Exploring Medical Student Experiences With Direct Observation During the Pediatric Clerkship.

PURPOSE: Direct observation (DO) enables assessment of vital competencies, such as clinical skills. Despite national requirement that medical students experience DOs during each clerkship, the frequency, length, quality, and context of these DOs are not well established. This study examines the quality, quantity, and characteristics of DOs obtained during pediatrics clerkships across multiple institutions. METHOD: This multimethod study was performed at 6 U.S.-based institutions from March through October 2022. In the qualitative phase, focus groups and/or semistructured interviews were conducted with third-year medical students at the conclusion of pediatrics clerkships. In the quantitative phase, the authors administered an internally developed instrument after focus group discussions or interviews. Qualitative data were analyzed using thematic analysis, and quantitative data were analyzed using anonymous survey responses. RESULTS: Seventy-three medical students participated in 20 focus groups, and 71 (97.3%) completed the survey. The authors identified 7 themes that were organized into key principles: before, during, and after DO. Most students reported their DOs were conducted primarily by residents (62 [87.3%]) rather than attendings (6 [8.4%]) in inpatient settings. Participants reported daily attending observation of clinical reasoning (38 [53.5%]), communication (39 [54.9%]), and presentation skills (58 [81.7%]). One-third reported they were never observed taking a history by an inpatient attending (23 [32.4%]), and one-quarter reported they were never observed performing a physical exam (18 [25.4%]). CONCLUSIONS: This study revealed that students are not being assessed for performing vital clinical skills in the inpatient setting by attendings as frequently as previously believed. When observers set expectations, create a safe learning environment, and follow up with actionable feedback, medical students perceive the experience as valuable; however, the DO experience is currently suboptimal. Therefore, a high-quality, competency-based clinical education for medical students is necessary to directly drive future patient care by way of a competent physician workforce.

Exploring the Value of Improvisational Theater in Medical Education for Advancing the Doctor-Patient Relationship and Health Equity.

PURPOSE: Health care inequities persist, and it is difficult to teach health professions students effectively about implicit bias, structural inequities, and caring for patients from underrepresented or minoritized backgrounds. Improvisational theater (improv), where performers create everything in a spontaneous and unplanned manner, may help teach health professions trainees about advancing health equity. Core improv skills, discussion, and self-reflection can help improve communication; build trustworthy relationships with patients; and address bias, racism, oppressive systems, and structural inequities. METHOD: Authors integrated a 90-minute virtual improv workshop using basic exercises into a required course for first-year medical students at University of Chicago in 2020. Sixty randomly chosen students took the workshop and 37 (62%) responded to Likert-scale and open-ended questions about strengths, impact, and areas for improvement. Eleven students participated in structured interviews about their experience. RESULTS: Twenty-eight (76%) of 37 students rated the workshop as very good or excellent, and 31 (84%) would recommend it to others. Over 80% of students perceived their listening and observation skills improved, and that the workshop would help them take better care of patients with experiences different than their own. Six (16%) students experienced stress during the workshop but 36 (97%) felt safe. Eleven (30%) students agreed there were meaningful discussions about systemic inequities. Qualitative interview analysis showed that students thought the workshop helped develop interpersonal skills (communication, relationship building, empathy); helped personal growth (insights into perception of self and others, ability to adapt to unexpected situations); and felt safe. Students noted the workshop helped them to be in the moment with patients and respond to the unexpected in ways more traditional communication curricula have not. The authors developed a conceptual model relating improv skills and equity teaching methods to advancing health equity. CONCLUSIONS: Improv theater exercises can complement traditional communication curricula to advance health equity.

Improvisational and Standup Comedy, Graphic Medicine, and Theatre of the Oppressed to Teach Advancing Health Equity.

Ninety-minute virtual workshops that used improvisational comedy, standup comedy, graphic medicine, and Theatre of the Oppressed were implemented in 2020 within a required health equity course at the University of Chicago Pritzker School of Medicine to train 90 first-year medical students in advancing health equity. Learning objectives were to (1) deepen understanding of diverse human experiences by developing relationship skills, such as empathy, active listening, engagement, and observation; (2) recognize how diverse patients perceive students and how students perceive them to gain insight into one's identity and how intersectional systems of oppression can stigmatize and marginalize different identities; and (3) engage in free, frank, fearless, and safe conversations about structural racism, colonialism, White and other social privileges, and systemic factors that lead to health inequities. With a 61% (109/180 [90 students × 2 workshops per student]) survey response rate, 72% of respondents thought workshops were very good or excellent, and 83% agreed or strongly agreed they would recommend workshops to others. Key recommendations are to (1) incorporate experiential storytelling and discussion; (2) define clear learning goals for each workshop, map exercises to these goals, and explain their relevance to students; and (3) create a safe, courageous, brave space for exploration and discussion. For health equity, transformation happens as students share their perspectives of curriculum content from their intersectional identities, experiences, and varied privileges; are challenged by others' perspectives; and attempt to understand how others can experience the same content differently. The arts create a powerful form of sharing beyond routine conversations or discussions, which is critical for honest dialogue on difficult topics, such as racism, homophobia, and White privilege and other social privileges. Educators should enable students to have the space, time, and courage to share their true perspectives and engage in authentic discussions that may be uncomfortable but transformative.

