Disparities in COVID-19 vaccine intentions, testing and trusted sources by household language for children with medical complexity.

OBJECTIVES: Children with medical complexity experienced health disparities during the coronavirus disease 2019 (COVID-19) pandemic. Language may compound these disparities since people speaking languages other than English (LOE) also experienced worse COVID-19 outcomes. Our objective was to investigate associations between household language for children with medical complexity and caregiver COVID-19 vaccine intentions, testing knowledge, and trusted sources of information. METHODS: This cross-sectional survey of caregivers of children with medical complexity ages 5 to 17 years was conducted from April-June 2022. Children with medical complexity had at least 1 Complex Chronic Condition. Households were considered LOE if they reported speaking any language other than English. Multivariable logistic regression examined associations between LOE and COVID-19 vaccine intentions, interpretation of COVID-19 test results, and trusted sources of information. RESULTS: We included 1,338 caregivers of children with medical complexity (49% response rate), of which 133 (10%) had household LOE (31 total languages, 58% being Spanish). There was no association between household LOE and caregiver COVID-19 vaccine intentions. Caregivers in households with LOE had similar interpretations of positive COVID-19 test results, but significantly different interpretations of negative results. Odds of interpreting a negative test as expected (meaning the child does not have COVID-19 now or can still get the virus from others) were lower in LOE households (aOR [95% CI]: 0.56 [0.34-0.95]). Households with LOE were more likely to report trusting the US government to provide COVID-19 information (aOR [95% CI]: 1.86 [1.24-2.81]). CONCLUSION: Differences in COVID-19 test interpretations based on household language for children with medical complexity were observed and could contribute to disparities in outcomes. Opportunities for more inclusive public health messaging likely exist.

Screening for Nephropathy in Pediatric Type 2 Diabetes: Quality Improvement to Increase Nephropathy Screening.

Background: Screening for early detection of microalbuminuria signaling kidney disease should begin as early as the time of diagnosis of youth-onset type 2 diabetes. This quality improvement initiative aimed to standardize urine nephropathy screening in pediatric patients with type 2 diabetes at a tertiary academic medical center and increase a baseline screening rate of 56%-75% over 6 months (September 2022-February 2023) and sustain that increase for 6 months (March through August 2023). Methods: A multi-disciplinary team used quality improvement methods and iterative Plan-Do-Study-Act cycles. Targeted interventions included previsit planning workflow, education, and a new-onset triage protocol. The team collected data at baseline and prospectively by reviewing electronic medical records. The primary outcome measure was pediatric type 2 diabetes clinic visits in diabetes clinic with urine nephropathy screening before or on the visit date. Results: A total of 121 youth were scheduled for T2D clinic visits between September 2021 and August 2023. The mean age was 14.5 years, and 60% were women, 40% were non-Hispanic Black, 28% were Hispanic/Latino, and 15% reported Spanish as their preferred language. Following the interventions of this project, urine nephropathy screening increased from 56% to 75%, and this change was sustained for 6 months. Conclusions: Interventions focused on efficient recognition of the population needing screening, coordinated internal processes around screening, a shared understanding between all stakeholders, and practical support in the healthcare system increased urine nephropathy screening with sustained improvement.

Multicenter Quality Collaborative to Reduce Overuse of High-Flow Nasal Cannula in Bronchiolitis.

