Hospital pediatrics

Desiree Yeboah

K. Casey Lion

Hospital Pediatrics

Hosp Pediatr

The Next Frontier in Quality Improvement

质量改进的下一个前沿领域

OBJECTIVE Delays in discharges have a downstream effect on emergency department admissions, wait times, intensive care unit transfers, and elective admissions. This quality improvement project’s aim was to increase the percentage of discharges before noon from a hospital medicine service from 19% to 30% over a 6-month period and sustain the increase for 6 months. METHODS Interventions included introduction of a dedicated patient flow provider (PFP), optimization of workflow, technology assistance with discharge tasks, and multidisciplinary education on patient flow. The primary outcome was percentage of discharges before noon, and secondary outcome was length of stay (LOS). The process measure compared discharges before noon with and without the PFP. Additional equity and regression analyses were completed. The balancing measure was 7-day readmissions. RESULTS Discharges before noon rose from baseline 19% to 34%. On days the PFP was present, discharges before noon were 43% vs 22% when not present. Rational subgrouping showed an initial and persistent disparity in discharges before noon for racial and ethnic minority patients and patients who use a language other than English (LOE). LOS remained stable from baseline 2.74 to 2.54 days. There was no change in 7-day readmission rate. CONCLUSION Discharges before noon significantly increased after the addition of a staff member dedicated to discharge tasks. Additional staffing represents a large investment, and additional studies are needed to quantify the financial impact of this intervention. Future targeted work to address persistent disparities in discharges before noon for racial and ethnic minority patients and those who use an LOE is also needed.

Yuliya Oumarbaeva-Malone

Kaitlyn McQuistion

Grace Quinn

Erik J. Mayer

Paul Manicone

Investing in a New Role to Increase Timely Morning Discharges in the Inpatient Setting

投资新角色以提高住院患者早晨及时出院率

To examine patient characteristics and resource utilization of hospitalized children and adolescents with somatic symptom and related disorders (SSRDs).

Kelly Roelf

Manaswitha Khare

Tiranun Rungvivatjarus

Elizabeth Mannino Avila

Christiane Lenzen

Aarti Patel

Erin Stucky Fisher

Melissa Camera

Characteristics and Resource Utilization of Hospitalized Children With Somatic Symptoms