Defining existing practices to support the sleep of hospitalized patients: A mixed-methods study of top-ranked hospitals.

The objective of this study was to understand the existing practices and attitudes regarding inpatient sleep at the 2020 US News and World Report (USNWR) Honor Roll pediatric (n = 10) and adult (n = 20) hospitals. Section chiefs of Hospital Medicine from these institutions were surveyed and interviewed between June and August 2021. Among 23 of 30 surveyed physician leaders (response rate = 77%), 96% (n = 22) rated patient sleep as important, but only 43% (n = 10) were satisfied with their institutions' efforts. A total of 96% (n = 22) of institutions lack sleep equity practices. Fewer than half (48%) of top hospitals have sleep-friendly practices, with the most common practices including reducing overnight vital sign monitoring (43%), decreasing ambient light in the wards (43%), adjusting lab and medication schedules (35%), and implementing quiet hours (30%). Major themes from qualitative interviews included: importance of universal sleep-friendly cultures, environmental changes, and external incentives to improve patient sleep.

Piloting I-SLEEP: a patient-centered education and empowerment intervention to improve patients' in-hospital sleep.

BACKGROUND: Sleep disturbances in hospitalized patients are linked to poor recovery. In preparation for a future randomized controlled trial, this pilot study evaluated the feasibility and acceptability of a multi-component intervention (I-SLEEP) that educates and empowers inpatients to advocate for fewer nighttime disruptions in order to improve sleep during periods of hospitalization. METHODS: Eligible inpatients received I-SLEEP, which included an educational video, brochure, sleep kit, and three questions patients can ask their team to reduce nighttime disruptions. Following I-SLEEP, inpatients were surveyed on the primary feasibility outcomes of satisfaction with and use of I-SLEEP components. Inpatients were also surveyed regarding empowerment and understanding of intervention materials. Patient charts were reviewed to collect data on nighttime (11 PM-7 AM) vital sign and blood draws disruptions. RESULTS: Ninety percent (n = 26/29) of patients were satisfied with the brochure and 87% (n = 27/31) with the video. Nearly all (95%, n = 36/37) patients felt empowered to ask their providers to minimize nighttime disruptions and 68% (n = 26/37) intended to alter sleep habits post-discharge. Forty-nine percent (n = 18/37) of patients asked an I-SLEEP question. Patients who asked an I-SLEEP question were significantly more likely to experience nights with fewer disruptions due to nighttime vitals (19% vs. 2.1%, p = 0.008). CONCLUSION: This pilot study found that I-SLEEP was well-accepted and enabled hospitalized patients to advocate for less disrupted sleep. Educating patients to advocate for reducing nighttime disruptions may be a patient-centered, low-cost strategy to improve patients' care and in-hospital experience. These results suggest that I-SLEEP is ready to be evaluated against routine care in a future randomized controlled trial. TRIAL REGISTRATION: ClinicalTrials.Gov NCT04151251 .

Objective Measures of Physical Distancing in the Hospital During the COVID-19 Pandemic.

During the COVID-19 pandemic, hospitals published physical-distancing guidance and created dedicated respiratory isolation units (RIUs) for patients with COVID-19. The degree to which such distancing occurred between clinicians and patients is unknown. In this study, heat sensors from an existing hospital hand-hygiene monitoring system objectively tracked room entries as a proxy for physical distancing in both RIUs and general medicine units before and during the pandemic. The RIUs saw a 60.6% reduction in entries per room per day (from 85.7 to 33.8). General medicine units that cared for patients under investigation for COVID-19 and other patients experienced a 14.7% reduction in entries per room per day (from 76.9 to 65.1). While gradual extinction was observed in both units as COVID-19 cases declined, the RIUs had a higher degree of physical distancing. Although the optimal level of physical distancing is unknown, sustaining physical distancing in the hospital may require re-education and real-time monitoring.

The impact of the COVID-19 pandemic on nighttime room entries and sleep disruptions for pediatric patients.