BACKGROUND AND OBJECTIVES: High-flow nasal cannula (HFNC) for bronchiolitis increased over the past decade without clear benefit. This quality improvement collaborative aimed to reduce HFNC initiation and treatment duration by 30% from baseline. METHODS: Participating hospitals either reduced HFNC initiation (Pause) or treatment duration (Holiday) in patients aged <24 months admitted for bronchiolitis. Participants received either Pause or Holiday toolkits, including: intervention protocol, training/educational materials, electronic medical record queries for data acquisition, small-group coaching, webinars, and real-time access to run charts. Pause arm primary outcome was proportion of patients initiated on HFNC. Holiday arm primary outcome was geometric mean HFNC treatment duration. Length of stay (LOS) was balancing measure for both. Each arm served as contemporaneous controls for the other. Outcomes analyzed using interrupted time series (ITS) and linear mixed-effects regression. RESULTS: Seventy-one hospitals participated, 30 in the Pause (5746 patients) and 41 in the Holiday (7903 patients). Pause arm unadjusted HFNC initiation decreased 32% without LOS change. ITS showed immediate 16% decrease in initiation (95% confidence interval [CI] -27% to -5%). Compared with contemporaneous controls, Pause hospitals reduced HFNC initiation by 23% (95% CI -35% to -10%). Holiday arm unadjusted HFNC duration decreased 28% without LOS change. ITS showed immediate 11.8 hour decrease in duration (95% CI -18.3 hours to -5.2 hours). Compared with contemporaneous controls, Holiday hospitals reduced duration by 11 hours (95% CI -20.7 hours to -1.3 hours). CONCLUSIONS: This quality improvement collaborative reduced HFNC initiation and duration without LOS increase. Contemporaneous control analysis supports intervention effects rather than secular trends toward less use.

Qualitative feedback from caregivers in a multidisciplinary pediatric neuromuscular clinic.

PURPOSE: This study explored family satisfaction and perceived quality of care in a pediatric neuromuscular care clinic to assess the value of the multidisciplinary clinic (MDC) model in delivering coordinated care to children with neuromuscular disorders, such as cerebral palsy. METHODS: Caregivers of 22 patients were administered a qualitative survey assessing their perceptions of clinic efficiency, care coordination, and communication. Surveys were audio-recorded and transcribed. Thematic analysis was completed using both deductive and inductive methods. RESULTS: All caregivers reported that providers adequately communicated next steps in the patient's care, and most reported high confidence in caring for the patient as a result of the clinic. Four major themes were identified from thematic analysis: Care Delivery, Communication, Care Quality, and Family-Centeredness. Caregivers emphasized that the MDC model promoted access to care, enhanced efficiency, promoted provider teamwork, and encouraged shared care planning. Caregivers also valued a physical environment that was suitable for patients with complex needs. CONCLUSION: This study demonstrated that caregivers believed the MDC model was both efficient and convenient for pediatric patients with neuromuscular disorders. This model has the potential to streamline medical care and can be applied more broadly to improve care coordination for children with medical complexity.

Domains of professional fulfillment for pediatric hospital medicine: A concept mapping study.

BACKGROUND: We know little about how pediatric hospital medicine (PHM) physicians conceptualize their professional fulfillment (PF). The objective of this study was to determine how PHM physicians conceptualize PF. OBJECTIVE: The objective of this study was to determine how PHM physicians conceptualize PF. METHODS: We performed a single-site group concept mapping (GCM) study to create a stakeholder-informed model of PHM PF. We followed established GCM steps. For brainstorming, PHM physicians responded to a prompt to generate ideas describing the concept of PHM PF. Next, PHM physicians sorted the ideas based on conceptual relatedness and ranked them on importance. Responses were analyzed to create point cluster maps where each idea represented one point, and point proximity illustrated how often ideas were sorted together. Using an iterative and consensus-driven approach, we selected a cluster map best representing the ideas. Mean rating scores for all the items in each cluster were calculated. RESULTS: Sixteen PHM physicians identified 90 unique ideas related to PHM PF. The final cluster map described nine domains for PHM PF: (1) work personal-fit, (2) people-centered climate, (3) divisional cohesion and collaboration, (4) supportive and growth-oriented environment, (5) feeling valued and respected, (6) confidence, contribution, and credibility, (7) meaningful teaching and mentoring, (8) meaningful clinical work, and (9) structures to facilitate effective patient care. The domains with the highest and lowest importance ratings were divisional cohesion and collaboration and meaningful teaching and mentoring. CONCLUSION: Domains of PF for PHM physicians extend beyond existing PF models, particularly the importance of teaching and mentoring.

Perspectives of Health Care Personnel on the Benefits of Bronchiolitis Interventions.

