Bio
Dr. Unaka is the inaugural Chief Health Equity Officer (CHEO) for Stanford Medicine Children’s Health (SMCH) and a Clinical Professor in the Department of Pediatrics at Stanford University School of Medicine. Prior to her transition to SMCH in July 2024, Dr. Unaka was a faculty member in the Division of Hospital Medicine at Cincinnati Children's Hospital. In addition to her clinical role as a pediatric hospitalist, Dr. Unaka served as the Associate Program Director of the Pediatric Residency Program from 2011 – January 2022. She served as the medical director of a 48- bed inpatient unit primarily for patients admitted to the Hospital Medicine service. In this role, Dr. Unaka was involved in several equity-oriented quality improvement initiatives which included work to identify, and address hunger among caregivers of hospitalized children insured by Medicaid.
Dr. Unaka worked on institution-level community health initiatives at Cincinnati Children’s. She served as the Medical Director of Quality Improvement and Data Analytics for Cincinnati Children’s Medicaid- focused, accountable care organization (HealthVine). In this role, she developed and led initiatives designed to improve the quality and efficiency of health care delivery to HealthVine’s patient population and helped lead the change management associated with the movement toward a population-health care model that improves quality, narrows equity gaps, streamlines care, and reduces costs. She helped define appropriate health care delivery, equity, and population health measures and quality benchmarks. Additionally, Dr. Unaka was a faculty lead within Cincinnati Children's Fisher Child Health Equity Center, and she specifically focused on working with operations leaders to ensure equity was embedded within all strategic plans, goals, and metrics across all sites of care. Dr. Unaka partnered with several colleagues to lead system-wide quality improvement initiatives including work accelerated via learning networks. She was the co-lead of Cincinnati Children's Health Equity Network (HEN), an initiative borne out of the pursuit of excellent and equitable health outcomes for youth in Greater Cincinnati. The HEN supports clinical teams seeking to eliminate disparities in child health outcomes by race, ethnicity, and/or socioeconomic status via targeted interventions and best practices by addressing both medical and social factors known to confer poor health outcomes.
Academic Appointments
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Clinical Professor, Pediatrics
Administrative Appointments
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Chief Health Equity Officer, Stanford Medicine Children's Health (2024 - Present)
Professional Education
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Board Certification, American Board of Pediatrics, Pediatric Hospital Medicine (2019)
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MEd, University of Cincinnati (2015)
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Chief Residency, Cincinnati Children's Hospital (2011)
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Board Certification, American Board of Pediatrics, General Pediatrics (2010)
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Pediatric Residency, Cincinnati Children's Hospital (2010)
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MD, University of Michigan (2007)
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BS, University of Oregon (2003)
All Publications
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Diversity, Equity, and Inclusion in Patient and Family Advisory Councils: Advancing Best Practice in Children's Hospitals.
Journal of pediatric health care : official publication of National Association of Pediatric Nurse Associates & Practitioners
2024; 38 (2): 184-193
Abstract
This qualitative research study explored practices that support and advance diverse membership in Patient and Family Advisory Councils (PFACs) in children's hospitals and the involvement of PFACs in organization-level diversity, equity, and inclusion work.This study consisted of a focused literature review and 17 key informant interviews. The study sought to identify important learnings about (1) recruiting and supporting patient and family advisors (PFAs) from historically marginalized populations and (2) ways to develop and sustain meaningful partnerships with PFAs and PFACs in diversity, equity, and inclusion work.The study findings highlighted a number of best practices for hospitals to adopt, including more actively reaching out to communities served, addressing barriers to participation through approaches and structures such as specialty PFACs and "tiered" options for participation by PFAs, and co-creation of inclusive environments.To move forward with this work, additional research, true commitment from health care organizations, and shared guidance and tools for the field are needed.
View details for DOI 10.1016/j.pedhc.2023.11.006
View details for PubMedID 38429030
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An Untold Story: The Feelings of Pediatric Residents Early in the Covid-19 Pandemic and What They Can Teach Us Today.
Academic pediatrics
2024: 102602
Abstract
To understand the feelings of pediatrics residents early in the COVID-19 pandemic and to offer insights still relevant today.We performed a thematic analysis exploring resident feelings early in the pandemic using free-text responses on a national survey distributed between May and June 2020. We analyzed responses from the following multi-part free text question embedded in the larger survey, "Which of the following feelings have you experienced in your role as a pediatric resident during the COVID-19 pandemic" with response prompts including relief, guilt, pride, sadness, worry, fear, and other.While many feelings that respondents shared were common to society at large, some were specific to their intersecting roles as healthcare workers, pediatricians, and trainees. Some issues uncovered have continued relevance today including varied interactions with program and institutional leadership, training away from established support networks and during an important life stage, and societal concerns.This study uncovered vulnerabilities inherent to being a trainee such as limited control over one's own schedule or institutional policies and training away from established supports. Their feelings shine light on the moral distress experienced in residency and the role program and institutional leadership can play in the experiences of residents.
View details for DOI 10.1016/j.acap.2024.102602
View details for PubMedID 39521047
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Potential Bias in Social Work Consultations in the Pediatric Inpatient Setting.
Hospital pediatrics
2024
Abstract
Failure to thrive, brief resolved unexplained event, accidental ingestion, and drowning admissions commonly involve social work (SW) consultation. Care team biases likely influence SW consultation decisions. We examined whether SW consultations varied by patient race for these diagnoses.We conducted a retrospective cohort study of children <6 years of age admitted for failure to thrive, brief resolved unexplained event, accidental ingestion, and drowning between July 1, 2012 and June 30, 2020 at a single, academic, standalone children's hospital in an urban environment. The outcome was SW consultation; the predictor was patient race. We used multivariable logistic regression, adjusting for ethnicity, language, insurance, and diagnosis. We completed a supplemental chart review of a random sample of 10% of patients with SW consultation to determine the reasons that consultations were placed.We included 1199 unique patients; 64% identified as white, and 22% identified as Black. Black patients had 1.61 times higher adjusted odds of SW consultation compared with white patients (95% confidence interval 1.14-2.29). Publicly insured, compared with privately insured, patients had 6.10 times higher adjusted odds of SW consultation (95% confidence interval 4.28-8.80). Upon supplemental chart review, Black patients had SW consultations that focused more often on abuse, neglect, and safety; this was also found for publicly insured patients. There was parity in consultation for resource needs across groups.Black children were more likely than white children to receive SW consultation during hospitalization, as were publicly insured children compared with their privately insured peers; in supplemental review, this was not due to differences in consultations for resource needs. The standardization of SW consultation may promote equitable care.
View details for DOI 10.1542/hpeds.2023-007637
View details for PubMedID 39224091
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Racial, Ethnic, and Language Inequities in Ambulatory Pediatrics Patient Family Experience.
Academic pediatrics
2024
Abstract
To determine the association of patient race, patient-provider racial congruence, patient ethnicity, and family primary language with patient family experience (PFE) survey responses.Cross-sectional review of PFE survey responses from all ambulatory medical encounters at a large, urban children's hospital system June 1, 2020-May 31, 2022. Exposures were patient race, patient-provider racial congruence, patient ethnicity, and family primary language. We adjusted analyses for neighborhood-level socioeconomic deprivation, patient sex and age, encounter specialty, and location of care. Outcomes were PFE survey scores for 5 questions focused on overall experience, respect, and safety; categorized using industry standard metric of presence of a "top-box" score, defined as a 9 or 10 for questions on an 11-point scale or as 4 on a 4-point scale.We included 89,175 surveys (15.6% response rate). The odds of having optimal, "top-box" responses for several assessed questions were lower for patients identified as Asian (e.g., adjusted odds ratio [OR] 0.46; 95% confidence interval [CI] 0.40, 0.52) or Black (e.g., OR 0.65; CI 0.60, 0.70) compared to White, and for Hispanic (e.g., OR 0.84; CI 0.72, 0.97) compared to non-Hispanic. Similarly, the odds of having "top-box" scores were lower for Spanish-primary-language (e.g., OR 0.38; CI 0.30, 0.48) compared to English-primary-language patients. Patient-provider racial congruence had higher odds of "top-box" responses for 2 of 5 assessed questions (e.g., OR 1.18; CI 1.04, 1.35).We found previously unreported inequities in ambulatory pediatric PFE outcomes, with worse experiences reported by Asian, Black, Hispanic, and Spanish-language patients.
View details for DOI 10.1016/j.acap.2024.08.015
View details for PubMedID 39216801
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"Racism happens every day, all the time": Black families' outpatient experiences of racism across a large pediatric system.
Academic pediatrics
2024
Abstract
OBJECTIVE: To qualitatively understand and characterize the experience of racism in outpatient pediatric healthcare settings from the perspectives of Black families.METHODS: We conducted focus groups with parents or guardians of Black children, recruited from academic primary care offices at a single pediatric institution. Focus groups were facilitated virtually by Black team members using an open-ended, semi-structured focus group guide. We analyzed focus group transcripts using iterative, thematic, inductive open coding performed independently by trained coders, with final codes reached by group consensus.RESULTS: We conducted 6 focus groups of 3 to 5 participants each and 1 individual interview, with 24 total parents. We identified the following themes: 1)"I just felt like we was a number": Black families perceived experiences which felt impersonal and lacked empathy; 2)"Why is the doctor treating me like I don't matter?": Black families perceived experiences with poor care, worse treatment; 3)Black families experience racism across socioecological levels when interacting with pediatric health systems; 4)Positive perceived experiences can guide improvement; and 5)Improvement will require antiracist efforts across the levels of racism.CONCLUSIONS: In this qualitative study, we found that Black families have had many poor pediatric experiences, perceive racism as affecting child health broadly across socioecological levels, and recommend a multidimensional antiracist approach to improvement. Our findings underscore the importance of elevating Black family voices in developing policies that prioritize antiracism and work to eliminate the harmful impacts of racism on child health.