住院儿童躯体症状的特点及资源利用

Stephanie P. Gilley

Maya Bunik

Breastfeeding for the Re-Hospitalized Infant

再住院婴儿的母乳喂养

In Canada, bathtub-related drowning events account for 10% of all drownings requiring hospitalization, with fatality rates of approximately 1.3 per 1 000 000 persons per year.1 Lack of adequate supervision, co-bathing, bath seats, and medical conditions have been identified as risk factors.2 This study aimed to determine the incidence of fatal unintentional pediatric bathtub drownings in Ontario from 2003 to 2022 and describe demographic and circumstantial factors.This study is a case series of all unintentional fatal pediatric bathtub drownings in Ontario, Canada, between January 1, 2003, and December 31, 2022. Any child (0–18 years) whose cause of death was determined to be the result of drowning in a bathtub was included. Cases were reviewed by forensic pathologists using coroners' records for all deaths in children attributed to drowning in a bathtub or when the deceased was discovered unresponsive or dead in a bathtub. Coroners', police, and autopsy reports were used to extract data. Annual crude rates of pediatric bathtub drownings per 1 000 000 children were used to determine incidence rates. The Ontario Marginalization Index was used to determine area-level marginalization quintiles.3 Descriptive statistics were performed. The study was approved by the University of Toronto Human Research Ethics Unit.We identified 47 unintentional childhood/adolescent bathtub drownings during the 20-year period. Fifty-five percent of unintentional pediatric drownings occurred in children aged younger than 24 months and 17% in adolescents aged older than 14 years. Lapse of supervision was reported in all 47 cases. More than a quarter (28%) of the fatalities were among children residing in neighborhoods in the greatest material deprivation quintile (Table 1). The annual incidence rate for unintentional pediatric bathtub drownings ranged from 0 to 2.71 per 1 000 000 children (age 0–14 years) from 2003 to 2022 with a mean incidence rate of 1/1 000 000 (Figure 1). During this study period, 76% of drownings occurred in children aged no more than 5 years. Among children aged 2–5 years, 8 (80%) had a seizure disorder. Two-thirds (18/27) reported a lapse in supervision of no more than 5 minutes, and a lapse of no more than 30 seconds was reported in 4 fatalities. Half of the children in this study were co-bathing with a sibling. Eight adolescents died by unintentional bathtub drowning, of whom 63% had a known seizure disorder. Two had a positive toxicology screen for street drugs, and 2 were noncompliant with their anticonvulsant medications.This is the first study describing all unintentional pediatric bathtub drownings in Canada's most populous province. This study has four main findings. First, the incidence has remained relatively stable over the last 20 years. Second, lapses in supervision remain a significant risk factor. Third, co-bathing continues to provide false reassurance. Fourth, seizure disorders are common among older children that drown in bathtubs.Although admittedly rare, pediatric bathtub drownings have failed to demonstrate the same decline in incidence when compared with other high-profile public health campaigns in Canada.4–9 The relatively static bathtub drowning rates of the past 20 years raise the question of renewed and revised public health messaging10 to mitigate these rare but preventable fatalities.In 2006, the 20-year single-center review of accidental pediatric bathtub drownings by Somers et al identified lack of adequate supervision, co-bathing, and bath seats as risk factors.2 These same factors persist 20 years later. Lapse in supervision, frequent in many childhood injuries, remains the most important factor to stress in bath safety education.Seizure disorder is a well-described risk factor for fatalities within bodies of water.11,12 In this study, 38% of cases had a known seizure disorder, including 63% of adolescents. Despite widespread education on the importance of water safety among those with a history of seizures,13,14 these data further highlight the importance of safety counselling for children with seizure disorders.The limitations of this study include that police reports, subject to recall bias, often relied on bystander recollection of traumatic events. Also, the lack of standardized reporting may have introduced observation bias.In conclusion, incidence rates in Ontario have remained relatively stable in Ontario from 2003 to 2022. This study highlights that no duration of supervision lapse is safe and co-bathing with an older sibling is not protective. Findings suggest that public health messaging regarding bath safety requires a renewed approach, perhaps using readily accessible online platforms and social media.

Oliver Venettacci

Bernard Pawlowicz

Gino R. Somers

Andrew S. Williams

Christina Maratta

Pediatric Bathtub Drownings in Ontario from 2003 to 2022: A Case Series

2003年至2022年安大略省儿童浴缸溺水事件：病例系列

OBJECTIVE To understand the experiences of parents and caregivers of hospitalized children with CommunityRx-Hunger, a social care intervention designed to address food insecurity and other health-related social risks (HRSRs). Perspectives on how clinicians can sensitively deliver information about HRSRs in the pediatric inpatient setting were also elicited. METHODS In-depth, semistructured qualitative interviews were conducted (April 2022 through April 2023) with caregivers of children hospitalized at an urban academic medical center. Caregivers (N = 23) were purposefully sampled from the intervention arm of the double-blind CommunityRx-Hunger randomized controlled trial (NCT4171999). Initiated during hospital discharge, CommunityRx-Hunger includes 3 evidence-based components: education about HRSRs, delivery of HRSR-related resource information, and ongoing support to boost the intervention over 12 months. Data were analyzed using directed content analysis. RESULTS Most caregivers identified as the child’s mother (n = 20) and as African American or Black (n = 19) and were partnered (n = 14). Three main themes emerged: (1) positive experiences with CommunityRx-Hunger, including the sentiment that caregivers were unaware of the amount of community resources available to address HRSRs and perceptions that caregivers “were set up for success once we left the hospital”; (2) barriers to integrating social care with medical care, including concern that clinicians “are gonna use [disclosure of HRSRs] against me”; and (3) recommendations for optimizing social care delivery, including a prevalent suggestion to “just give the information” to caregivers, without asking about risks or needs. CONCLUSION CommunityRx-Hunger was mostly well received by caregivers. Routinely providing resource information to all caregivers of hospitalized children, regardless of need, could help alleviate concerns about disclosing HRSRs.