OBJECTIVES: Many interventions in bronchiolitis are low-value or poorly studied. Inpatient bronchiolitis management is multidisciplinary, with varying degrees of registered nurse (RN) and respiratory therapist (RT) autonomy. Understanding the perceived benefit of interventions for frontline health care personnel may facilitate deimplementation efforts. Our objective was to examine perceptions surrounding the benefit of common inpatient bronchiolitis interventions. METHODS: We conducted a cross-sectional survey of inpatient pediatric RNs, RTs, and physicians/licensed practitioners (P/LPs) (eg, advanced-practice practitioners) from May to December of 2021 at 9 university-affiliated and 2 community hospitals. A clinical vignette preceded a series of inpatient bronchiolitis management questions. RESULTS: A total of 331 surveys were analyzed with a completion rate of 71.9%: 76.5% for RNs, 57.4% for RTs, and 71.2% for P/LPs. Approximately 54% of RNs and 45% of RTs compared with 2% of P/LPs believe albuterol would be "extremely or somewhat likely" to improve work of breathing (P < .001). Similarly, 52% of RNs, 32% of RTs, and 23% of P/LPs thought initiating or escalating oxygen in the absence of hypoxemia was likely to improve work of breathing (P < .001). Similar differences in perceived benefit were observed for steroids, nebulized hypertonic saline, and deep suctioning, but not superficial nasal suctioning. Hospital type (community versus university-affiliated) did not impact the magnitude of these differences. CONCLUSIONS: Variation exists in the perceived benefit of several low-value or poorly studied bronchiolitis interventions among health care personnel, with RNs/RTs generally perceiving higher benefit. Deimplementation, educational, and quality improvement efforts should be designed with an interprofessional framework.

Multicenter Study of High-Flow Nasal Cannula Initiation and Duration of Use in Bronchiolitis.

BACKGROUND AND OBJECTIVES: There is a paucity of multicenter data on rates of high flow nasal cannula (HFNC) usage in bronchiolitis in the United States, largely because of the absence of standardized coding, with HFNC often subsumed into the larger category of noninvasive mechanical ventilation. METHODS: We examined HFNC utilization in patients with bronchiolitis from a sample of hospitals participating in a national bronchiolitis quality improvement collaborative. Medical records of patients aged <2 years admitted November 2019 to March 2020 were reviewed and hospital-specific bronchiolitis policies were collected. Exclusion criteria were prematurity <32 weeks, any use of mechanical ventilation, and presence of comorbidities. HFNC utilization (including initiation, initiation location, and treatment duration), and hospital length of stay (LOS) were calculated. HFNC utilization was analyzed by individual hospital HFNC policy characteristics. RESULTS: Sixty-one hospitals contributed data on 8296 patients; HFNC was used in 52% (n = 4286) of admissions, with the most common initiation site being the emergency department (ED) (75%, n = 3226). Hospitals that limited HFNC use to PICUs had reduced odds of initiating HFNC (odds ratio, 0.3; 95% confidence interval [CI], 0.3 to 0.4). Hospitals with an ED protocol to delay HFNC initiation had shorter HFNC treatment duration (-12 hours; 95% CI, -15.6 to -8.8) and shorter LOS (-14.9 hours; 95% CI, -18.2 to -11.6). CONCLUSIONS: HFNC was initiated in >50% of patients admitted with bronchiolitis in this hospital cohort, most commonly in the ED. In general, hospitals with policies to limit HFNC use demonstrated decreased odds of HFNC initiation, shorter HFNC duration, and reduced LOS compared with the study population.

Gender Difference in Teaching Evaluation Scores of Pediatric Faculty.