View details for DOI 10.1016/j.acap.2024.08.011
View details for PubMedID 39191371
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An Institutional Approach to Equity and Improvement in Child Health Outcomes.
Pediatrics
2024
Abstract
Pediatric health inequities are pervasive. Approaches by health care institutions to address inequities often, and increasingly, focus on social needs screening without linked, robust responses. Even when actions in pursuit of health equity do occur within health care institutions, efforts occur in isolation from each other, standing in the way of cross-learning and innovation. Learning network methods hold promise when institutions are confronted with complex, multidimensional challenges. Equity-oriented learning networks may therefore accelerate action to address complex factors that contribute to inequitable pediatric health outcomes, enabling rapid learning along the way. We established an institutional Health Equity Network (HEN) in pursuit of excellent and equitable health outcomes for children and adolescents in our region. The HEN supports action teams seeking to eliminate pediatric health inequities in their clinical settings. Teams deploy targeted interventions to meet patients' and families' needs, addressing both medical and social factors affecting health and wellbeing. The primary, shared HEN measure is the equity gap in hospitalization rates between Black patients and all other patients. The HEN currently has 10 action teams and promotes rapid learning and scaling of interventions via monthly "action period calls" and "solutions labs" focused on successes, challenges, and potential common solutions (eg, scaling of existing medical-legal partnership to subspecialty clinics). In this Advocacy Case Study, we detail the design, implementation, and early outcomes from the HEN, our equity-oriented learning network.
View details for DOI 10.1542/peds.2023-064994
View details for PubMedID 38953125
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A Road Map for Population Health and Health Equity Research
JAMA PEDIATRICS
2024
View details for DOI 10.1001/jamapediatrics.2024.1550
View details for Web of Science ID 001247598300001
View details for PubMedID 38857018
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The role of competency based medical education in addressing health inequities and cultivating inclusive learning environments.
Current problems in pediatric and adolescent health care
2024: 101641
Abstract
Pediatric health inequities are pervasive and reflect the confluence of social and structural determinants of health including racism in all its forms. Current approaches in graduate medical education that prepare trainees to address health inequities and improve population health are inadequate. Competency based medical education (CBME) can advance equity-oriented efforts to improve patient outcomes, optimize the learning environment and encourage lifelong learning. We briefly describe the impact of racism and discrimination on the clinical learning environment. We then highlight how to apply the 5 core principles of CBME to equip learners across the continuum to address health inequities. We provide specific examples including 1) how CBME can inform teaching, assessment and professional development activities to promote equitable pediatric health outcomes via enturstable professional activities, 2) competency-focused instruction that address racism and inequities, 3) multimodal learning approaches to facilitate the acquisition of the desired competencies to address health inequities, 4) sequenced learning approaches across the continuum of practicing pediatricians, and 5) tools and resources for programmatic assessment of trainee and program performance in addressing pediatric health inequities.
View details for DOI 10.1016/j.cppeds.2024.101641
View details for PubMedID 38851972
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Addressing food insecurity in the inpatient setting: Results of a postdischarge pilot study.
Journal of hospital medicine
2024
Abstract
With a growing interest in screening for food insecurity (FI) during pediatric hospitalization, there is a parallel need to develop interventions. With input from caregivers experiencing FI, we sought to identify interventions to assist with short-term FI after discharge and evaluate their feasibility, acceptability, and appropriateness.We first employed qualitative methods to identify potential interventions. Next, we conducted a pilot study of selected interventions for families experiencing FI. Seven days postdischarge, caregivers rated the intervention's feasibility, acceptability, and appropriateness. We also assessed for ongoing FI. We summarized the median and proportion of "completely agree" responses to feasibility, acceptability, and appropriateness questions, and we compared in-hospital and postdischarge FI using McNemar's test.In the qualitative stage, 14 caregivers prioritized three interventions: grocery store gift cards, grocery delivery/pick-up, and frozen meals. In the pilot study, 53 caregivers (25% of those screened) endorsed FI during their child's hospitalization and received one or more of the interventions. Every caregiver selected the grocery gift card option; 37 families (69.8%) also received frozen meals. Seven days after discharge, most caregivers rated the intervention as "completely" feasible (76%), acceptable (90%), and appropriate (88%). There was a significant decrease in caregivers who reported FI after discharge compared to during the hospitalization (p < .001).This study demonstrates the feasibility, acceptability, and appropriateness of inpatient interventions to address FI, particularly at the time of pediatric hospital discharge and transition home. Randomized trials are needed to further evaluate the efficacy of interventions employed during hospitalization.
View details for DOI 10.1002/jhm.13421
View details for PubMedID 38837594
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Potential causes of delays in paediatric perforated appendicitis: A prospective interview study.
Journal of paediatrics and child health
2024; 60 (6): 193-199
Abstract
Delays in care may be a driver of inequities in perforated appendicitis rates. The goal of this study was to explore potential causes of delay in care for children with perforated appendicitis.We conducted an interview study of caregivers of children admitted with perforated appendicitis to a children's hospital between December 2022 and March 2023. Semi-structured interviews based on an iteratively revised interview guide were conducted in-person during the child's admission. All interviews were transcribed, coded and underwent a process of thematic analysis.We reached thematic saturation after 12 interviews. The median age for children was 13.5 years, 50% were male, 83% of caregivers self-identified as White, and one interview required an interpreter. Through thematic analysis, four major themes for potential causes of delay emerged. The first theme of symptom recognition includes delays related to recognising the symptoms, their severity and the need for medical evaluation. The second theme - accessing care - describes delays that occur after a decision was made to seek care until the child was evaluated. The third theme includes delays that occur in making the diagnosis after evaluation. The last theme captures potential delays in definitive treatment after a diagnosis of appendicitis is made.We identify four major themes from the patient and family perspective, each with multiple sub-themes, for potential delays in definitive care for children with perforated appendicitis. Additional research is needed to further characterise these potential delays and quantify their role in contributing to inequities in perforation rates.
View details for DOI 10.1111/jpc.16556
View details for PubMedID 38695512
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Development of a multimodal geomarker pipeline to assess the impact of social, economic, and environmental factors on pediatric health outcomes
JOURNAL OF THE AMERICAN MEDICAL INFORMATICS ASSOCIATION
2024; 31 (7): 1471-1478
Abstract
We sought to create a computational pipeline for attaching geomarkers, contextual or geographic measures that influence or predict health, to electronic health records at scale, including developing a tool for matching addresses to parcels to assess the impact of housing characteristics on pediatric health.We created a geomarker pipeline to link residential addresses from hospital admissions at Cincinnati Children's Hospital Medical Center (CCHMC) between July 2016 and June 2022 to place-based data. Linkage methods included by date of admission, geocoding to census tract, street range geocoding, and probabilistic address matching. We assessed 4 methods for probabilistic address matching.We characterized 124 244 hospitalizations experienced by 69 842 children admitted to CCHMC. Of the 55 684 hospitalizations with residential addresses in Hamilton County, Ohio, all were matched to 7 temporal geomarkers, 97% were matched to 79 census tract-level geomarkers and 13 point-level geomarkers, and 75% were matched to 16 parcel-level geomarkers. Parcel-level geomarkers were linked using our exact address matching tool developed using the best-performing linkage method.Our multimodal geomarker pipeline provides a reproducible framework for attaching place-based data to health data while maintaining data privacy. This framework can be applied to other populations and in other regions. We also created a tool for address matching that democratizes parcel-level data to advance precision population health efforts.We created an open framework for multimodal geomarker assessment by harmonizing and linking a set of over 100 geomarkers to hospitalization data, enabling assessment of links between geomarkers and hospital admissions.
View details for DOI 10.1093/jamia/ocae093
View details for Web of Science ID 001219738600001
View details for PubMedID 38733117
View details for PubMedCentralID PMC11187418
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Paediatric resident identification of cardiac emergencies.
Cardiology in the young
2024: 1-6
Abstract
Critical CHD is associated with morbidity and mortality, worsened by delayed diagnosis. Paediatric residents are front-line clinicians, yet identification of congenital CHD remains challenging. Current exposure to cardiology is limited in paediatric resident education. We evaluated the impact of rapid cycle deliberate practice simulation on paediatric residents' skills, knowledge, and perceived competence to recognise and manage infants with congenital CHD.We conducted a 6-month pilot study. Interns rotating in paediatric cardiology completed a case scenario assessment during weeks 1 and 4 and participated in paired simulations (traditional debrief and rapid cycle deliberate practice) in weeks 2-4. We assessed interns' skills during the simulation using a checklist of "cannot miss" tasks. In week 4, they completed a retrospective pre-post knowledge-based survey. We analysed the data using summary statistics and mixed effect linear regression.A total of 26 interns participated. There was a significant increase in case scenario assessment scores between weeks 1 and 4 (4, interquartile range 3-6 versus 8, interquartile range 6-10; p-value < 0.0001). The percentage of "cannot miss" tasks on the simulation checklist increased from weeks 2 to 3 (73% versus 83%, p-value 0.0263) and from weeks 2-4 (73% versus 92%, p-value 0.0025). The retrospective pre-post survey scores also increased (1.67, interquartile range 1.33-2.17 versus 3.83, interquartile range 3.17-4; p-value < 0.0001).Rapid cycle deliberate practice simulations resulted in improved recognition and initiation of treatment of simulated infants with congenital CHD among paediatric interns. Future studies will include full implementation of the curriculum and knowledge retention work.
