-induced antimicrobial responses. STUDY DESIGN: Plasma concentrations of 25(OH)D and 1,25(OH)(2)D were measured from cord blood of 23 newborns. Human monocytes were cultured in cord blood plasma and stimulated with TLR2 and TLR4 ligands, and then antimicrobial gene expression was analyzed using quantitative PCR. RESULTS: Cord blood 25(OH)D and 1,25(OH)(2)D concentrations were positively correlated to each other (r = 0.78; P <0.0001). Compared with those conditioned in vitamin D-sufficient plasma [25(OH)D > 75 nmol/liter], monocytes cultured in severely vitamin D-deficient plasma [25(OH)D < 30 nmol/liter] exhibited decreased TLR-induced cathelicidin expression (P <0.05). Supplementation in vitro of vitamin D-deficient plasma with 25(OH)D(3) increased antimicrobial peptide gene expression. CONCLUSIONS: Cord blood vitamin D deficiency, by its effects on TLR-induced antimicrobial production, altered in vitro monocyte responses. The observation that exogenous 25(OH)D(3) in vitro recovered TLR-induced antimicrobial responses suggests the need for additional prospective investigations to further delineate the role of vitamin D in the newborn immune response.