A 'PEaRL' of Support and Cooperative Learning: A Pilot Study Shifting the Sands of the Dreaded Morbidity and Mortality Conference.

BACKGROUND: When unanticipated and/or poor patient outcomes occur, clinicians frequently experience guilt, anger, psychological distress, and fear, which can be intensified by traditional morbidity and mortality conferences. METHODS: The Pediatric Event Review and Learning (PEaRL) curriculum was developed to discuss unanticipated and/or poor patient outcomes and foster support while highlighting foundational safety concepts. Pre- and post-implementation evaluations of quarterly cased-based sessions were completed. RESULTS: All respondents endorsed that unanticipated and/or poor patient outcomes affected their mood, well-being, and functioning. Post-implementation of the PEaRL curriculum, significantly more respondents endorsed existence of a safe environment and structured format to discuss these outcomes, as well as feeling more supported. DISCUSSION: The PEaRL curriculum provides a valuable opportunity for trainees and experienced clinicians alike to explore and discuss unanticipated and/or poor patient outcomes while addressing key patient safety principles.

Kwashiorkor in an 8-Month-Old Infant Due to Homemade Formula Use.

INTRODUCTION: Kwashiorkor is a malnutrition syndrome most commonly seen in the United States among patients with malabsorptive conditions. While it is rare in otherwise healthy individuals, cases can develop where low nutritional literacy or unorthodox diets are a factor. CASE PRESENTATION: We present an 8-month-old infant who developed kwashiorkor after transitioning to homemade infant formula. DISCUSSION: This patient developed severe malnutrition due to consumption of homemade formula that did not meet nutritional standards. The recipe was promoted by an alternative health organization as a healthy option, and the difficulty in identifying reliable health information online also played a significant role. CONCLUSIONS: Families of young children face many challenges, particularly during the recent infant formula shortage. Maintaining strong relationships and open communication with trusted health care professionals is vital to combating health misinformation and helping patients and families navigate these challenges safely.

Diagnostic Time-Outs to Improve Diagnosis.

Diagnostic errors harm patients. While the underlying causes of diagnostic error and the settings in which they occur are diverse, the use of a cognitive forcing function in the form of a diagnostic time-out can mitigate the risk of diagnostic error. Barriers to the implementation of diagnostic time-outs remain. In our survey of neonatal intensive care unit (NICU) providers, perceived time constraints were universally cited as a barrier. Attending neonatologists and neonatology nurse practitioners reported decreased perception of the risk of diagnostic error impacting patient outcomes, relative to the perception among neonatology fellowship trainees. Future directions include addressing concerns over the perceived time investment required for a diagnostic time-out and increasing provider appreciation of the nature and impact of diagnostic error on patient outcomes.

A pause in pediatrics: implementation of a pediatric diagnostic time-out.

OBJECTIVES: Diagnostic errors are frequently the product of cognitive biases that arise when heuristic-based approaches fail. The efficiency-thoroughness tradeoff (ETTO) principle states sacrificing thoroughness for efficiency is normal and occurs frequently in medicine. The goal of a diagnostic timeout was to provide an actionable template for when providers transition to an analytical mindset and to help incorporate the ETTO principle during the diagnostic process. METHODS: A diagnostic time-out was adapted for use in pediatric hospital medicine (PHM). In this prospective study, a group of eight PHM providers piloted the time-out in the hospitalized setting. Data was collected over 12 months and descriptive statistics were used for analysis. RESULTS: Cases were most frequently chosen for time-out use due to clinician intuition. In more than half the cases the time-out didn't confirm the initial diagnosis and alternate diagnoses for the wrong diagnosis were pursued. There was only one case of the time-out being burdensome from a time perspective. Learners participated in all cases. As a result of the diagnostic time-out, new actions were taken in all cases. CONCLUSIONS: Implementation of a diagnostic time out provides an actionable template for providers to actively change their mindset to an analytical thinking process to counteract cognitive biases and potentially reduce diagnostic errors in the pediatric inpatient setting.

Pausing During the Pandemic: Addressing Cognitive Biases in Providers' Medical Decision-Making During the COVID-19 Era.