View details for DOI 10.1017/S104795112400074X
View details for PubMedID 38646892
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Causal Mediation of Neighborhood-Level Pediatric Hospitalization Inequities.
Pediatrics
2024; 153 (4)
Abstract
Population-wide racial inequities in child health outcomes are well documented. Less is known about causal pathways linking inequities and social, economic, and environmental exposures. Here, we sought to estimate the total inequities in population-level hospitalization rates and determine how much is mediated by place-based exposures and community characteristics.We employed a population-wide, neighborhood-level study that included youth <18 years hospitalized between July 1, 2016 and June 30, 2022. We defined a causal directed acyclic graph a priori to estimate the mediating pathways by which marginalized population composition causes census tract-level hospitalization rates. We used negative binomial regression models to estimate hospitalization rate inequities and how much of these inequities were mediated indirectly through place-based social, economic, and environmental exposures.We analyzed 50 719 hospitalizations experienced by 28 390 patients. We calculated census tract-level hospitalization rates per 1000 children, which ranged from 10.9 to 143.0 (median 45.1; interquartile range 34.5 to 60.1) across included tracts. For every 10% increase in the marginalized population, the tract-level hospitalization rate increased by 6.2% (95% confidence interval: 4.5 to 8.0). After adjustment for tract-level community material deprivation, crime risk, English usage, housing tenure, family composition, hospital access, greenspace, traffic-related air pollution, and housing conditions, no inequity remained (0.2%, 95% confidence interval: -2.2 to 2.7). Results differed when considering subsets of asthma, type 1 diabetes, sickle cell anemia, and psychiatric disorders.Our findings provide additional evidence supporting structural racism as a significant root cause of inequities in child health outcomes, including outcomes at the population level.
View details for DOI 10.1542/peds.2023-064432
View details for PubMedID 38426267
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Building a regional pediatric asthma learning health system in support of optimal, equitable outcomes.
Learning health systems
2024; 8 (2): e10403
Abstract
Asthma is characterized by preventable morbidity, cost, and inequity. We sought to build an Asthma Learning Health System (ALHS) to coordinate regional pediatric asthma improvement activities.We generated quantitative and qualitative insights pertinent to a better, more equitable care delivery system. We used electronic health record data to calculate asthma hospitalization rates for youth in our region. We completed an "environmental scan" to catalog the breadth of asthma-related efforts occurring in our children's hospital and across the region. We supplemented the scan with group-level assessments and focus groups with parents, clinicians, and community partners. We used insights from this descriptive epidemiology to inform the definition of shared aims, drivers, measures, and prototype interventions.Greater Cincinnati's youth are hospitalized for asthma at a rate three times greater than the U.S. average. Black youth are hospitalized at a rate five times greater than non-Black youth. Certain neighborhoods bear the disproportionate burden of asthma morbidity. Across Cincinnati, there are many asthma-relevant activities that seek to confront this morbidity; however, efforts are largely disconnected. Qualitative insights highlighted the importance of cross-sector coordination, evidence-based acute and preventive care, healthy homes and neighborhoods, and accountability. These insights also led to a shared, regional aim: to equitably reduce asthma-related hospitalizations. Early interventions have included population-level pattern recognition, multidisciplinary asthma action huddles, and enhanced social needs screening and response.Learning health system methods are uniquely suited to asthma's complexity. Our nascent ALHS provides a scaffold atop which we can pursue better, more equitable regional asthma outcomes.
View details for DOI 10.1002/lrh2.10403
View details for PubMedID 38633017
View details for PubMedCentralID PMC11019385
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Forging a Path to Effective Inpatient Health-Related Social Needs Screening and Response.
Hospital pediatrics
2024; 14 (4): e209-e211
View details for DOI 10.1542/hpeds.2023-007668
View details for PubMedID 38463006
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Characterizing Inequities in Pediatric Appendicitis Delayed Diagnosis and Perforation.
Journal of pediatrics. Clinical practice
2024; 11: 200108
Abstract
We sought to characterize the impact of a child's sociodemographic characteristics on their odds of delayed diagnosis and perforation in pediatric appendicitis.We performed a single-center, retrospective cohort study of all pediatric appendicitis admissions between 2016 and 2021. Using a multivariable model, we evaluated for associations between delayed diagnosis and perforation and a child's sociodemographic characteristics, including their age, sex, race and ethnicity, insurance status, and their home census-tract Material Community Deprivation Index value.The study included 3248 patients. The median age was 12.1 years (IQR 9.5-14.9 years). Most patients were male (60.3%), identified as non-Hispanic White (78.0%), and had private insurance (55.4%). The delayed diagnosis and perforation rates were 6.4% and 25.1%, respectively. Delayed diagnosis cases had a greater perforation rate (56% compared with 21.5%, P < .001). On adjusted analysis, older age decreased the odds (OR 0.91, CI 0.87-0.94) of delayed diagnosis, whereas female sex (OR 1.50, CI 1.13-2.00) and socioeconomic disadvantage (OR 1.56 for quartile 4 vs quartile 1, CI 1.00-2.43) increased the odds. Furthermore, older age (OR 0.91, CI 0.89-0.93) decreased the odds of perforation, whereas non-Hispanic Black (OR 1.72, CI 1.3-2.29) or Hispanic (OR 1.60, CI 1.24-2.08) compared with non-Hispanic White identification and socioeconomic disadvantage (OR 1.43 Q4 vs Q1, CI 1.12-1.83) increased the odds.Our reported delayed diagnosis rate is greater than recent literature, highlighting the need to consider visits that occur across different health care settings. We further identify sociodemographic factors, including socioeconomic status, that impact a child's risk of delayed diagnosis and perforation.
View details for DOI 10.1016/j.jpedcp.2024.200108
View details for PubMedID 38827485
View details for PubMedCentralID PMC11138256
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Out for the count: Hospitalization as an opportunity to intervene for patients experiencing homelessness.
Journal of hospital medicine
2024; 19 (1): 79-80
View details for DOI 10.1002/jhm.13254
View details for PubMedID 38085736
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Family-Centered Rounds Requires an Equity Oriented Approach.
Hospital pediatrics
2023; 13 (11): e342-e344
View details for DOI 10.1542/hpeds.2023-007472
View details for PubMedID 37842731
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Crossing the Quality Chasm and the Ignored Pillar of Health Care Equity.
Pediatric clinics of North America
2023; 70 (4): 855-861
Abstract
Although there has been tremendous progress toward the aspiration of delivering quality health care, among the National Academy of Medicine's (previously Institute of Medicine) six pillars of quality (health care should be safe, effective, timely, patient-centered, efficient, and equitable), the last pillar, equity, has been largely ignored. Examples of how the quality improvement (QI) process leads to improvements are numerous and must be applied to the pillar of equity related to race/ethnicity and socioeconomic status. This article describes how equity should be addressed using the QI process.
View details for DOI 10.1016/j.pcl.2023.03.013
View details for PubMedID 37422318
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The Autonomy Toolbox: A Multicenter Collaborative to Promote Resident Autonomy.
Hospital pediatrics
2023; 13 (6): 490-503
Abstract
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.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.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.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.
View details for DOI 10.1542/hpeds.2022-006827
View details for PubMedID 37153964
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Reducing Caregiver Hunger During Pediatric Hospitalization.
Pediatrics
2023; 151 (5)
Abstract
Pediatric hospitalizations are costly, stressful events for families. Many caregivers, especially those with lower incomes, struggle to afford food while their child is hospitalized. We sought to decrease the mean percentage of caregivers of Medicaid-insured and uninsured children who reported being hungry during their child's hospitalization from 86% to <24%.Our quality improvement efforts took place on a 41-bed inpatient unit at our large, urban academic hospital. Our multidisciplinary team included physicians, nurses, social workers, and food services leadership. Our primary outcome measure was caregiver-reported hunger; we asked caregivers near to the time of discharge if they experienced hunger during their child's hospitalization. Plan-do-study-act cycles addressed key drivers: awareness of how to obtain food, safe environment for families to seek help, and access to affordable food. An annotated statistical process control chart tracked our outcome over time. Data collection was interrupted because of the COVID-19 pandemic; we used that time to advocate for hospital-funded support for optimal and sustainable changes to caregiver meal access.We decreased caregiver hunger from 86% to 15.5%. A temporary test of change, 2 meal vouchers per caregiver per day, resulted in a special cause decrease in the percentage of caregivers reporting hunger. Permanent hospital funding was secured to provide cards to purchase 2 meals per caregiver per hospital day, resulting in a sustained decrease in rates of caregiver hunger.We decreased caregivers' hunger during their child's hospitalization. Through a data-driven quality improvement effort, we implemented a sustainable change allowing families to access enough food.
