Patient- and Family-centered Rounding: A Single-site Look into the Room.

INTRODUCTION: The American Academy of Pediatrics recommends Patient- and Family-centered Rounds (PFCRs) to improve communication between the healthcare team and families while allowing the latter to participate in medical decision-making. PFCRs have a secondary goal of increasing rounds' efficiency and providing a positive learning environment for residents and students. There are many published best practices for PFCR. Our study provides an observational evaluation of PFCR in an academic tertiary medical center using a checklist created from such published best practices. METHODS: We created a standardized observation checklist based on published guidelines. Study members observed 200 individual rounding encounters using this instrument. All inpatient, nonsurgical rounding teams in the fall of 2014 were included and analyzed using descriptive statistics. RESULTS: The average rounding encounter included 9 team members, lasted 9 minutes and 24 seconds, with the medical team entering the patient room for 80.0% of encounters. Families were invited to participate in 60% of the encounters. Lay language was utilized in 62% of the encounters, although 99.5% of the encounters staff used medical terminology. Nursing was present in 64.5% of encounters but presented in only 13.5% of those encounters. The teaching-attending modeled patient interaction behaviors such as eye contact, nodding, and leaning forward in 31%-51% of encounters. CONCLUSIONS: Despite published best practices, medical teams at a large tertiary care center did not adhere to many components of published PCFR guidelines. Future studies should focus on family and physician experience to identify improvement strategies for rounds.

Evaluating the effect of hospital setting on outcomes for neonatal abstinence syndrome.

OBJECTIVES: This study aims to evaluate the impact of hospital setting on outcomes for infants with neonatal abstinence syndrome. STUDY DESIGN: We conducted a retrospective study in two hospitals and three different hospital units. The inpatient group (n = 60) was managed on general inpatient floors, the NICU group (n = 50) was managed primarily in an NICU, and the combination group (n = 49) was managed in both NICU and inpatient units. The primary outcome was length of stay. Secondary outcomes included breastfeeding rates, morphine usage rates, and hospital costs. RESULTS: The length of stay in the inpatient group (8.5 days) was significantly lower than the combination group (18 days) and NICU group (23 days) (p < 0.01). The inpatient group had significantly lower rates of morphine treatment and hospital costs with no difference in breastfeeding rates. CONCLUSIONS: Infants with neonatal abstinence syndrome had a significantly shorter length of stay and less use of morphine when managed on inpatient units versus NICU.

Firearms Screening in the Pediatric Inpatient Setting.

OBJECTIVES: Firearm-related deaths remain a top cause of mortality in American children and adolescents. In a 2012 policy statement, the American Academy of Pediatrics urged pediatricians to incorporate questions about the availability of firearms into their patient history taking. We aim to evaluate the frequency of screening for home firearms in an academic tertiary-care hospital inpatient setting. METHODS: This retrospective chart review examined patients with the following pediatric diagnoses admitted to a tertiary-care pediatric hospital from 2006 to 2015: asthma, bronchiolitis, cellulitis, jaundice, single liveborn infant, bacterial and viral pneumonia, and all mood disorders. Data analysts then searched the patient charts that met these inclusion criteria for documentation of firearm screening as indicated by use of the terms "firearm," "pistol," "gun," "handgun," "bullet," "ammunition," or "rifle" in the admissions history and physical. RESULTS: Evidence of screening for firearms in the home was found in 1196 of the 40 658 charts included in the study (2.94%). The most frequently screened diagnosis and admitting service were mood disorders and child psychiatry, respectively (1159 of 3107; 37.3%). Only 19.8% of identified gun-owning families received specific anticipatory guidance. CONCLUSIONS: Firearm screening and gun safety education occurred infrequently in the inpatient setting. Inpatient encounters may provide an opportunity for increased screening and education because the hospital environment also includes additional resources, exposure to a greater number of providers, and the presence of more family members or caregivers. Further studies are warranted to explore barriers to inpatient screening and possible mechanisms for improvement.

Pediatric Chief Residents' Experiences as Inpatient Attending Physicians.

BACKGROUND: Some pediatric chief residents perform supervisory clinical duties during chief residency, but these activities are highly variable and descriptions are limited. Our goals were to characterize inpatient service performed by pediatric chief residents and to explore factors that influence their experiences as inpatient attending physicians. METHODS: Pediatric chief residents at Accreditation Council for Graduate Medical Education-accredited programs in 2016 were invited to complete a 40-item electronic questionnaire about their inpatient service obligation as well as attitudes regarding this experience. Data were analyzed using Chi-square, analysis of variance tests, and logistic regression. Open-ended responses underwent content analysis. RESULTS: There were 116 completed surveys from a national sample of 223 (response rate 52%); 66% served as inpatient attending physicians during chief residency. On average, chief residents spent 5.5 weeks (range 1-16) in this role with a daily census of 11.5 patients (range 5-20). Those entering primary care were significantly less likely to spend time as an inpatient attending compared with chiefs entering fellowship or hospital medicine (45.7 vs 67.3 vs 83.3%, P = .01). Overall, 92% regarded their inpatient clinical experience positively and indicated they would like the same (40%) or more time (52%) in this role. The average favorability rating was 8.2 of 10, and this was not associated with clinical workload or career choice. CONCLUSIONS: Most chief residents serve as inpatient attending physicians during chief residency. They rate their inpatient experience positively despite wide variability in clinical experiences, patient population, and clinical load. Further studies should examine the value of this experience and its impact on chief residents' future practice.