Emily M. Abramsohn

Tania A. Mendoza

Allison H. Bartlett

Nathaniel J. Glasser

Mellissa Grana

Jessica Jerome

Doriane C. Miller

Jeff Murphy

Christine O’Malley

Elaine Waxman

Stacy Tessler Lindau

Caregivers’ Views of a Pediatric Inpatient Intervention to Address Health-Related Social Risks

住院患儿干预措施以解决健康相关社会风险的护理者观点

BACKGROUND AND OBJECTIVES There is a need to accurately capture family demographic information to ensure appropriate delivery of services, optimize patient experiences, and examine health disparities; however, we lack a standardized and inclusive approach to collect demographic data. Our objective was to design a set of inclusive survey items for common demographic categories that can be used for clinical care and research. METHODS In this prospective, mixed-methods study, we used a rigorous survey design approach to conduct a literature review, seek expert validation, and perform cognitive pretesting with families between October 2021 and September 2023 to iteratively develop an inclusive demographic survey. Survey iterations were made based on triangulation of rankings for each candidate survey item and content analysis of feedback from content experts and families. RESULTS We incorporated 21 sources from the literature review, feedback from 7 content experts, and cognitive pretesting data from 57 patient and family respondents from diverse backgrounds. We developed a final survey assessing the following categories: gender identity and sex (2 items), race and ethnicity identity (1 item), language for care (4 items), household education (1 item), and household socioeconomic status (1 item). The final survey captures nuances in demographic information (eg, racial and ethnic identity) within a parsimonious survey structure and optimizes the use of respectful, inclusive language. CONCLUSIONS We used a rigorous, family-centered survey design approach to develop a novel inclusive demographic survey, providing a standardized tool for comprehensive and accurate demographic data collection in clinical care and research.