View details for DOI 10.1542/peds.2022-058080
View details for PubMedID 37078248
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Effects of a Curriculum Addressing Racism on Pediatric Residents' Racial Biases and Empathy.
Journal of graduate medical education
2022; 14 (4): 407-413
Abstract
Racism is a longstanding driver of health inequities. Although medical education is a potential solution to address racism in health care, best practices remain unknown.We sought to evaluate the impact of participation in a curriculum addressing racism on pediatric residents' racial biases and empathy.A pre-post survey study was conducted in 2 urban, university-based, midsized pediatric residency programs between July 2019 and June 2020. The curriculum sessions included Self-Reflection on Implicit Bias, Historical Trauma, and Structural Racism. All sessions were paired with empathy and perspective-taking exercises and were conducted in small groups to facilitate reflective discussion. Wilcoxon signed rank tests were used to assess changes in racial bias and empathy. Linear regression was used to assess the effect of resident characteristics on racial bias and empathy.Ninety of 111 residents receiving the curriculum completed pre-surveys (81.1%), and among those, 65 completed post-surveys (72.2%). Among participants with baseline pro-White bias, there was a statistically significant shift (0.46 to 0.36, P=.02) toward no preference. Among participants with a baseline pro-Black bias, there was a statistically significant shift (-0.38 to -0.21, P=.02), toward no preference. Among participants with baseline pro-White explicit bias, there was a statistically significant shift (0.54 to 0.30, P<.001) toward no preference. Among all residents, there was a modest but statistically significant decrease in mean empathy (22.95 to 22.42, P=.03).Participation in a longitudinal discussion-based curriculum addressing racism modestly reduced pediatric residents' racial preferences with minimal effects on empathy scales.
View details for DOI 10.4300/JGME-D-21-01048.1
View details for PubMedID 35991090
View details for PubMedCentralID PMC9380619
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US News & World Report and quality metrics: Inclusion of sickle cell disease is a matter of equity.
Pediatric blood & cancer
2022; 69 (8): e29679
View details for DOI 10.1002/pbc.29679
View details for PubMedID 35441787
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Lifting the mask mandate puts our priorities in plain sight.
Journal of hospital medicine
2022; 17 (8): 668-670
View details for DOI 10.1002/jhm.12909
View details for PubMedID 35797479
View details for PubMedCentralID PMC9542800
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"It Makes Me a Better Person and Doctor": A Qualitative Study of Residents' Perceptions of a Curriculum Addressing Racism.
Academic pediatrics
2022; 22 (2): 332-341
Abstract
Explore how pediatric residents perceive the impact of a curriculum addressing racism on their knowledge, motivation, skills and behaviors, and investigate the contextual factors that promote or impede the curriculum's effectiveness.Open-ended, semistructured interviews were conducted at 2 academic medical centers between August 2019 and 2020 among pediatric residents who participated in the curriculum. Interviews were recorded, transcribed, and analyzed by using inductive content analysis.Pediatric residents (n = 16) were predominantly white (66.7%), female (86.7%) interns (60%) from the Midwest (40%). Six major themes emerged describing the perceived impact of the curriculum on: knowledge - (1) Understanding of race and racism as structural forces in a historical context; motivation - (2) Owning the issue of racism, (3) Having the curriculum makes a statement; skills - (4) Critical self-reflection, (5) Perceived development of skills to mitigate biases; and action-planning - (6) Turning insight into strategies to combat racism and improve patient care. Two additional themes emerged describing contextual factors that promoted or impeded the curriculum such as the content of the curriculum itself, the racial demographics of the participants, the implementation infrastructure and environmental factors such as the culture of the training program.Medical education addressing racism can facilitate the perceived acquisition of foundational knowledge regarding race and racism; motivation and skill-building to combat racism; and action planning aimed at improving patient care. Contextual factors should be considered when developing and implementing such curricula to not only promote racial equity but avoid unintended harms.
View details for DOI 10.1016/j.acap.2021.12.012
View details for PubMedID 34923147
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An Entrustable Professional Activity Addressing Racism and Pediatric Health Inequities.
Pediatrics
2022; 149 (2)
Abstract
Racism and discrimination are the root of many pediatric health inequities and are well described in the literature. Despite the pervasiveness of pediatric health inequities, we have failed to adequately educate and prepare general pediatricians and pediatric subspecialists to address them. Deficiencies within education across the entire continuum and in our health care systems as a whole contribute to health inequities in unacceptable ways. To address these deficiencies, the field of pediatrics, along with other specialties, has been on a journey toward a more competency-based approach to education and assessment, and the framework created for the future is built on entrustable professional activities (EPAs). Competency-based medical education is one approach to addressing the deficiencies within graduate medical education and across the continuum by allowing educators to focus on the desired equitable patient outcomes and then develop an approach to teaching and assessing the tasks, knowledge, skills, and attitudes needed to achieve the goal of optimal, equitable patient care. To that end, we describe the development and content of a revised EPA entitled: Use of Population Health Strategies and Quality Improvement Methods to Promote Health and Address Racism, Discrimination, and Other Contributors to Inequities Among Pediatric Populations. We also highlight the ways in which this EPA can be used to inform curricula, assessments, professional development, organizational systems, and culture change.
View details for DOI 10.1542/peds.2021-054604
View details for PubMedID 35001103
View details for PubMedCentralID PMC9647957
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Microaggressions: Privileged Observers' Duty to Act and What They Can Do.
Pediatrics
2021; 148 (6)
Abstract
Racism and sexism that manifest as microaggressions are commonly experienced by members of minoritized groups. These actions and comments erode their subjects' vitality and sense of belonging. Individuals from minoritized groups are often left in a quandary, weighing the potential benefits and risks of addressing the comments. Placing the burden to interrupt bias on our marginalized colleagues is unjust. In part, it is inappropriate to expect them to dismantle a system that they did not create. It is essential for individuals with privilege who observe microaggressions to address the speaker and support their colleagues. In this Ethics Rounds, we present 2 cases in which individuals from minoritized groups experience racism and sexism that manifest as microaggressions. The first case involves a Black female physician making recommendations in a business meeting being characterized by a male colleague as emotional. The commentators analyze how both gender and race constrain the range of acceptable emotions one may exhibit and the harm that this causes. The second case involves a Black intern being identified by a parent as a custodian. Commentators describe how such microaggressions can harm trainees' performance and sense of belonging. In both cases, observers did nothing or only spoke to the subject in private. Commentators provide specific guidance regarding actions that bystanders can take to become upstanders and how they can decenter themselves and their discomfort and leverage their privilege to interrupt microaggressions. By becoming upstanders, individuals can remove the disproportionate responsibility for addressing microaggressions from marginalized colleagues.
View details for DOI 10.1542/peds.2021-052758
View details for PubMedID 34851409
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Falling Through the Cracks.
Journal of hospital medicine
2021; 16 (11): 694-698
View details for DOI 10.12788/jhm.3578
View details for PubMedID 34328836
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Improving Discharge Instructions for Hospitalized Children With Limited English Proficiency.
Hospital pediatrics
2021; 11 (11): 1213-1222
Abstract
Patients with limited English proficiency (LEP) have increased risk of adverse events after hospitalization. At our institution, LEP families did not routinely receive translated discharge instructions in their preferred language. Our objective for this study was to increase the percentage of patients with LEP on the hospital medicine (HM) service receiving translated discharge instructions from 12% to 80%.Following the Model for Improvement, we convened an interdisciplinary team that included HM providers, pediatric residents, language access services staff, and nurses to design and test interventions aimed at key drivers through multiple plan-do-study-act cycles. Interventions addressed the translation request process, care team education, standardizing discharge instructions for common conditions, and identification and mitigation of failures. We used established rules for analyzing statistical process control charts to evaluate the percentage of patients with translated discharge instructions for all languages and for Spanish.During the study period, 540 patients with LEP were discharged from the HM service. Spanish was the preferred language for 66% of patients with LEP. The percentage of patients with LEP who received translated discharge instructions increased from 12% to 50% in 3 months and to 77% in 18 months. For patients whose preferred language was Spanish, the percentage increased from 16% to 69% in 4 months and to 96% in 18 months.Interventions targeting knowledge of the translation process and standardized Spanish discharge instructions were associated with an increased percentage of families receiving translated discharge instructions. Future work will be used to assess the impact of these interventions on postdischarge disparities, including emergency department revisits and readmissions.
View details for DOI 10.1542/hpeds.2021-005981
View details for PubMedID 34654727
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Racism and pediatric health outcomes.
Current problems in pediatric and adolescent health care
2021; 51 (10): 101087
Abstract
Racism- a system operating at the intrapersonal, interpersonal, institutional, and structural levels- is a serious threat to the health and wellbeing of children and adolescents. This narrative review highlights racism as a social determinant of health, and describes how racism breeds disparate pediatric health outcomes in infant health, asthma, Type 1 diabetes, mental health, and pediatric surgical conditions. Key examples include the association of residential racial segregation and the alarming infant mortality rate among Black infants as well as the role of redlining and discriminatory housing practices on asthma morbidity among Black children and adolescents. Furthermore, inequitable care practices such as (1) racial and ethnic disparities in insulin pump usage in patients with Type 1 diabetes, (2) lower rates pharmacotherapy initiation in racialized children with mental health disorders, and (3) decreased pain medication management and confirmatory imaging in Black children with acute appendicitis, highlight the role of interpersonal racism in propagating poor health outcomes. An urgent call to action is needed to address pediatric health inequities and ensure all children can live healthy lives. Key strategies must tackle racism at the individual, institutional, and structural levels and include building a diverse workforce, prioritizing research to describe the impact of racism on pediatric health outcomes, initiating improvement efforts to close equity gaps, building community partnerships, co-designing solutions alongside patients and families, and advocating for policy change to address the social conditions that impact children and adolescents of color.