Adherence to AAP Healthy Newborn Discharge Criteria in a Tertiary Care Children's Hospital.

OBJECTIVES: In 2015, the American Academy of Pediatrics (AAP) published an updated consensus statement containing 17 discharge recommendations for healthy term newborn infants. In this study, we identify whether the AAP criteria were met before discharge at a tertiary care academic children's hospital. METHODS: A stratified random sample of charts from newborns who were discharged between June 1, 2015, and May 31, 2016, was reviewed. Of the 531 charts reviewed, 433 were included in the study. A review of each chart was performed, and data were collected. RESULTS: Descriptive statistics for our study population (N = 433) revealed that all 17 criteria were followed <5% of the time. The following criteria were met 100% of the time: clinical course and physical examination, postcircumcision bleeding, availability of family members or health care providers to address follow-up concerns, anticipatory guidance, first appointment with the physician scheduled or parents knowing how to do so, pulse oximetry screening, and hearing screening. These criteria were met at least 95% to 99% of the time: appropriate vital signs, regular void and stool frequency, appropriate jaundice and sepsis management, and metabolic screening. The following criteria were met 50% to 95% of the time: maternal serologies, hepatitis B vaccination, and social risk factor assessment. Four of the criteria were met <50% of the time: feeding assessment, maternal vaccination, follow-up timing for newborns discharged at <48 hours of life, and car safety-seat assessment. CONCLUSIONS: Our data reveal that the AAP healthy term newborn discharge recommendations are not consistently followed in our institution.

A Novel Approach to Assessing Infants With Neonatal Abstinence Syndrome.

OBJECTIVES: Neonatal abstinence syndrome (NAS) is a growing problem and poses a significant burden on the health care system. The traditional Finnegan Neonatal Abstinence Scoring System (FNASS) assessment approach may lead to unnecessary opioid treatment of infants with NAS. We developed a novel assessment approach and describe its effect on the management of infants with NAS. METHODS: We retrospectively compared treatment decisions of 50 consecutive opioid-exposed infants managed on the inpatient unit at the Yale New Haven Children's Hospital. All infants had FNASS scores recorded every 2 to 6 hours but were managed by using the Eat, Sleep, Console (ESC) assessment approach. Actual treatment decisions made by using the ESC approach were compared with predicted treatment decisions based on recorded FNASS scores. The primary outcome was postnatal treatment with morphine. RESULTS: By using the ESC approach, 6 infants (12%) were treated with morphine compared with 31 infants (62%) predicted to be treated with morphine by using the FNASS approach (P < .001). The ESC approach started or increased morphine on 8 days (2.7%) compared with 76 days (25.7%) predicted by using the FNASS approach (P < .001). There were no readmissions or adverse events reported. CONCLUSIONS: Infants managed by using the ESC approach were treated with morphine significantly less frequently than they would have been by using the FNASS approach. The ESC approach is an effective method for the management of infants with NAS that limits pharmacologic treatment and may lead to substantial reductions in length of stay.

An Initiative to Improve the Quality of Care of Infants With Neonatal Abstinence Syndrome.

BACKGROUND AND OBJECTIVES: The incidence of neonatal abstinence syndrome (NAS), a constellation of neurologic, gastrointestinal, and musculoskeletal disturbances associated with opioid withdrawal, has increased dramatically and is associated with long hospital stays. At our institution, the average length of stay (ALOS) for infants exposed to methadone in utero was 22.4 days before the start of our project. We aimed to reduce ALOS for infants with NAS by 50%. METHODS: In 2010, a multidisciplinary team began several plan-do-study-act cycles at Yale New Haven Children's Hospital. Key interventions included standardization of nonpharmacologic care coupled with an empowering message to parents, development of a novel approach to assessment, administration of morphine on an as-needed basis, and transfer of infants directly to the inpatient unit, bypassing the NICU. The outcome measures included ALOS, morphine use, and hospital costs using statistical process control charts. RESULTS: There were 287 infants in our project, including 55 from the baseline period (January 2008 to February 2010) and 44 from the postimplementation period (May 2015 to June 2016). ALOS decreased from 22.4 to 5.9 days. Proportions of methadone-exposed infants treated with morphine decreased from 98% to 14%; costs decreased from $44 824 to $10 289. No infants were readmitted for treatment of NAS and no adverse events were reported. CONCLUSIONS: Interventions focused on nonpharmacologic therapies and a simplified approach to assessment for infants exposed to methadone in utero led to both substantial and sustained decreases in ALOS, the proportion of infants treated with morphine, and hospital costs with no adverse events.