OBJECTIVE: To evaluate associations between faculty gender and milestone-based teaching assessment scores assigned by residents. METHODS: We performed a retrospective cohort study of milestone-based clinical teaching assessments of pediatric faculty completed by pediatric residents at a mid-sized residency program from July 2016 to June 2019. Assessments included 3 domains (Clinical Interactions, Teaching Skills, Role Modeling/Professionalism) comprised of a total of 11 sub-competency items. We used multilevel logistic regression accounting for repeat measures and clustering to evaluate associations between faculty gender and assessment scores in the 1) top quartile, 2) bottom quartile, or 3) top-box (highest score). Findings were adjusted for faculty rank and academic track, and resident year and gender. RESULTS: Over 3 years, 2889 assessments of 104 faculty were performed by 91 residents. Between assessments of women and men faculty, there were no significant differences in the odds of receiving a score in the top quartile for the 3 domains (Clinical aOR 0.99, P = .86; Teaching aOR 0.99, P = .93; Role Modeling aOR 0.87, P = .089). However, assessments of women were more likely to receive a score in the bottom quartile in both Teaching (aOR 1.23, P = .019) and Role Modeling (aOR 1.26, P = .008). Assessments of women also had lower odds of receiving the highest score in 6 of 11 sub-competencies. CONCLUSION: Results suggest that gender bias may play a role in resident assessments of pediatric faculty. Future studies are needed to determine if findings are replicated in other settings and to identify opportunities to reduce the gender gap in pediatric academic medicine.

COVID-19 Vaccination Intentions for Children With Medical Complexity.

OBJECTIVES: The chronic conditions and functional limitations experienced by children with medical complexity (CMC) place them at disproportionate risk for COVID-19 transmission and poor outcomes. To promote robust vaccination uptake, specific constructs associated with vaccine hesitancy must be understood. Our objective was to describe demographic, clinical, and vaccine perception variables associated with CMC parents' intention to vaccinate their child against COVID-19. METHODS: We conducted a cross-sectional survey (June-August 2021) for primary caregivers of CMC between ages 5 to 17 at an academic medical center in the Midwest. Multivariable logistic regression examined associations between vaccination intent and selected covariates. RESULTS: Among 1330 families, 65.8% indicated vaccination intent. In multivariable models, demographics had minimal associations with vaccination intent; however, parents of younger children (<12 years) had significantly lower adjusted odds of vaccination intent (adjusted odds ratio [95% confidence interval]: 0.26 [0.17-0.3]) compared to parents of older children (≥12 years). CMC with higher severity of illness, ie, those with ≥1 hospitalization in the previous year (versus none) or >1 complex chronic condition (vs 1), had higher adjusted odds of vaccination intent (1.82 [1.14-2.92] and 1.77 [1.16-2.71], respectively). Vaccine perceptions associated with vaccine intention included "My doctor told me to get my child a COVID-19 vaccine" (2.82 [1.74-4.55]); and "I'm concerned about my child's side effects from the vaccine" (0.18 [0.12-0.26]). CONCLUSIONS: One-third of CMC families expressed vaccine hesitation; however, constructs strongly associated with vaccination intent are potentially modifiable. Pediatrician endorsement of COVID-19 vaccination and careful counseling on side effects might be promising strategies to encourage uptake.

Association of Patient Characteristics With Postoperative Mortality in Children Undergoing Tonsillectomy in 5 US States.

