Implementation and Outcomes of an Academic Peer Coaching Program for Pediatric Residents.

Introduction Academic coaching fosters self-directed learning and is growing in popularity within residency programs. Implementation is often limited by available faculty time and funding. Peer coaching is an emerging alternative but is not well studied. This study aims to demonstrate the acceptability, feasibility, and efficacy of a resident peer coaching program. Methodology In the 2021-2022 academic year, within a large pediatric residency program, we selected and trained senior residents as coaches and interns who opted in as coachees. Coaching dyads began meeting in the fall and worked toward individualized goals throughout the year; control interns participated in routine didactics. Outcomes included Accreditation Council for Graduate Medical Education (ACGME) milestone scores and a self-assessment survey (SAS). Results We enrolled 15/42 (36%) interns as coachees, with the remaining 27 (64%) as controls. Narrative feedback from coaches and coachees was overall positive, and time commitment was feasible for program staff (10-12 hours/month), coaches (three to four hours/month), and coachees (one to two hours/month) with minimal financial needs. Post-intervention, more coachees than controls scored ≥4.0 on ACGME milestones systems-based practice 3 (SBP3; 3/15, 20%, vs. 2/27, 7%), SBP4 (4/15, 27%, vs. 5/27, 19%), and practice-based learning and improvement 1 (4/15, 27%, vs. 3/27, 11%). SAS response rate was 8/15 (53%) for coachees and 5/27 (19%) for controls. More coachees than controls reported baseline difficulty with time management often (3/8, 38%, vs. 1/5, 20%); only coachees improved post-intervention, with 0/8 (0%) having difficulty often versus 2/5 (40%) of controls. Conclusions Resident peer coaching is acceptable and feasible to implement. Coachees reported more improvement in time management than controls, and ACGME milestone scores suggest improved use of evidence-based medicine and interprofessional care coordination among coachees.

The Autonomy Toolbox: A Multicenter Collaborative to Promote Resident Autonomy.

OBJECTIVES: Autonomy is necessary for resident professional development and well-being. A recent focus on patient safety has increased supervision and decreased trainee autonomy. Few validated interventions exist to improve resident autonomy. We aimed to use quality improvement methods to increase our autonomy metric, the Resident Autonomy Score (RAS), by 25% within 1 year and sustain for 6 months. METHODS: We developed a bundled-intervention approach to improve senior resident (SR) perception of autonomy on Pediatric Hospital Medicine (PHM) services at 5 academic children's hospitals. We surveyed SR and PHM faculty perceptions of autonomy and targeted interventions toward areas with the highest discordance. Interventions included SR and faculty development, expectation-setting huddles, and SR independent rounding. We developed a Resident Autonomy Score (RAS) index to track SR perceptions over time. RESULTS: Forty-six percent of SRs and 59% of PHM faculty completed the needs assessment survey querying how often SRs were afforded opportunities to provide autonomous medical care. Faculty and SR ratings were discordant in these domains: SR input in medical decisions, SR autonomous decision-making in straightforward cases, follow-through on SR plans, faculty feedback, SR as team leader, and level of attending oversight. The RAS increased by 19% (3.67 to 4.36) 1 month after SR and faculty professional development and before expectation-setting and independent rounding. This increase was sustained throughout the 18-month study period. CONCLUSIONS: SRs and faculty perceive discordant levels of SR autonomy. We created an adaptable autonomy toolbox that led to sustained improvement in perception of SR autonomy.

Preterm and Term Infants Evaluated for Sepsis: Differences in Management and Clinical Outcomes.

BACKGROUND AND OBJECTIVES: To describe differences in practice patterns and outcomes of young preterm versus age-matched term infants evaluated for sepsis, because evaluation and management of this group are not well defined. METHODS: We conducted a retrospective single-center study at an academic, freestanding children's hospital of previously healthy preterm and term infants aged 0 to 60 days, who presented for initial evaluation of fever and/or hypothermia from 2014 to 2019. We classified infants by gestational age as preterm (32-36 6/7 weeks) and term (37-42 weeks) and compared diagnostic evaluation, management, and clinical outcomes. RESULTS: Out of 363 preterm infants evaluated for sepsis, 336 met inclusion criteria; within the same study period, 2331 term infants were evaluated for sepsis, of which 600 were randomly selected and 554 were included. Clinicians performed inflammatory marker testing and chest x-rays more frequently in preterm infants 31% vs 25% (P = .034) and 50% vs 32% (P < .001), respectively. Preterm infants had a higher rate of bacteremia 5.9% vs 2.5% (P = .035), were hospitalized more frequently 72% vs 63% (P = .006), and required ICU level of care more often 32% vs 5% (P < .001) than term infants. They had lower rates of viral infections 33% vs 42% (P = .015) and no significant increased return visits. Febrile preterm and term infants, and older hypothermic preterm infants had relatively higher rates of serious bacterial infections. Hypothermic preterm infants had the longest hospitalizations. CONCLUSIONS: Preterm infants had increased rates of bacteremia and required higher level of care compared with age-matched term infants, likely reflecting their increased risk for sepsis and other concomitant morbidities associated with preterm birth.