OBJECTIVES/BACKGROUND: Sleep is critical to recovery, but inpatient sleep is often disrupted. During the COVID-19 pandemic, social distancing efforts to minimize spread may have improved hospitalized children's sleep by decreasing unnecessary overnight disruptions. This study aimed to describe the impact of these efforts on pediatric inpatient sleep using objective and subjective metrics. METHODS: Sleep disruptions for pediatric inpatients admitted prior to and during the COVID-19 pandemic were compared. Hand hygiene sensors tracking room entries were utilized to measure objective overnight disruptions for 69 nights pre-pandemic and 154 pandemic nights. Caregiver surveys of overnight disruptions, sleep quantity, and caregiver mood were adopted from validated tools: the Karolinska Sleep Log, Potential Hospital Sleep Disruptions and Noises Questionnaire, and Visual Analog Mood Scale. RESULTS: Nighttime room entries initially decreased 36% (95% CI: 30%, 42%, p < 0.001), then returned towards baseline, mirroring the COVID-19 hospital census. However, surveyed caregivers (n_pre = 293, n_post = 154) reported more disrupted sleep (p < 0.001) due to tests (21% vs. 38%), anxiety (23% vs. 41%), and pain (23% vs. 48%). Caregivers also reported children slept 61 fewer minutes (95% CI: -12 min, -110 min, p < 0.001). Caregivers self-reported feeling more sad, weary, and worse overall (p < 0.001 for all). CONCLUSIONS: Despite a decrease in objective room entries during the pandemic, caregivers reported their children were disrupted more and slept less. Caregivers also self-reported worse mood. This highlights the effects of the COVID-19 pandemic on subjective experiences of hospitalized children and their caregivers. Future work targeting stress and anxiety could improve pediatric inpatient sleep.

Optimizing Oral Medication Schedules for Inpatient Sleep: A Quality Improvement Intervention.

OBJECTIVES: Hospitalized children experience frequent nighttime awakenings. Oral medications are commonly administered around the clock despite the comparable efficacy of daytime administration schedules, which promote sleep. With this study, we evaluated the effectiveness of a quality improvement initiative to increase the proportion of sleep-friendly antibiotic administration schedules. METHODS: Interprofessional stakeholders modified computerized provider order entry defaults for 4 oral antibiotic medications, from around the clock to administration occurring exclusively during waking hours. Additionally, care-team members received targeted education. Outcome measures included the proportion of sleep-friendly administration schedules and patient caregiver-reported disruptions to sleep. Pre- and posteducation surveys were used to evaluate education effectiveness. Balancing measures were missed antibiotic doses and related escalations of care. RESULTS: Interrupted time series analysis revealed a 72% increase (interceptpre: 18%; interceptpost: 90%; 95% confidence interval: 65%-79%; P < .001) in intercept for percentage of orders with sleep-friendly administration schedules (orders: n pre = 1014 and n post = 649). Compared with preeducation surveys, care-team members posteducation were more likely to agree that oral medications scheduled around the clock cause sleep disruption (resident: 71% pre, 90% post [P = .01]; nurse: 63% pre, 79% post [P = .03]). Although sleep-friendly orders increased, patient caregivers reported an increase in sleep disruption due to medications (pre 28%, post 46%; P < .001). CONCLUSIONS: A simple, low-cost intervention of computerized provider order entry default modifications and education can increase the proportion of sleep-friendly oral antibiotic administration schedules for hospitalized children. Patient perception of sleep is impacted by multiple factors and often does not align with objective data. An increased focus on improving sleep during hospitalization may result in heightened awareness of disruptions.

COVID-19 pneumonia in an infant with a hemodynamically significant ventricular septal defect.

Reports thus far suggest a mild course for acute COVID-19 infection in children; however, its effects in vulnerable paediatric populations, including children with haemodynamically significant congenital heart disease, have rarely been reported. We therefore report on a 4-month-old Hispanic male with a moderate sized conoventricular ventricular septal defect and pulmonary overcirculation who presented with COVID-19-associated pneumonia.

Improving Hospitalized Children's Sleep by Reducing Excessive Overnight Blood Pressure Monitoring.