Importance: The rate of postoperative death in children undergoing tonsillectomy is uncertain. Mortality rates are not separately available for children at increased risk of complications, including young children (aged <3 y) and those with sleep-disordered breathing or complex chronic conditions. Objective: To estimate postoperative mortality following tonsillectomy in US children, both overall and in relation to recognized risk factors for complications. Design, Setting, and Participants: Retrospective cohort study based on longitudinal analysis of linked records in state ambulatory surgery, inpatient, and emergency department discharge data sets distributed by the Healthcare Cost and Utilization Project for 5 states covering 2005 to 2017. Participants included 504 262 persons younger than 21 years for whom discharge records were available to link outpatient or inpatient tonsillectomy with at least 90 days of follow-up. Exposures: Tonsillectomy with or without adenoidectomy. Main Outcome and Measures: Postoperative death within 30 days or during a surgical stay lasting more than 30 days. Modified Poisson regression with sample weighting was used to estimate postoperative mortality per 100 000 operations, both overall and in relation to age group, sleep-disordered breathing, and complex chronic conditions. Results: The 504 262 children in the cohort underwent a total of 505 182 tonsillectomies (median [IQR] patient age, 7 [4-12] years; 50.6% females), of which 10.1% were performed in young children, 28.9% in those with sleep-disordered breathing, and 2.8% in those with complex chronic conditions. There were 36 linked postoperative deaths, which occurred a median (IQR) of 4.5 (2-20.5) days after surgical admission, and most of which (19/36 [53%]) occurred after surgical discharge. The unadjusted mortality rate was 7.04 (95% CI, 4.97-9.98) deaths per 100 000 operations. In multivariable models, neither age younger than 3 years nor sleep-disordered breathing was significantly associated with mortality, but children with complex chronic conditions had significantly higher mortality (16 deaths/14 299 operations) than children without these conditions (20 deaths/490 883 operations) (117.22 vs 3.87 deaths per 100 000 operations; adjusted rate difference, 113.55 [95% CI, 51.45-175.64] deaths per 100 000 operations; adjusted rate ratio, 29.39 [95% CI, 13.37-64.62]). Children with complex chronic conditions accounted for 2.8% of tonsillectomies but 44% of postoperative deaths. Most deaths associated with complex chronic conditions occurred in children with neurologic/neuromuscular or congenital/genetic disorders. Conclusions and Relevance: Among children undergoing tonsillectomy, the rate of postoperative death was 7 per 100 000 operations overall and 117 per 100 000 operations among children with complex chronic conditions. These findings may inform decision-making for pediatric tonsillectomy.

US Hospital Stays in Children and Adolescents With Acetaminophen Poisoning.

OBJECTIVES: Acetaminophen poisoning occurs in all age groups; however, hospital-based outcomes of children with these poisonings were not well characterized. Our objectives were to describe the incidence, characteristics, and outcomes of hospital stays in children with acetaminophen poisoning and evaluate the contribution of intentionality. METHODS: We used the 2016 Kids' Inpatient Database and validated International Classification of Diseases, 10th Revision diagnostic codes to identify hospitalizations of children aged 0 to 19 years for acetaminophen poisoning. We used standard survey methods to generate weighted population estimates and describe characteristics and outcomes, both overall and stratified by intentionality. RESULTS: There were 9935 (95% confidence interval [CI], 9252-10 619) discharges from acute care hospitals for acetaminophen poisoning in U.S. children aged 0 to 19 years during 2016, corresponding to a population rate of 12.1 (95% CI, 11.3-12.9) hospitalizations per 100 000 children. Most hospitalizations for both intentional and unintentional acetaminophen poisoning occurred in females, with a strongly age-related sex distribution. Median length of stay was 2 days (interquartile range, 1-4 days); however, nearly half of discharges were subsequently transferred to another type of facility (eg, psychiatric hospital). Median hospital charges for acute care were $14 379 (interquartile range, $9162-$23 114), totaling $204.7 million (95% CI, $187.4-$221.9) in aggregate. Of 31 632 hospital discharges associated with self-harm medication poisoning in children aged 0 to 19 years, acetaminophen was the single most commonly implicated agent. CONCLUSIONS: Acetaminophen poisoning was the most common cause of U.S. hospital stays associated with medication self-harm poisoning. More effective acetaminophen poisoning prevention strategies are needed, which may reduce the burden of this common adolescent malady.

Association Between Neighborhood Disadvantage and Pediatric Readmissions.