View details for DOI 10.1016/j.cppeds.2021.101087
View details for PubMedID 34711499
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Seven practices for pursuing equity through learning health systems: Notes from the field.
Learning health systems
2021; 5 (3): e10279
Abstract
Despite learning health systems' focus on improvement in health outcomes, inequities in outcomes remain deep and persistent. To achieve and sustain health equity, it is critical that learning health systems (LHS) adapt and function in ways that directly prioritize equity.We present guidance, including seven core practices, borne from theory, evidence, and experience, for actors within LHS pursuing equity.We provide a foundational definition of equity. We then offer seven core practices for how LHS may effectively pursue equity in health: establish principle, measure for equity, lead from lived experience, co-produce, redistribute power, practice a growth mindset, and engage beyond the healthcare system. We include three use cases that illustrate ways in which we have begun to center equity in the work of our own LHS.The achievement of equity requires real transformation at individual, institutional, and structural levels and requires sustained and persistent effort.
View details for DOI 10.1002/lrh2.10279
View details for PubMedID 34277945
View details for PubMedCentralID PMC8278437
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Nurse/Resident Reciprocal Shadowing to Improve Interprofessional Communication.
Hospital pediatrics
2021; 11 (5): 435-445
Abstract
Poor communication is a major contributor to sentinel events in hospitals. Suboptimal communication between physicians and nurses may be due to poor understanding of team members' roles. We sought to evaluate the impact of a shadowing experience on nurse-resident interprofessional collaboration, bidirectional communication, and role perceptions.This mixed-methods study took place at 2 large academic children's hospitals with pediatric residency programs during the 2018-2019 academic year. First-year residents and nurses participated in a reciprocal, structured 4-hour shadowing experience. Participants were surveyed before, immediately after, and 6 months after their shadowing experience by using an anonymous web-based platform containing the 20-item Interprofessional Collaborative Competency Attainment Survey, as well as open-ended qualitative questions. Quantitative data were analyzed via linear mixed models. Qualitative data were thematically analyzed.Participants included 33 nurses and 53 residents from the 2 study sites. The immediate postshadowing survey results revealed statistically significant improvements in 12 Interprofessional Collaborative Competency Attainment Survey question responses for nurses and 19 for residents (P ≤ .01). Subsequently, 6 questions for nurses and 17 for residents revealed sustained improvements 6 months after the intervention. Qualitative analysis identified 5 major themes related to optimal nurse-resident engagement: effective communication, collaboration, role understanding, team process, and patient-centered.The reciprocal shadowing experience was associated with an increase in participant understanding of contributions from all interprofessional team members. This improved awareness may improve patient care. Future work may be conducted to assess the impact of spread to different clinical areas and elucidate patient outcomes that may be associated with this intervention.
View details for DOI 10.1542/hpeds.2020-002345
View details for PubMedID 33875534
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Decreasing Hospital Observation Time for Febrile Infants.
Journal of hospital medicine
2021; 16 (5): 267-273
Abstract
Febrile infants aged 0 to 60 days are often hospitalized for a 36-to-48 hour observation period to rule out invasive bacterial infections (IBI). Evidence suggests that monitoring blood and cerebrospinal fluid (CSF) cultures for 24 hours may be appropriate for most infants. We aimed to decrease the average culture observation time (COT) from 38 to 30 hours among hospitalized infants 0 to 60 days old over 12 months.This quality improvement initiative occurred at a large children's hospital, in conjunction with development of a multidisciplinary evidence-based guideline for the management of febrile infants. We included infants aged 0 to 60 days admitted with fever without a clear infectious source. We excluded infants who had positive blood, urine, or CSF cultures within 24 hours of incubation and infants who were hospitalized for other indications (eg, bronchiolitis). Interventions included guideline dissemination, education regarding laboratory monitoring practices, standardized order sets, and near-time identification of failures. Our primary outcome was COT, defined as time between initiation of culture incubation and hospital discharge in hours. Interventions were tracked on an annotated statistical process control chart. Our balancing measure was identification of IBI after hospital discharge.In our cohort of 184 infants aged 0 to 60 days, average COT decreased from 38 hours to 32 hours after structured guideline dissemination and order-set standardization; this decrease was sustained over 17 months. IBI was not identified in any patients after discharge.Implementation of an evidence-based guideline through education, transparency of laboratory procedures, creation of standardized order sets, and near-time feedback was associated with shorter COT for febrile infants aged 0 to 60 days.
View details for DOI 10.12788/jhm.3593
View details for PubMedID 33929946
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Pediatricians Contributing to Poverty Reduction Through Clinical-Community Partnership and Collective Action: A Narrative Review.
Academic pediatrics
2021; 21 (8S): S200-S206
Abstract
Poverty affects child health and well-being in short- and long-term ways, directly and indirectly influencing a range of health outcomes through linked social and environmental challenges. Given these links, pediatricians have long advocated for poverty reduction in both clinical settings and society. Pediatricians and others who work in pediatric settings are well-suited to address poverty given frequent touchpoints with children and families and the trust that develops over repeated encounters. Many pediatricians also recognize the need for cross-sector engagement, mobilization, and innovation in building larger collaborative efforts to combat the harmful effects of poverty. A range of methods, like co-design, community organizing, and community-engaged quality improvement, are necessary to achieve measurable progress. Moreover, advancing meaningful representation and inclusion of those from underrepresented racial and ethnic minority groups will augment efforts to address poverty within and equity across communities. Such methods promote and strengthen key clinical-community partnerships poised to address poverty's upstream root causes and its harmful consequences downstream. This article focuses on those clinical-community intersections and cross-sector, multi-disciplinary programs like Medical-Legal Partnerships, Medical-Financial Partnerships, clinic-based food pantries, and embedded behavioral health services. Such programs and partnerships increase access to services difficult for children living in poverty to obtain. Partnerships can also broaden to include community-wide learning networks and asset-building coalitions, poised to accelerate meaningful change. Pediatricians and allied professionals can play an active role; they can convene, catalyze, partner, and mobilize to create solutions designed to mitigate the harmful effects of poverty on child health.
View details for DOI 10.1016/j.acap.2021.04.010
View details for PubMedID 34740429
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New Author Guidelines for Addressing Race and Racism in the Journal of Hospital Medicine.
Journal of hospital medicine
2021; 16 (4): 197
View details for DOI 10.12788/jhm.3598
View details for PubMedID 33617442
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Disparity in Nurse Discharge Communication for Hospitalized Families Based on English Proficiency.
Hospital pediatrics
2021; 11 (3): 245-253
Abstract
Effective communication is critical for safely discharging hospitalized children, including those with limited English proficiency (LEP), who are at high risk of reuse. Our objective was to describe and compare the safety and family centeredness of nurse communication at hospital discharge for English-proficient (EP) and LEP families.In this single-center, cross-sectional study, we used direct observation of hospital discharges for EP and LEP children. Observers recorded quantitative and qualitative details of nurse-family communication, focusing on 3 domains: safe discharge, family centeredness, and family engagement. Patient characteristics and percentages of encounters in which all components were discussed within each domain were compared between EP and LEP encounters by using Fisher's exact tests. We used field notes to supplement quantitative findings.We observed 140 discharge encounters; 49% were with LEP families. Nurses discussed all safe discharge components in 31% of all encounters, most frequently omitting emergency department return precautions. Nurses used all family-centered communication components in 11% and family-engagement components in 89% of all encounters. Nurses were more likely to discuss all components of safe discharge in EP encounters when compared with LEP encounters (53% vs 9%; P < .001; odds ratio: 11.5 [95% confidence interval 4.4-30.1]). There were no differences in family centeredness or family engagement between LEP and EP encounters.Discharge encounters of LEP patients were less likely to include all safe discharge communication components, compared with EP encounters. Opportunities to improve nurse-family discharge communication include providing written discharge instructions in families' primary language, ensuring discussion of return precautions, and using teach-back to optimize family engagement and understanding.
View details for DOI 10.1542/hpeds.2020-000745
View details for PubMedID 33531376
View details for PubMedCentralID PMC7898234
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Counterpoint: Prioritizing Healthcare Workers for Scarce Critical Care Resources Is Impractical and Unjust.
Journal of hospital medicine
2021; 16 (3): 182-183
View details for DOI 10.12788/jhm.3597
View details for PubMedID 33617445
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What Should an Intern Do When She Disagrees With the Attending?