Meeting the challenge of teaching bioethics: a successful residency curricula utilizing Team-Based Learning.

BACKGROUND: Despite recognition by both the Accreditation Council of Graduate Medical Education (ACGME) and the American Board of Paediatrics (ABP) of the importance of bioethics education, curricular crowding, lack of perceived significance, and insufficient administrative support remain significant barriers to trainees gaining competency in bioethics. Few bioethics curricula at the graduate medical education level are evidence-based or comprehensive. We sought to develop and assess the effectiveness of a Team Based Learning (TBL) curriculum in improving residents' bioethics knowledge and their ability to evaluate ethical dilemmas. METHODS: We integrated L. Dee Fink's curricular design principles of "Significant Learning," Jonsen et. al's "Four-Box Method" of ethical analysis, and ABP bioethics content specifications to create 10 TBL bioethics sessions. Paediatric residents at a major academic centre then completed a 3-year longitudinal, integrated TBL-based bioethics curriculum. Primary outcomes included individual and group readiness assessment tests (iRAT/gRAT), pre-work completion, and satisfaction with sessions. RESULTS: The TBL-based bioethics curriculum contains 10 adaptable modules. Paediatric residents (n = 348 total resident encounters) were highly engaged and satisfied with the curriculum. gRAT scores (mean 89%) demonstrated significant improvement compared to iRAT scores (72%) across all TBLs and all post-graduate years (p < .001). Higher gRAT scores correlated with higher level of training. Although pre-work completion was low (28%), satisfaction was high (4.42/5 on Likert scale). CONCLUSIONS: Our TBL-based bioethics curriculum was effective in improving knowledge, practical and flexible in its implementation, and well-received. We attribute its success to its grounding in ethical theory, relevance to ABP specifications, and a multi-modal, engaging format. This curriculum is easily modified to different specialties, virtual formats, or other specific institutional needs.Key messagesDespite formidable challenges to teaching bioethics in residency education, evidence-based methods such as Team-Based Learning (TBL) can be employed to increase knowledge and satisfaction.This study reports the first successful TBL bioethics curriculum, planned and executed longitudinally over 3 years, with paediatric residents at a large academic children's hospital in the US.TBL can be utilised to teach bioethics at the graduate medical education level and is adaptable to different situational factors, disciplines, and levels of clinical experience.

A diagnostic time-out to improve differential diagnosis in pediatric abdominal pain.

BACKGROUND: Pediatric abdominal pain is challenging to diagnose and often results in unscheduled return visits to the emergency department. External pressures and diagnostic momentum can impair physicians from thoughtful reflection on the differential diagnosis (DDx). We implemented a diagnostic time-out intervention and created a scoring tool to improve the quality and documentation rates of DDx. The specific aim of this quality improvement (QI) project was to increase the frequency of resident and attending physician documentation of DDx in pediatric patients admitted with abdominal pain by 25% over 6 months. METHODS: We reviewed a total of 165 patients admitted to the general pediatrics service at one institution. Sixty-four history and physical (H&P) notes were reviewed during the baseline period, July-December 2017; 101 charts were reviewed post-intervention, January-June 2018. Medical teams were tasked to perform a diagnostic time-out on all patients during the study period. Metrics tracked monthly included percentage of H&Ps with a 'complete' DDx and quality scores (Qs) using our Differential Diagnosis Scoring Rubric. RESULTS: At baseline, 43 (67%) resident notes and 49 (77%) attending notes documented a 'complete' DDx. Post-intervention, 59 (58%) resident notes and 69 (68%) attending notes met this criteria. Mean Qs, pre- to post-intervention, for resident-documented differential diagnoses increased slightly (2.41-2.47, p = 0.73), but attending-documented DDx did not improve (2.85-2.82, p = 0.88). CONCLUSIONS: We demonstrated a marginal improvement in the quality of resident-documented DDx. Expansion of diagnoses considered within a DDx may contribute to higher diagnostic accuracy.

The Diagnostic Error Index: A Quality Improvement Initiative to Identify and Measure Diagnostic Errors.

OBJECTIVE: To develop a diagnostic error index (DEI) aimed at providing a practical method to identify and measure serious diagnostic errors. STUDY DESIGN: A quality improvement (QI) study at a quaternary pediatric medical center. Five well-defined domains identified cases of potential diagnostic errors. Identified cases underwent an adjudication process by a multidisciplinary QI team to determine if a diagnostic error occurred. Confirmed diagnostic errors were then aggregated on the DEI. The primary outcome measure was the number of monthly diagnostic errors. RESULTS: From January 2017 through June 2019, 105 cases of diagnostic error were identified. Morbidity and mortality conferences, institutional root cause analyses, and an abdominal pain trigger tool were the most frequent domains for detecting diagnostic errors. Appendicitis, fractures, and nonaccidental trauma were the 3 most common diagnoses that were missed or had delayed identification. CONCLUSIONS: A QI initiative successfully created a pragmatic approach to identify and measure diagnostic errors by utilizing a DEI. The DEI established a framework to help guide future initiatives to reduce diagnostic errors.

Pediatric Inpatient Problem List Review and Accuracy Improvement.