OBJECTIVE: Although individual-level social determinants of health (SDH) are known to influence 30-day readmission risk, contextual-level associations with readmission are poorly understood among children. This study explores associations between neighborhood disadvantage measured by Area Deprivation Index (ADI) and pediatric 30-day readmissions. METHODS: This retrospective cohort study included discharges of patients aged < 20 years from Maryland's 2013-2016 all-payer dataset. The ADI, which quantifies 17 indicators of neighborhood socioeconomic disadvantage within census block groups, is used as a proxy for contextual-level SDH. Readmissions were identified with the 30-day Pediatric All-Condition Readmissions measure. Associations between ADI and readmission were identified with generalized estimating equations adjusted for patient demographics and clinical severity (Chronic Condition Indicator [CCI], Pediatric Medical Complexity Algorithm [PMCA], Index Hospital All Patients Refined Diagnosis Related Groups [APR-DRG]), and hospital discharge volume. RESULTS: Discharges (n = 138,998) were mostly female (52.7%), publicly insured (55.1%), urban-dwelling (93.0%), with low clinical severity levels (0-1 CCIs [82.3%], minor APR-DRG severity [48.4%]). Overall readmission rate was 4.0%. Compared to the least disadvantaged ADI quartile, readmissions for the most disadvantaged quartile were significantly more likely (aOR 1.19, 95% CI 1.09-1.30). After adjustment, readmissions were associated with public insurance and indicators of medical complexity (higher number of CCIs, complex-chronic disease PMCA, and APR-DRG severity). CONCLUSION: In this all-payer, statewide sample, living in the most socioeconomically disadvantaged neighborhoods independently predicted pediatric readmission. While the relative magnitude of neighborhood disadvantage was modest compared to medical complexity, disadvantage is modifiable and thus represents an important consideration for prevention and risk stratification efforts.

Reducing Delays in a Pediatric Procedural Unit With Ultrasound-Guided Intravenous Line Insertion.

OBJECTIVES: Delay in vascular access is a leading cause of procedure delay in our pediatric procedure and infusion center. Use of ultrasound decreases time to peripheral intravenous catheter (PIV) insertion; however, ultrasound availability in our center was limited to an external venous access team (VAT). The objective of this project was to reduce PIV-related delays by 25%. METHODS: Stakeholders convened and theorized that creating a unit-based nurse team specializing in ultrasound-guided peripheral intravenous catheter (USgPIV) insertion would facilitate faster access and a reduction in delayed procedures. An initial plan-do-study-act cycle was performed, training 2 nurses in USgPIV placement. Subsequent cycles were focused on increasing availability of USgPIV-trained nurses. The outcome measure was the rate of procedures delayed by PIV placement, analyzed on a statistical process control U-chart. The process measure was the percentage of USgPIV placements requiring consultations to the VAT, analyzed on a statistical process control P-chart. The balancing measure was the success rate per method of insertion. Comparisons of success rates were conducted by using a χ2 test and Fisher's exact test. RESULTS: The mean rate of procedures delayed because of vascular access fell by special cause variation from 10.8% to 6.4%. The mean VAT consultation rate fell from 86.4% to 32.0%. The VAT had higher rates of overall success (100% vs 87%; P = .01) and first-attempt success (93% vs 77%; P = .03) compared with unit nurse USgPIV placement. CONCLUSIONS: Unit-based USgPIV placement in a pediatric procedural center was successfully implemented, with a significant decline in procedures delayed by PIV access.

Complex Care Program Enrollment and Change in ED and Hospital Visits from Medical Device Complications.

INTRODUCTION: Medical device-related complications often lead to emergency department (ED) visits and hospitalizations for children with medical complexity (CMC), and pediatric complex care programs may be one way to decrease unnecessary encounters. METHODS: A retrospective cohort study comparing ED and inpatient encounters due to device complications of 2 cohorts of CMC at a single children's hospital during 2014-2016; 99 enrolled in a complex care program and 244 in a propensity-matched comparison group. Structured chart reviews identified ED and inpatient encounters due to device complications. The outcome was a change in the frequency of these encounters from the year before to the year after enrollment in the hospital's complex care program. Program effects were estimated with weighted difference-in-differences (DiDs), comparing the change in mean encounter frequency for CMC enrolled in the program with change for propensity-matched children not enrolled in the program. RESULTS: Mean encounters related to device complications decreased for both groups. Complication-related ED encounters per year decreased from a weighted mean (SD) of 0.74 (0.85) to 0.30 (0.44) in enrolled children and 0.26 (0.89) to 0.12 (0.56) in comparison children, a DiD of 0.30 fewer [95% confidence interval (CI) -0.01 to 0.60]. The largest reductions in device complication ED visits were among those with enteral tubes [0.36 fewer (95% CI 0.04-0.68)]. Hospitalizations decreased over time, but DiDs were not significantly different between groups. CONCLUSIONS: Acute care use from device complications decreased with time. Complex care program enrollment may be associated with more substantial reductions in device complication ED visits, and effects may be most pronounced for CMC with enteral tubes.