Pediatrics
2021; 147 (3)
Abstract
Disagreements, including those between residents and attending physicians, are common in medicine. In this Ethics Rounds article, we present a case in which an intern and attending disagree about discharging the patient; the attending recommends that the patient be hospitalized longer without providing evidence to support his recommendation. Commentators address different aspects of the case. The first group, including a resident, focus on the intern's potential moral distress and the importance of providing trainees with communication and conflict resolution skills to address inevitable conflicts. The second commentator, a hospitalist and residency program director, highlights the difference between residents' decision ownership and attending physicians' responsibilities and the way in which attending physicians' responsibilities for patients can conflict with their roles as teachers. She also highlights a number of ways training programs can support both trainees and attending physicians in addressing conflict, including cultivating a learning environment in which questioning is encouraged and celebrated. The third commentator, a hospitalist, notes the importance of shared decision-making with patients and their parents when decisions involve risk and uncertainty. Family-centered rounds can facilitate shared decision-making.
View details for DOI 10.1542/peds.2020-049646
View details for PubMedID 33627371
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Health literacy and caregiver understanding in the CHD population.
Cardiology in the young
2020; 30 (10): 1439-1444
Abstract
CHD is the most common birth defect type, with one-fourth of patients requiring intervention in the first year of life. Caregiver understanding of CHD may vary. Health literacy may be one factor contributing to this variability.The study occurred at a large, free-standing children's hospital. Recruitment occurred at a free-of-charge CHD camp and during outpatient cardiology follow-up visits. The study team revised the CHD Guided Questions Tool from an eighth- to a sixth-grade reading level. Caregivers of children with CHD completed the "Newest Vital Sign" health literacy screen and demographic surveys. Health literacy was categorised as "high" (Newest Vital Sign score 4-6) or "low" (score 0-3). Caregivers were randomised to read either the original or revised Guided Questions Tool and completed a validated survey measuring understandability and actionability of the Guided Questions Tool. Understandability and actionability data analysis used two-sample t-testing, and within demographic group differences in these parameters were assessed via one-way analysis of variance.Eighty-two caregivers participated who were largely well educated with a high income. The majority (79.3%) of participants scored "high" for health literacy. No differences in understanding (p = 0.43) or actionability (p = 0.11) of the original and revised Guided Questions Tool were noted. There were no socio-economic-based differences in understandability or actionability (p > 0.05). There was a trend towards improved understanding of the revised tool (p = 0.06).This study demonstrated that readability of the Guided Questions Tool could be improved. Future work is needed to expand the study population and further understand health literacy's impact on the CHD community.
View details for DOI 10.1017/S1047951120002243
View details for PubMedID 32746956
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Truth in Tension: Reflections on Racism in Medicine.
Journal of hospital medicine
2020; 15: 572-573
View details for DOI 10.12788/jhm.3492
View details for PubMedID 32816670
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Improving the Transition of Intravenous to Enteral Antibiotics in Pediatric Patients with Pneumonia or Skin and Soft Tissue Infections.
Journal of hospital medicine
2020; 15 (1): 10-15
Abstract
Despite national recommendations for early transition to enteral antimicrobials, practice variability has existed at our hospital.The aim of this study was to increase the proportion of enterally administered antibiotic doses for Pediatric Hospital Medicine patients aged >60 days admitted for uncomplicated community-acquired pneumonia or skin and soft tissue infections from 44% to 75% in eight months.This quality improvement study was conducted at a large, urban, academic children's hospital. The study population included Hospital Medicine patients aged >60 days with diagnoses of pneumonia or skin and soft tissue infections. Interventions included education on intravenous and enteral antibiotic charge differentials, documentation of transition plan, structured discussions of transition criteria, and real-time identification of failures with feedback. Our process measure was the total number of enteral antibiotic doses divided by all antibiotic doses in patients receiving enteral medications on the same day. An annotated statistical process control chart tracked the impact of interventions on the administration route of antibiotic doses over time. Additional outcome measures included antimicrobial costs per patient encounter using average wholesale prices and length of stay.The percentage of enterally administered antibiotic doses increased from 44% to 80% within eight months. Antimicrobial costs per patient encounter and the associated standard deviation of costs for our target diagnoses decreased by 70% and 84%, respectively. Average length of stay did not change.Standardized communication about criteria for transition from intravenous to enteral antibiotics can lead to earlier transitions for patients with pneumonia or skin and soft tissue infections, subsequently reducing costs and prescribing variability.
View details for DOI 10.12788/jhm.3253
View details for PubMedID 31339843
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Improving Efficiency of Pediatric Hospital Medicine Team Daily Workflow.
Hospital pediatrics
2019; 9 (11): 867-873
Abstract
Workflow inefficiencies by medical teams caring for hospitalized patients may affect patient care and team experience. At our institution, complexity and clinical volume of the pediatric hospital medicine (HM) service have increased over time; however, efficient workflow expectations were lacking. We aimed to increase the percentage of HM teams meeting 3 efficiency criteria (70% nurses present for rounds, rounds completed by 11:30 am, and HM attending notes completed by 5 pm) from 28% to 80% within 1 year.Improvement efforts targeted 5 HM teams at a large academic hospital. Our multidisciplinary team, including HM attending physicians, pediatric residents, and nurses, focused on several key drivers: shared expectations, enhanced physician and nursing buy-in and communication, streamlined rounding process, and data transparency. Interventions included (1) daily rounding expectations with prerounds huddle, (2) visible reminders, (3) complex care team scheduled rounds, (4) real-time nurse notification of rounds via electronic platform, (5) workflow redesign, (6) attending feedback and data transparency, and (7) resource attending implementation. Attending physicians entered efficiency data each day through a Research Electronic Data Capture survey. Annotated control charts were used to assess the impact of interventions over time.Through sequential interventions, the percentage of HM teams meeting all 3 efficiency criteria increased from 28% to 61%. Nursing presence on rounds improved, and rounds end time compliance remained high, whereas attending note completion time remained variable.Inpatient workflow for pediatric providers was improved by setting clear expectations and enhancing team communication; competing demands while on service contributed to difficulty in improving timely attending note completion.
View details for DOI 10.1542/hpeds.2019-0094
View details for PubMedID 31628203
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Inpatient Communication Barriers and Drivers When Caring for Limited English Proficiency Children.
Journal of hospital medicine
2019; 14 (10): 607-613
Abstract
Achieving effective communication between medical providers and families with limited English proficiency (LEP) in the hospital is difficult.Our objective was to identify barriers to and drivers of effective interpreter service use when caring for hospitalized LEP children from the perspectives of pediatric medical providers and interpreters.We used Group Level Assessment (GLA), a structured qualitative participatory method that allows participants to directly produce and analyze data in an interactive group session. Participants from a single academic children's hospital generated individual responses to prompts and identified themes and relevant action items. Themes were further consolidated by our research team and verified by stakeholder groups.Four GLA sessions were conducted including 64 participants: hospital medicine physicians and pediatric residents (56%), inpatient nursing staff (16%), and interpreter services staff (28%). Barriers identified included: (1) difficulties accessing interpreter services; (2) uncertainty in communication with LEP families; (3) unclear and inconsistent expectations and roles of team members; and (4) unmet family engagement expectations. Drivers of effective communication were: (1) utilizing a team-based approach between medical providers and interpreters; (2) understanding the role of cultural context in providing culturally effective care; (3) practicing empathy for patients and families; and (4) using effective family-centered communication strategies.Participants identified unique barriers and drivers that impact communication with LEP patients and their families during hospitalization. Future directions include exploring the perspective of LEP families and utilizing team-based and family-centered communication strategies to standardize and improve communication practices.
View details for DOI 10.12788/jhm.3240
View details for PubMedID 31339836
View details for PubMedCentralID PMC6817305
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Failure to Thrive and Frequent PICU Admissions in a 2-year-old Boy.
Pediatrics in review
2019; 40 (Suppl 1): 29-30
View details for DOI 10.1542/pir.2018-0068
View details for PubMedID 31575692
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Objective Assessment of Resident Teaching Competency Through a Longitudinal, Clinically Integrated, Resident-as-Teacher Curriculum.
Academic pediatrics
2019; 19 (6): 698-702
Abstract
Competency-based training should be paired with objective assessments. To date, there has been limited objective assessment of resident-as-teacher curricula (RATC). We sought to assess the impact of a longitudinal RATC on postgraduate year-1 (PGY1) resident teaching competency using Observed Structured Teaching Encounters (OSTEs) for the skills of 1) brief didactic teaching [DT], 2) feedback [FB], and 3) precepting [PR].A controlled, prospective, educational study was conducted from May 2015 to June 2016. The RATC consisted of a workshop series with reinforcement of key skills (DT, FB) during clinical rotations. Intervention residents participated in the RATC and completed OSTEs at the beginning and end of the academic year. A control group, PGY1 residents that matriculated the year previously, completed the OSTEs before starting their PGY2 year. OSTEs were reviewed by 2 blinded study personnel. We assessed reliability between raters via intraclass correlation coefficients and differences in OSTE scores via least squared mean differences (LSMD).In total, 92.5% (n = 37) of eligible control and 100% (n = 41) of eligible intervention residents participated. The OSTEs demonstrated excellent agreement between reviewers (DT: 0.99, FB: 0.89, PR: 0.98). A significant pre-post difference was demonstrated in the intervention group for DT (LSMD [95% confidence interval], 3.14 [2.49-3.79], P < .0001), FB (0.93 [0.49-1.37], P < .0001), and PR (0.64 [0.09-1.18], P < .022). A significant difference between the control and intervention groups was demonstrated for DT (3.00 [2.05-3.96], P < .0001).Skill-based OSTEs can be used to detect changes in residents' teaching competency and may represent a potential component of programmatic evaluation of resident-as-teacher curricula.