Elizabeth Nguyen-Kearns

Jacqueline Burgara

Dureti Hajikedir

Tommy Nguyen

Elizabeth Wingfield

Kendra Liljenquist

Arti D. Desai

Development of an Inclusive Demographic Survey for Clinical Care and Research

临床护理与研究包容性人口统计调查的开发

In many health systems, hospital infrastructure has aligned around 5 of the Institute of Medicine's 6 domains of health care quality: safety, effectiveness, patient-centeredness, timeliness, and efficiency. Equity, the sixth domain,1 has lacked equivalent investment despite evidence supporting the importance of diversity, equity, and inclusion (DEI) to the health of our patients and workforce in academic medicine. Inequities and health disparities continue to disproportionately affect the health of minoritized patients and families, and underrepresented faculty experience discrimination, barriers to career advancement and leadership opportunities, and lack of representation.2–10 For example, our institution had established programs for patient safety (safety), clinical effectiveness (effectiveness), patient and family experience (patient-centeredness), and performance improvement/patient flow (timeliness and efficiency) without equivalent programmatic support for equity.Recognizing its crucial importance, our institution invested meaningfully in DEI over the past decade through the creation of a hospital Department of Diversity, Health Equity, & Inclusion with an inaugural Chief Equity Officer. Teams at other institutions have shown meaningful reductions in health disparities in pediatric hospital settings through deliberate quality improvement.11 Despite this, our Section of Hospital Medicine continued to lack internal infrastructure for DEI improvement, and hospitalist faculty pursued DEI efforts individually or not at all, with important opportunity costs and unrealized potential in hospitalist DEI advancement.In response to this gap, we aimed to develop foundational infrastructure for coordinated hospitalist DEI improvement within our Section of Hospital Medicine.We are an academically affiliated hospitalist section with more than 100 faculty. We serve patients throughout our 7-state region and provide general pediatric inpatient care to local communities. Our primary health system includes 4 freestanding children's hospitals, including a centralized, quaternary care children's hospital. We also deliver newborn care at 9 unaffiliated community hospitals and acute care at 2 unaffiliated, rural community sites. Our nonclinical pursuits span the academic spectrum of research, quality, education, advocacy, and hospital administration. No existing legislation affected our efforts, unlike other areas of the country where state legislation limited DEI improvement in academic institutions.12We applied Design for Six Sigma (DFSS)—guided by frameworks for DEI quality improvement including the AAP Equity Agenda13–15 and in partnership with hospital DEI leaders—to design new Section of Hospital Medicine DEI infrastructure. DFSS is a collection of tools and best practices for developing new processes that has been applied successfully in health care in many areas.16–18We intended to complete a 4-month, 9-session DEI Steering Team series to achieve our aim. The initial concept for our DEI Steering Team began as a capstone project for our institutional Captains of Inclusion Development Program, which aims to develop cohorts of DEI leaders in our institution by challenging, connecting, educating, and inspiring participants to build an inclusive institutional culture that values difference.19We performed an internal, open recruitment for DEI Steering Team volunteer members in January 2023. We supplemented this open recruitment with individual direct requests to ensure our team included members with expertise or experience in DEI concepts, quality improvement, and our local health system and community.13 Volunteers did not receive dedicated nonclinical time for this work.The DEI Steering Team meeting series consisted of 9 biweekly virtual meetings and was designed around 3 domains: team-building, education, and action (Table 1). In the team-building and education sessions, we aimed to first establish psychological safety and a shared mental model around fundamental DEI concepts and team goals. We reviewed local processes, policies, and programs to understand our institutional culture around DEI. In the action sessions, we aimed to produce the desired output through group consensus. To accomplish these aims, we applied published team facilitation tools20 for consensus building (eg, brainstorming).During the action sessions, the DEI Steering Team developed a Section of Hospital Medicine DEI values statement and key driver diagram (KDD) through facilitated brainstorming. DEI Steering Team members contributed cards to a virtual Dotstorming21 board in response to the following prompt: What do we need to do to fulfill our Section of Hospital Medicine DEI values statement? Through facilitated group consensus, individual cards with the same intention were combined, after which all remaining cards were clustered based on identified themes (Supplemental Figure 1). These themes then informed the creation of primary and secondary drivers on our initial KDD.To obtain interdisciplinary perspectives, the KDD was presented to nonfaculty partner groups and amended accordingly with minor language changes. Specifically, we discussed the KDD virtually with the system-wide family advisory council comprising caregivers of current and past patients. It was also presented to hospital executive leadership and acute care nursing and respiratory therapy leadership.The KDD was then presented at the opening session of a 2-day Section of Hospital Medicine leadership retreat to the entire leadership team representing all domains across the system: clinical, research, education, and quality. Each leader was individually challenged to consider the application of the KDD to their focus areas and prompted to provide DEI report outs throughout the retreat with accountability for specific DEI change ideas going forward.Our Organizational Research Risk and Quality Improvement Review Panel reviewed this initiative and provided a not human subjects research determination.We completed 9 DEI Steering Team sessions with a cohort of 21 hospital medicine section members including 1 hospital medicine fellow, 4 advanced practitioners, and 16 physicians with diversity in clinical and nonclinical focus. The faculty included 7 instructors (4 senior instructor), 10 assistant professors, 2 associate professors, and 