Evaluation and Improvement of Intern Progress Note Assessments and Plans.

OBJECTIVES: Progress notes communicate providers' assessments of patients' diagnoses, progress, and treatment plans; however, providers perceive that note quality has degraded since the introduction of electronic health records. In this study, we aimed to (1) develop a tool to evaluate progress note assessments and plans with high interrater reliability and (2) assess whether a bundled intervention was associated with improved intern note quality without delaying note file time. METHODS: An 8-member stakeholder team developed a 19-item progress note assessment and plan evaluation (PNAPE) tool and bundled intervention consisting of a new note template and intern training curriculum. Interrater reliability was evaluated by calculating the intraclass correlation coefficient. Blinded assessors then used PNAPE to evaluate assessment and plan quality in pre- and postintervention notes (fall 2017 and 2018). RESULTS: PNAPE revealed high internal interrater reliability between assessors (intraclass correlation coefficient = 0.86; 95% confidence interval: 0.66-0.95). Total median PNAPE score increased from 13 (interquartile range [IQR]: 12-15) to 15 (IQR: 14-17; P = .008), and median file time decreased from 4:30 pm (IQR: 2:33 pm-6:20 pm) to 1:13 pm (IQR: 12:05 pm-3:59 pm; P < .001) in pre- and postintervention notes. In the postintervention period, a higher proportion of assessments and plans indicated the primary problem requiring ongoing hospitalization and progress of this problem (P = .0016 and P < .001, respectively). CONCLUSIONS: The PNAPE tool revealed high reliability between assessors, and the bundled intervention may be associated with improved intern note assessment and plan quality without delaying file time. Future studies are needed to evaluate whether these improvements can be sustained throughout residency and reproduced in future intern cohorts and other inpatient settings.

Resident Workshop to Improve Inpatient Documentation Using the Progress Note Assessment and Plan Evaluation (PNAPE) Tool.

Introduction: Physicians enter residency with varied knowledge regarding the purpose of progress notes and proficiency writing them. The objective of this study was to test whether resident knowledge, beliefs, and confidence writing inpatient progress notes improved after a 2.5-hour workshop intervention. Methods: An educational workshop and note assessment tool was constructed by resident and faculty stakeholders based on a review of literature and institutional best practices. The Progress Note Assessment and Plan Evaluation (PNAPE) tool was designed to assess adherence to best practices in the assessment and plan section of progress notes. Thirty-four residents from a midsized pediatric residency program attended the workshop, which consisted of didactics and small-group work evaluating sample notes using the PNAPE tool. Participants completed a four-question online pre- and postworkshop survey to evaluate their knowledge of progress note components and attitudes regarding note importance. Pre-post analysis was performed with Chi-square testing for true/false questions, and Mann-Whitney testing for Likert scale questions and summative scores. Results: A majority of pediatric residents completed the preintervention (n = 26, 76% response rate) and postintervention (n = 23, 68% response rate) surveys. Accurate response rate improved in 15 of 20 of the true/false items, with a statistically significant improvement in five items. Resident perceptions of note importance and confidence in note writing also increased. Discussion: A workshop intervention may effectively educate pediatric residents about progress note best practices. Further studies should assess the impact of the intervention on sustained knowledge and beliefs about progress notes and subsequent note quality.

Priorities and Outcomes for Youth-Adult Transitions in Hospital Care: Perspectives of Inpatient Clinical Leaders at US Children's Hospitals.