View details for DOI 10.1016/j.acap.2019.01.011
View details for PubMedID 30853578
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Diagnosis and Management of Infectious Diarrhea.
JAMA pediatrics
2018; 172 (8): 775-776
View details for DOI 10.1001/jamapediatrics.2018.1172
View details for PubMedID 29889925
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Fathers Know Best: Inner-City African American Fathers' Perceptions Regarding Their Involvement in the Pediatric Medical Home.
Journal of racial and ethnic health disparities
2018; 5 (3): 617-622
Abstract
Despite nearly three in four African American (AA) children being born to unwed mothers, AA fathers maintain relatively high levels of parenting engagement, whether or not they live with their children. While father involvement correlates with decreased adverse child health outcomes, the nature of AA father involvement in child health-including engagement in the pediatric medical home-remains largely unexplored. Our study aimed to assess perceptions of pediatric medical home participation among a cohort of urban, AA fathers.Group level assessments (GLA; N = 17) were conducted among AA fathers in an urban, Midwestern neighborhood to examine perceptions regarding pediatric medical home involvement. Study participants generated themes based on GLA responses, and study staff used grounded theory as a framework for qualitative analysis of thematic data.Fathers desired to have their parental role acknowledged by mothers and pediatricians. They perceived unrecognized parenting strengths, including being role models, teachers, and providers for their children. Respondents endorsed uncertainty navigating the pediatric health care system, unawareness of their children's pediatric appointments, and feeling excluded from health care decision-making by their children's mothers and pediatric providers.In our cohort, AA fathers have a strong desire to be involved in their children's healthy development, but feel marginalized in their parenting role. AA fathers want improved communication with physicians and their children's mothers and to be actively included in health care decision-making. Enhanced efforts to engage fathers in the pediatric medical home may lead to improved health outcomes and reduced disparities for minority children.
View details for DOI 10.1007/s40615-017-0407-4
View details for PubMedID 28730559
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Preparing from the Outside Looking In for Safely Transitioning Pediatric Inpatients to Home.
Journal of hospital medicine
2018; 13 (4): 287-288
View details for DOI 10.12788/jhm.2935
View details for PubMedID 29394298
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Improving the Readability of Pediatric Hospital Medicine Discharge Instructions.
Journal of hospital medicine
2017; 12 (7): 551-557
Abstract
Readable discharge instructions may help caregivers understand and implement care plans following hospitalization. Many caregivers of hospitalized children, however, have limited literacy. We aimed to increase the percentage of discharge instructions written at 7th grade level or lower for hospital medicine patients from 13% to 80% in 6 months.Quality improvement efforts targeted a 42-bed unit at the community satellite of our large, urban academic hospital. A multidisciplinary team of physicians, nurses, and parents focused on key drivers: family engagement in discharge process, standardization of discharge instructions, staff engagement in discharge preparedness, and audit and feedback of data. Improvement cycles included 1) education and implementation of a general discharge instruction template in the electronic health record (EHR); 2) visible reminders and tips for writing readable discharge instructions; 3) implementation of disease-specific discharge instruction templates in the EHR; and 4) individualized feedback to staff on readability and content of their written discharge instructions. Instructions were individually scored for readability using an online platform. An annotated control chart assessed the impact of interventions over time.Through sequential interventions over 6 months, the percentage of discharge instructions written at 7th grade or lower readability level increased from 13% to 98% and has been sustained for 4 months. The reliable use of the EHR templates was associated with our largest improvements.Use of standardized discharge instruction templates and rapid feedback to staff improved the readability of instructions. Next steps include adaptation and spread to other patient populations.
View details for DOI 10.12788/jhm.2770
View details for PubMedID 28699944
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Development of a New Care Model for Hospitalized Children With Medical Complexity.
Hospital pediatrics
2017; 7 (7): 410-414
Abstract
Children with medical complexity are a rapidly growing inpatient population with frequent, lengthy, and costly hospitalizations. During hospitalization, these patients require care coordination among multiple subspecialties and their outpatient medical homes. At a large freestanding children's hospital, a new inpatient model of care was developed in an effort to consistently provide coordinated, family-centered, and efficient care. In addition to expanding the multidisciplinary team to include a pharmacist, dietician, and social worker, the team redesign included: (1) medication reconciliation rounds, (2) care coordination rounds, and (3) multidisciplinary weekly handoff with outpatient providers. During weekly medication reconciliation rounds, the team pharmacist reviews each patient's current medications with the team. In care coordination rounds, the team collaborates with unit care managers to identify discharge needs and complete discharge tasks. Finally, at the end of the week, the outgoing hospital medicine attending physician hands off patient care to the incoming attending with input from the team's pharmacist, dietician, and social worker. Families and providers noted improvements in care coordination with the new care model. Remaining challenges include balancing resident autonomy and attending supervision, as well as supporting providers in delivering care that can be emotionally challenging. Aspects of this care model could be tested and adapted at other hospitals that care for children with medical complexity. Additionally, future work should study the impact of inpatient complex care models on patient health outcomes and experience.
View details for DOI 10.1542/hpeds.2016-0149
View details for PubMedID 28596445
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Increasing Physical Exam Teaching on Family-Centered Rounds Utilizing a Web-Based Tool.
Pediatric quality & safety
2017; 2 (4): e032
Abstract
Millennial trainees prefer innovative, multimodal education on topics including the physical exam (PE). Attendings inconsistently meet these needs on family-centered rounds. To enhance PE teaching, a Web site (PEToolkit) was created, but its use was infrequent. We aimed to increase PEToolkit use from 2 to 5 page counts per week in 7 months.This quality improvement project took place at a large academic center in 1 Hospital Medicine team. Key drivers informed interventions, and an annotated run chart tracked progress. We tracked secondary measures, including changes in perception of teaching skill among attendings and resident-observed methods of PE teaching, through survey methodology.Median page counts increased to 5 counts per week in 7 months. The most impactful interventions included training senior residents to teach with the PEToolkit Web site and team feedback on Web site usage midweek. Survey responses from 37 attendings showed that those with more exposure to PEToolkit had increased self-perceived skill of PE teaching (P = 0.02). Survey responses from 52 residents showed that those on the intervention team reported more use of video for PE teaching (P < 0.001) and higher frequency of PE teaching (P = 0.02), compared with those on the nonintervention team.We increased PEToolkit Web site use during family-centered rounds, thereby emphasizing the importance of PE teaching in this setting in an innovative way. Engagement of learners, frequent feedback, and coaching should be considered when incorporating technology in teaching.
View details for DOI 10.1097/pq9.0000000000000032
View details for PubMedID 30229169
View details for PubMedCentralID PMC6132483
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Five Steps for Success in Building Your Own Educational Web Site.
Academic pediatrics
2017; 17 (4): 345-348
View details for DOI 10.1016/j.acap.2017.03.004
View details for PubMedID 28300656
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Assessment of readability, understandability, and completeness of pediatric hospital medicine discharge instructions.
Journal of hospital medicine
2017; 12 (2): 98-101
Abstract
The average American adult reads at an 8th-grade level. Discharge instructions written above this level might increase the risk of adverse outcomes for children as they transition from hospital to home. We conducted a cross-sectional study at a large urban academic children's hospital to describe readability levels, understandability scores, and completeness of written instructions given to families at hospital discharge. Two hundred charts for patients discharged from the hospital medicine service were randomly selected for review. Written discharge instructions were extracted and scored for readability (Fry Readability Scale [FRS]), understandability (Patient Education Materials Assessment Tool [PEMAT]), and completeness (5 criteria determined by consensus). Descriptive statistics enumerated the distribution of readability, understandability, and completeness of written discharge instructions. Of the patients included in the study, 51% were publicly insured. Median age was 3.1 years, and median length of stay was 2.0 days. The median readability score corresponded to a 10th-grade reading level (interquartile range, 8-12; range, 1-13). Median PEMAT score was 73% (interquartile range, 64%-82%; range, 45%-100%); 36% of instructions scored below 70%, correlating with suboptimal understandability. The diagnosis was described in only 33% of the instructions. Although explicit warning signs were listed in most instructions, 38% of the instructions did not include information on the person to contact if warning signs developed. Overall, the readability, understandability, and completeness of discharge instructions were subpar. Efforts to improve the content of discharge instructions may promote safe and effective transitions home. Journal of Hospital Medicine 2017;12:98-101.
View details for DOI 10.12788/jhm.2688
View details for PubMedID 28182805
View details for PubMedCentralID PMC6327837
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Implementation of an Innovative Pediatric Hospital Medicine Education Series.