BACKGROUND AND OBJECTIVES: The problem list (PL) is a meaningful use-incentivized criterion for electronic health record documentation. Inconsistent use or inaccuracy of the PL can create communication gaps among providers, potentially leading to diagnostic delays and serious safety events. The objective of the study was to increase the rate of PL review by attending physicians for inpatients discharged from hospital pediatrics and infectious disease services from a baseline of 70% to 80% by June 2018 and to sustain the rate for 6 months. The secondary aim was to improve PL accuracy by decreasing the rate of duplicate codes and red code diagnoses that should resolve before discharge from a baseline of 12% and 11%, respectively, to 5% and sustaining the rate for 6 months. METHODS: A quality improvement team used the Institute for Healthcare Improvement Model for Improvement. We tracked duplicate codes and red codes as surrogate markers of PL quality. Rates of PL review and PL quality were analyzed monthly via statistical process control charts (p-charts) with 3-σ control limits to identify special cause variation. RESULTS: PL review improved from a baseline of 70% to 90%, and the change was sustained for 1 year. PL quality improved as duplicate codes at the time of discharge decreased from 12% to 6% and as red codes decreased from a baseline of 11% to 6%. CONCLUSIONS: The PL is an important communication tool that is underused. By engaging and educating stakeholders, incentivizing compliance, standardizing PL management, leveraging electronic health record enhancements, and providing physician feedback, we improved PL meaningful use and quality.

Team-Based Learning in Bioethics Education: Creating a Successful Curriculum for Residents in an Era of "Curricular Squeeze".

BACKGROUND: Team-based learning has been utilized inside and outside of medical education with success. Its use in bioethics education-particularly in graduate medical education-has been limited, despite its proven pedagogical strength and the critical importance of ethics and professionalism. ACTIVITY: From 2015-2018, we created and administered 10 TBL bioethics modular exercises using L. Dee Fink's "Principles of Significant Learning" and the evidence-based methodology of TBL (with some modifications, given the nature of graduate medical education) to pediatric residents. We evaluated the TBL curriculum and report satisfaction scores and qualitative thematic analysis of strengths and weaknesses. RESULTS AND DISCUSSION: Pediatric residents, despite a perception of "curricular squeeze" and lack of interest in ethics, were highly engaged and satisfied with a TBL-only-based bioethics curriculum. We were able to successfully adapt the TBL structure to the situational factors surrounding the rigors and unpredictable nature of clinical graduate education. We offer four "Lessons Learned" for creating and implementing TBL exercises in graduate medical education. TBL can be used in bioethics education successfully, not just for individual exercises, but also to create a comprehensive ethics curriculum.

Adrenal extracellular matrix scaffolds support adrenocortical cell proliferation and function in vitro.

Transplantation of functional adrenal cortex cells could reduce morbidity and increase the quality of life of patients with adrenal insufficiency. Our aim was to determine whether adrenal extracellular matrix (ECM) scaffolds promote adrenocortical cell endocrine function and proliferation in vitro. We seeded decellularized porcine adrenal ECM with primary human fetal adrenocortical (HFA) cells. Adrenocortical function was quantified by cortisol secretion of HFA-ECM constructs after stimulation with adrenocorticotropic hormone. Proliferation was assessed by adenosine triphosphate assay. HFA-ECM construct morphology was evaluated by immunofluorescence microscopy and scanning electron microscopy. Adrenal HFA-ECM constructs coated with laminin were compared to uncoated constructs. Laminin coating did not significantly affect HFA morphology, proliferation, or function. We demonstrated HFA cell attachment to adrenal ECM scaffolds. Cortisol production and HFA cell proliferation were significantly increased in HFA-ECM constructs compared to controls (p < 0.05), and cortisol secretion rate per cell is comparable to that of human adult and fetal explants. We conclude that adrenal ECM supports endocrine function and proliferation of adrenocortical cells in vitro. Adrenal ECM scaffolds may form the basis for biocompatible tissue-engineered adrenal replacements.

Surface characterization of extracellular matrix scaffolds.

Extracellular matrix (ECM) scaffolds prepared from different tissue sources or using different methods have been demonstrated to have distinctive effects upon cell adhesion patterns and the ability to support and maintain differentiated phenotypes. It is unknown whether the molecular composition or the ultrastructure of the ECM plays a greater role in determining the phenotype of the cells with which it comes into contact. However, when implanted, the topology and ligand landscape of the material will determine the host molecules that bind and the type and behavior of cells that mediate the host response. Therefore, a comprehensive understanding of surface characteristics is essential in the design of scaffolds for specific clinical applications. The surface characteristics of ECM scaffolds derived from porcine urinary bladder, small intestine, and liver as well as the effects of two commonly used methods of chemical cross-linking upon UBM were investigated. Electron microscopy and time of flight secondary ion mass spectroscopy were used to examine the surface characteristics of the scaffolds. The results show that ECM scaffolds have unique morphologic and structural properties which are dependant on the organ or tissue from which the scaffold is harvested. Furthermore, the results show that the surface characteristics of an ECM scaffold are changed through chemical cross-linking.