OBJECTIVES: Adults with chronic conditions originating in childhood experience ongoing hospitalizations; however, efforts to guide youth-adult transitions rarely address transitioning to adult-oriented inpatient care. Our objectives were to identify perceptions of clinical leaders on important and feasible inpatient transition activities and outcomes, including when, how, and for whom inpatient transition processes are needed. METHODS: Clinical leaders at US children's hospitals were surveyed between January and July 2016. Questionnaires were used to assess 21 inpatient transition activities and 13 outcomes. Perceptions about feasible and important outcome measures and appropriate patients and settings for activities were summarized. Each transition activity was categorized into one of the Six Core Elements (policy, tracking, readiness, planning, transfer, or completion). Associations between perceived transition activity importance or feasibility, hospital characteristics, and transition activity performance were evaluated. RESULTS: In total, 96 of 195 (49.2%) children's hospital leaders responded. The most important and feasible activities were identifying patients needing or overdue for transition, discussing transition timing with youth and/or families, and informing youth and/or families that future stays would be at an adult facility. Feasibility, but not importance, ratings were associated with current performance of transition activities. Inpatient transition activities were perceived to be important for children with medical and/or social complexity or high hospital use. Emergency department visits and patient experience during transition were top outcome measurement priorities. CONCLUSIONS: Children's hospital clinical leaders rated inpatient youth-adult transition activities and outcome measures as important and feasible; however, feasibility may ultimately drive implementation. This work should be used to inform initial research and quality improvement priorities, although additional stakeholder perspectives are needed.

Ambulatory quality, special health care needs, and emergency department or hospital use for US children.

OBJECTIVE: This study examined family-reported ambulatory care quality and its association with emergency department and hospital utilization, and how these relationships differed across levels of medical complexity. DATA SOURCES: The 2006-2013 Medical Expenditure Panel Survey (MEPS). STUDY DESIGN: Secondary analysis of MEPS data. Variables fitting the National Quality Measures Clearinghouse clinical quality measures domain framework were selected. Exploratory factor analysis grouped ambulatory quality into 12 access, experience, or process measures. Weighted negative binomial regression stratified by health status identified associations between ambulatory quality and ED visits or hospitalizations. DATA COLLECTION: 41,497 children ≤18 years were included. The 5-item special health care needs (SHCN) screener categorized health status as complex, less complex, or no SHCN. PRINCIPAL FINDINGS: Weighted SHCN proportions were 1.6 Percent complex, 18.2 Percent less complex, and 80.0 Percent no SHCN. Mean ED visits were 130 and 335 visits/1000 children/year for no/ complex SHCN, respectively. Mean hospitalizations were 20 and 175 hospitalizations/1000 children/year for no/complex SHCN, respectively. ED visits were associated with 8 of 12 quality measures for no/less complex SHCN. For example, usually/always receiving needed care right away was associated with 22 Percent lower ED visit rate (95% CI 0.64-0.96). Hospitalizations were associated with 4 of 12 quality measures for less complex SHCN. In complex SHCN, associations between ambulatory quality and ED/hospital use were weak and inconsistent. CONCLUSIONS: Ambulatory quality may best predict ED and hospital use for children with no or less complex SHCN. Whether and how ambulatory care predicts emergency and hospital care in complex SHCN remains an important question.

Exploring Academic Pediatrician Perspectives of Factors Impacting Physician Well-Being.

OBJECTIVE: Promotion of physician well-being has emerged as a national priority, yet meaningful interventions depend on further understanding the factors that promote and detract from physician well-being. The aim of this study was to better understand the perspectives of academic pediatricians regarding the factors influencing their well-being. METHODS: We conducted a qualitative study using grounded theory methodology. In June 2018, we performed facilitated focus groups with academic pediatric faculty at our institution. Focus groups were audio recorded, transcribed, and analyzed using the constant comparative method to identify key themes. RESULTS: Fifty-four pediatricians participated in the focus groups. Key themes included 1) pediatricians feel inundated by collective professional and personal pressures, 2) pediatricians feel they have lost control over how time at work is spent, and 3) obscured professional-personal boundaries can cause erosion of personal life. CONCLUSIONS: Pediatricians identified 3 key barriers to well-being: collective pressures, including increasing and competing academic and clinical responsibilities; low value tasks that consume their time; and erosion of personal life. This study adds to the growing literature describing physician well-being as strongly influenced by workplace factors, and offers examples of modifiable factors for further investigation.