BACKGROUND: Although required for healing, sleep is often disrupted during hospitalization. Blood pressure (BP) monitoring can be especially disruptive for pediatric inpatients and has few clinical indications. Our aim in this pilot study was to reduce unnecessary overnight BP monitoring and improve sleep for pediatric inpatients. METHODS: The intervention in June 2018 involved clinician education sessions and updated electronic health record (EHR) orders that enabled the forgoing of overnight BP checks. The postintervention period from July 2018 to May 2019 examined patient-caregiver surveys as outcome measures. These surveys measured inpatient sleep and overnight disruptions and were adopted from validated surveys: the Patient Sleep Questionnaire, expanded Brief Infant Sleep Questionnaire, and Potential Hospital Sleep Disruptions and Noises Questionnaire. Uptake of new sleep-friendly EHR orders was a process measure. Reported patient care escalations served as a balancing measure. RESULTS: Interrupted time series analysis of EHR orders (npre = 493; npost = 1472) showed an increase in intercept for the proportion of patients forgoing overnight BP postintervention (+50.7%; 95% confidence interval 41.2% to 60.3%; P < .001) and a subsequent decrease in slope each week (-0.16%; 95% confidence interval -0.32% to -0.01%; P = .037). Statistical process control of surveys (npre = 263; npost = 131) showed a significant increase in sleep duration for patients older than 2, and nighttime disruptions by clinicians decreased by 19% (P < .001). Annual estimated cost savings were $15 842.01. No major adverse events in patients forgoing BP were reported. CONCLUSIONS: A pilot study combining EHR changes and clinician education safely decreased overnight BP checks, increased pediatric inpatient sleep duration, and reduced nighttime disruptions by clinicians.

Characterizing pediatric inpatient sleep duration and disruptions.

OBJECTIVE: To contextualize inpatient sleep duration and disruptions in a general pediatric hospital ward by comparing in-hospital and at-home sleep durations to recommended guidelines and to objectively measure nighttime room entries. METHODS: Caregivers of patients four weeks - 18 years of age reported patient sleep duration and disruptions in anonymous surveys. Average at-home and in-hospital sleep durations were compared to National Sleep Foundation recommendations. Objective nighttime traffic was evaluated as the average number of room entries between 11:00pm and 7:00am using GOJO brand hand-hygiene room entry data. RESULTS: Among 246 patients, patients slept less in the hospital than at home with newborn and infant cohorts experiencing 7- and 4-h sleep deficits respectively (Newborn: 787 ± 318 min at home vs. 354 ± 211 min in hospital, p < 0.001; Infants: 703 ± 203 min at home vs. 412 ± 152 min in hospital, p < 0.01). Newborn children also experienced >2 h sleep deficits at home when compared to NSF recommendations (Newborns: 787 ± 318 min at home vs. 930 min recommended, p < 0.05). Objective nighttime traffic measures revealed that hospitalized children experienced 7.3 room entries/night (7.3 ± 0.25 entries). Nighttime traffic was significantly correlated with caregiver-reported nighttime awakenings (Spearman Rank Correlation Coefficient: 0.83, p < 0.001). CONCLUSION: Hospitalization is a missed opportunity to improve sleep both in the hospital and at home.

Caregiver and Staff Perceptions of Disruptions to Pediatric Inpatient Sleep.

STUDY OBJECTIVES: Sleep is critical to a child's health and well-being, but children are likely to sleep less and be awakened more often during the night in the hospital than at home. To date no studies have compared caregiver, nurse, and physician perspectives of nighttime sleep disruptions in the pediatric general medicine setting. Our aim was to assess caregiver, nurse, and physician perspectives on the most frequent in-hospital disruptors of sleep for pediatric patients. Additionally, we evaluated the degree of agreement of those opinions between the caregivers and medical team. METHODS: Caregivers, nurses, and physicians were surveyed using the Potential Hospital Sleep Disruption and Noises Questionnaire (PHSDNQ) regarding their opinions on factors that disrupt sleep. Caregiver responses were collected via a convenience sample of patients hospitalized from February to August 2017 and hospital staff was surveyed once regarding overall perception. The perceived percentage of patients disrupted by each factor was calculated and compared among groups using chi-square tests. Using caregiver rank order based on mean response as the reference gold standard, the absolute differences of nurse and physician rank orders were summed and analyzed using a two-sample test of proportion. In addition, staff was asked knowledge and empowerment questions about how to maximize patient sleep in the hospital and responses were compared using chi-square tests. RESULTS: A total of 162 caregivers, 77 nurses (84% response rate), and 81 physicians (90% response rate) completed surveys. Checking vital signs (50%), nurse/physician interruption (49%), and continuous pulse oximetry (38%) were the three most prevalent disruptors of pediatric inpatient sleep as reported by caregivers. Significant differences were observed between caregiver, nurse, and physician responses for pain, anxiety, alarms, noise, and tests (P ≤ .001 for all). Both nurse and physician rank orders were discordant when compared to caregivers; there was no significant difference between the two staff groups. When compared to physicians, nurses reported doing more to help children sleep in the hospital (33% versus 94%, P < .001). CONCLUSIONS: Although caregivers report medical interventions such as checking vital signs, nurse/physician interruption, and continuous pulse oximetry as the most frequent disruptors of inpatient pediatric sleep, pediatric staff has poor insight into these disruptions.