INTRODUCTION: The COVID-19 pandemic has not only exacerbated traditional cognitive biases but also created new cognitive biases specific to the pandemic that contribute to diagnostic errors. Cases of suspected multisystem inflammatory syndrome in children (MIS-C)-one of the more clinically significant manifestations of COVID-19 in children-need to be reported and reviewed by clinicians as they have varied presentations and lack definitive confirmatory testing, presenting challenges to effective diagnosis. CASE PRESENTATION: We present 3 cases of pediatric patients initially diagnosed with COVID-19/MIS-C who were ultimately found to have alternative diagnoses. DISCUSSION: For each case, we describe conventional and COVID-19-related cognitive biases to enhance awareness of their role in diagnostics and promote strategies to support diagnostic accuracy and timeliness. CONCLUSION: With rapidly changing knowledge about COVID-19 and MIS-C, providers must remain diligent to counteract heuristic thinking and provide timely and accurate diagnostic evaluations.

The Great Gut Mimicker: A case report of MIS-C and appendicitis clinical presentation overlap in a teenage patient.

BACKGROUND: Abdominal pain and other gastrointestinal symptoms are common presenting features of multisystem inflammatory syndrome in children (MIS-C) and can overlap with infectious or inflammatory abdominal conditions, making accurate diagnosis challenging. CASE PRESENTATION: We describe the case of a 16-year-old female who presented with clinical symptoms suggestive of appendicitis and an abdominal computed tomography (CT) that revealed features concerning for appendicitis. After laparoscopic appendectomy, histopathology of the appendix demonstrated only mild serosal inflammation and was not consistent with acute appendicitis. Her overall clinical presentation was felt to be consistent with MIS-C and she subsequently improved with immunomodulatory and steroid treatment. CONCLUSIONS: We note that MIS-C can mimic acute appendicitis. This case highlights MIS-C as a cause of abdominal imaging with features concerning for appendicitis, and MIS-C should be considered in the differential for a patient with appendicitis-like symptoms and a positive COVID-19 IgG. Lab criteria, specifically low-normal white blood cell count and thrombocytopenia, appears to be of high relevance in differing MIS-C from acute appendicitis, even when appendix radiologically is dilated.

One Call Away: Addressing a Safety Gap for Urgent Issues Post Discharge.

OBJECTIVES: The transition period from hospitalization to outpatient care can be high risk for pediatric patients. Our aim was to profile the use of a "safety net" for families through provision of specific inpatient provider contact information for urgent issues post discharge. METHODS: In this prospective study, we implemented an updated after-visit summary that directed families to call the hospital operator and specifically ask for the pediatric hospital medicine attending on call if they were unable to reach their primary care provider (PCP) with an urgent postdischarge concern. Education for nursing staff, operators, and pediatric hospital medicine providers was completed, and contact information was automatically populated into the after-visit summary. Information collected included the number of calls, the topic, time spent, whether the family contacted the PCP first, and the time of day. Descriptive statistics and Fisher's exact test were used to summarize findings. RESULTS: Over a 13-month period, of 5145 discharges, there were 47 postdischarge phone calls, which averaged to 3.6 calls per month. The average length of time spent on a call was 21 minutes. For 30% of calls, families had tried contacting their PCPs first, and 55% of calls occurred at night. Topics of calls included requesting advice about symptoms, time line for reevaluation, and assistance with medications. CONCLUSIONS: This safety net provided families with real-time problem-solving for an urgent need post discharge, which included triaging patient symptoms at home, counseling on medication questions, information about the time line of illness recovery, and provision of additional resources.

Severe methemoglobinemia due to topical dapsone misuse in a teenage girl.

Dapsone gel is a topical treatment for facial acne in adolescents and adults, and while systemic dapsone therapy is known to be associated with methemoglobinemia, once-daily topical dapsone has been well tolerated with few side effects in large randomized controlled trials. We describe the first reported case of severe methemoglobinemia in a healthy adolescent using daily topical dapsone. Although the medication was prescribed for facial use only, the patient reported topical use over her back and chest as well. This case illustrates the potential for significant systemic dapsone absorption even with daily topical dosing and demonstrates the need for clear anticipatory guidance to prevent the potential morbidity and mortality associated with methemoglobinemia from improper topical dapsone use.