Hospital pediatrics
2016; 6 (3): 151-6
Abstract
Limitations on resident duty hours require formal education programs to be high-yield and impactful. Hospital medicine (HM) topics provide the foundation for inpatient pediatric knowledge pertinent to pediatric residents and medical students. Our primary objective was to describe the creation of an innovative pediatric HM curriculum designed to increase learners’ medical knowledge and their confidence in communicating with patients and families about these topics; our secondary objective was to evaluate the level of innovation of the conference sessions perceived by the learners.A systematic approach was used to develop a curriculum framework incorporating a variety of interactive and engaging educational strategies. Six sessions were studied over the 2012–2013 academic year. The bimonthly sessions were presented during the resident daily conference schedule as a recurring pediatric HM series. Change in learners’ medical knowledge and confidence in communicating with families were analyzed presession to postsession by using McNemar’s test and the Wilcoxon signed rank test, respectively. Learners rated the level of innovation for each session on a 5-point Likert scale.Content covered during the 6 sessions included bronchiolitis, child abuse, health care systems, meningitis/fever, urinary tract infection, and wheezing. Medical knowledge increased presession to postsession (P < .001), as did confidence in communicating about each topic with families (P < .01). The average rating score for all sessions was highly innovative.A systematic approach is useful for developing new curricula for pediatric learners. Focusing on high-yield topics and established competencies allows impactful education sessions within the confines of pediatric learners’ schedule constraints.
View details for DOI 10.1542/hpeds.2015-0141
View details for PubMedID 26908825
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Revisiting the History: Hypereosinophilia in a 4-Year-Old With Purpura.
Hospital pediatrics
2015; 5 (7): 399-402
View details for DOI 10.1542/hpeds.2014-0186
View details for PubMedID 26136315
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An Observed Structured Teaching Evaluation Demonstrates the Impact of a Resident-as-Teacher Curriculum on Teaching Competency.
Hospital pediatrics
2015; 5 (6): 342-7
Abstract
Residents play a critical role in the education of peers and medical students, yet attainment of teaching skills is not routinely assessed. The primary aim of this study was to develop a novel, skill-based Observed Structured Teaching Evaluation (OSTE) and self-assessment survey to measure the impact of a resident-as-teacher curriculum on teaching competency. The secondary aim was to determine interrater reliability of the OSTE.A prospective study quantitatively assessed intern teaching competency via videotaped teaching encounters (videos) before and after a month-long hospital medicine rotation and self-assessment surveys over a 5-month period. The intervention group received the resident-as-teacher curriculum. Videos were evaluated by 2 blinded faculty via an OSTE covering 9 skills within 3 core components: preparation, teaching, and reflection. Pre- to post-HM rotation month differences were evaluated within and between groups using the Wilcoxon signed rank test and Wilcoxon rank-sum test, respectively.Twenty-two of 25 (88%) control and 27 of 28 (96%) intervention interns participated; 100% of participants completed the study. The intervention group's pre-post difference for the total OSTE score and the average self-assessed competence statistically improved; however, no significant difference was seen between groups. The difference in preparation scores was significant for the intervention compared with the control. The OSTE's interrater reliability demonstrated good agreement with weighted kappas of 0.86 for preparation, 0.71 for teaching, and 0.93 for reflection.Implementation of an objective, skill-based OSTE detected observable changes in interns' teaching competency after implementation of a brief resident-as-teacher curriculum. The OSTE's good interrater reliability may allow standardized assessment of skill attainment over time.
View details for DOI 10.1542/hpeds.2014-0134
View details for PubMedID 26034166
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A Rare Case of Pulmonary Artery Sling and Complete Atrioventricular Canal Defect in an Infant With Trisomy 21.
World journal for pediatric & congenital heart surgery
2014; 5 (3): 470-2
Abstract
Pulmonary artery sling is a very rare congenital vascular anomaly. Patients usually present in infancy with symptoms of airway compression. Patients with trisomy 21 often have upper airway obstruction, most commonly related to pharyngeal causes or subglottic stenosis. Although the incidence of congenital heart defects in patients with trisomy 21 is very high, a review of the literature showed only one previously reported case of pulmonary artery sling in an infant with trisomy 21. We report a case of pulmonary artery sling and complete atrioventricular canal defect in a one-month-old female with trisomy 21. Echocardiography is an important diagnostic method for pulmonary artery sling, but this anomaly may be easily overlooked in the presence of more commonly anticipated defects in this population.
View details for DOI 10.1177/2150135114526422
View details for PubMedID 24958055
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Effects of the 2011 duty hour restrictions on resident education and learning from patient admissions.
Hospital pediatrics
2014; 4 (4): 222-7
Abstract
In July 2011, new duty hour limits for resident physicians were instituted to address concerns about the effects of sleep deprivation on patient care and trainee experience. We sought to evaluate potential educational impacts of these duty hour changes with regard to learning and frequency of attending interactions during patient admissions.Forty-nine residents on general pediatric teams participated in a prospective observational cohort study. Intervention residents (n = 23) worked a shift-based schedule compliant with new requirements. Control residents (n = 26) were on call every fourth night and compliant with 2003 work hour limits. Faculty members were present 16 hours daily. Resident surveys assessed learning from admissions (frequency of attending interaction and perceived learning during admissions). Data were analyzed with generalized linear mixed models to account for multiple responses from each resident.Intervention interns and seniors were less likely to present admissions to faculty during morning rounds, but there were no differences between intervention and control groups in percentage of admissions discussed with faculty at any time. Perceived learning from admissions was not different between the 2 groups.Faculty-resident interaction decreased during morning rounds; however, overall attending contact did not, suggesting inpatient teaching approaches must adapt to meet learners' needs throughout the workday.
View details for DOI 10.1542/hpeds.2014-0004
View details for PubMedID 24986991
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Assessment of active play, inactivity and perceived barriers in an inner city neighborhood.
Journal of community health
2014; 39 (3): 538-44
Abstract
Avondale, a disadvantaged neighborhood in Cincinnati, lags behind on a number of indicators of child well-being. Childhood obesity has become increasingly prevalent, as one-third of Avondale's kindergarteners are obese or overweight. The study objective was to determine perceptions of the quantity of and obstacles to childhood physical activity in the Avondale community. Caregivers of children from two elementary schools were surveyed to assess their child's physical activity and barriers to being active. Three hundred and forty surveys were returned out of 1,047 for a response rate of 32%. On school days, 41% of caregivers reported that their children spent more than 2 h watching television, playing video games, or spending time on the computer. While over half of respondents reported that their children get more than 2 h of physical activity on school days, 14% of children were reported to be physically active less than 1 h per day. Caregivers identified violence, cost of extracurricular activities, and lack of organized activities as barriers to their child's physical activity. The overwhelming majority of caregivers expressed interest in a program to make local playgrounds safer. In conclusion, children in Avondale are not participating in enough physical activity and are exposed to more screen time than is recommended by the AAP. Safety concerns were identified as a critical barrier to address in future advocacy efforts in this community. This project represents an important step toward increasing the physical activity of children in Avondale and engaging the local community.
View details for DOI 10.1007/s10900-013-9794-6
View details for PubMedID 24306236
View details for PubMedCentralID PMC4004696
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Effect of a face sheet tool on medical team provider identification and family satisfaction.
Journal of hospital medicine
2014; 9 (3): 186-8
Abstract
Resident duty hour restrictions may expose families to more trainees during hospitalization and hinder recognition of medical team members. This may negatively impact family satisfaction. Our study sought to determine the effects of a face sheet tool on families' identification and satisfaction rating of the medical team. One of 2 general pediatric units at a large academic center was assigned to intervention; the other served as the concurrent control. Families on the intervention unit were given a face sheet tool with medical team members' photos and role descriptions. Upon discharge, caregivers matched names, photos, and roles to providers they encountered, answered a 10-question satisfaction survey, and answered an overall hospital experience satisfaction question. Caregivers encountered a median of 8 (range, 3-14) medical team members. Caregivers in the intervention group were more likely to correctly identify providers by name (median correct, 25% vs 11% for controls; P < 0.01) and provider roles (median correct, 50% vs 25%; P < 0.01). No significant difference was noted between groups for overall satisfaction. A face sheet tool helped caregivers identify their child's care providers' names and roles, although identification remained poor.
View details for DOI 10.1002/jhm.2114
View details for PubMedID 24243584
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Utilizing improvement science methods to improve physician compliance with proper hand hygiene.
Pediatrics
2012; 129 (4): e1042-50
Abstract
In 2009, The Joint Commission challenged hospitals to reduce the risk of health care-associated infections through hand hygiene compliance. At our hospital, physicians had lower compliance rates than other health care workers, just 68% on general pediatric units. We used improvement methods and reliability science to increase compliance with proper hand hygiene to >95% by inpatient general pediatric teams.Strategies to improve hand hygiene were tested through multiple plan-do-study-act cycles, first by 1 general inpatient medical team and then spread to 4 additional teams. At the start of each rotation, residents completed an educational module and posttest about proper hand hygiene. Team compliance data were displayed daily in the resident conference room. Real-time identification and mitigation of failures by a hand-washing champion encouraged shared accountability. Organizational support ensured access to adequate hand hygiene supplies. The main outcome measure was percent compliance with acceptable hand hygiene, defined as use of an alcohol-based product or hand-washing with soap and turning off the faucet without using fingers or palm. Compliance was defined as acceptable hand hygiene before and after contact with the patient or care environment. Covert bedside observers recorded at least 8 observations of physicians' compliance per day.Physician compliance with proper hand hygiene improved to >95% within 6 months and was sustained for 11 months.Instituting a hand-washing champion for immediate identification and mitigation of failures was key in sustaining results. Improving physician compliance with proper hand hygiene is achievable and a first step in decreasing health care-associated infections.
View details for DOI 10.1542/peds.2011-1864
View details for PubMedID 22392176