1 professor. A hospital-employed DEI consultant also participated in the sessions. The sessions lasted less than 1 hour (mean 52.4 +/− 5.5 minutes) with 65% attendance (mean 13 +/− 2 faculty).These sessions culminated in the completion of an interdisciplinary values statement and KDD for hospital medicine DEI improvement (Figure 1). We identified 7 primary drivers with 21 secondary drivers. The 7 primary drivers were: Commit to advancing DEI with unequivocal investmentMinimize child health disparities for our hospitalized patients and familiesBuild a culture of inclusivity and belonging intolerant of discriminationRecruit, develop, advance, and sustain a diverse workforceBuild DEI knowledge and awarenessEngage diverse partners in all Section of Hospital Medicine activitiesDevelop foundational data systems to guide the above DEI effortsFeedback from relevant stakeholders included recognition of the importance of this body of work, appreciation for the deliberate engagement of diverse partners, and an acknowledgment of the enormity of the task ahead. Specifically, our patient and family partners highlighted the importance of maintaining momentum to translate these planning steps to improved outcomes.Guided by this KDD and the change ideas produced at our Leadership Retreat, our Section of Hospital Medicine faculty have completed the following efforts since completion of the DEI Steering Team: faculty education on implicit biases and microaggressions, quality improvement to increase in-person medical interpreter use, research to understand inequity in response to patient behavioral escalation, updated faculty recruitment strategies to deliberately and fairly recruit individuals with diverse lived experiences, quality improvement to reduce bias in narrative assessment of trainees, and incorporation of inequity as a prompt for Section-wide case review. We also recruited our inaugural Section of Hospital Medicine DEI Lead whose responsibilities—supported by 0.1 nonclinical full-time equivalent from internal Section funds managed by our Section Head—included DEI incorporation into Section of Hospital Medicine pursuits through advocacy, education, and collaboration/consultation with leaders in other domains (Supplemental Figure 2). Our next steps center around the development of a Section-level strategic approach to DEI improvement that prioritizes and addresses each of our key drivers in a coordinated manner.Our Section of Hospital Medicine DEI Steering Team successfully developed a values statement and KDD through team consensus building inclusive of interdisciplinary perspectives. The KDD provided a guiding framework to our faculty for ongoing DEI improvement coordination, priority setting, and accountability for hospitalist-driven efforts within our Section of Hospital Medicine.Our KDD and its development approach may have different utility to hospitalist groups at different stages of DEI improvement work. We included a detailed description of our approach to development of this KDD in hopes that the preparatory steps taken by the DEI Steering Team may inform similar work at other institutions looking to embark on DEI improvement. For institutions further along in their DEI effort, this work may provide a framework for translating ideas into practice and/or opportunities for collaboration and benchmarking across institutions.Identified as a secondary driver for primary driver #7 above, we must underscore the importance of data-driven DEI improvement. Clearly defined measures, goal setting, and data tracking over time facilitate more effective interventions and enhance accountability. Whereas some patient-focused equity measures may require sophisticated data systems, other workforce-focused measures may be more easily evaluated with basic human resources data. Institutions may start with measures associated with known problems in pediatric hospital medicine, including inequity in patient safety3 and gender pay gaps.22 For us, we identified measures around our key change ideas including medical interpreter use, workforce diversity, and cognitive bias training for faculty.Our study has several limitations. Specifically, although we took measures to promote inclusivity and recruit diverse perspectives, our DEI Steering Team consisted entirely of hospitalist faculty members without consistent contributions from nonhospitalist, interdisciplinary partners. Similarly, our work aimed to achieve team consensus among hospitalist faculty from a single health system, limiting the generalizability of our output. Additionally, we reside in a state unaffected by legislation limiting DEI efforts by academic and/or health care institutions, limiting generalizability to affected states and highlighting the importance of political advocacy. Finally, this work does not improve diversity, equity, or inclusion without translating our KDD into realized change, and we do not yet have evidence that this KDD impacts actual DEI outcomes.Hospitalists have privilege and influence that position them as crucial change agents within their health systems and communities. Through facilitated brainstorming and consensus building, our team identified 7 primary drivers of pediatric hospitalist advancement of DEI. This first step can facilitate systematic change driven by pediatric hospitalist groups.We wish to acknowledge Diversity, Health Equity, & Inclusion leadership at Children's Hospital Colorado for their support of this effort and dedication. Specifically, we wish to acknowledge the Captains of Inclusion program for its profound impact on individuals and system culture.

Justin M. Lockwood

Brandy A. Davis

Jillian M. Cotter

Peggy Guo

Alexandra Kilinsky

Edward E. Kim

Jessica B. Landry

Marla Laufer

Elizabeth McKelvey

Nicole Penwill

Jennifer W. Reese

D. David Scudamore

Anna Ruman

Maureen A. Cunningham

Seven Key Drivers of Pediatric Hospital Medicine Advancement of Diversity, Equity, and Inclusion

儿科医院医学发展中多样性、公平性和包容性的七大关键驱动力

ISSN	2154-1663, 2154-1671
h-index	35

Publication Information	Publisher: American Academy of Pediatrics，Publishing cycle: ，Journal Type: journal，Open Access Journals: No
Basic data	Year of publication: 2012，Proportion of original research papers: 0.00%，Self Citation Rate:N.A.， Gold OA Rate: 0.00%

Hospital pediatrics

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The Next Frontier in Quality Improvement

Investing in a New Role to Increase Timely Morning Discharges in the Inpatient Setting

Characteristics and Resource Utilization of Hospitalized Children With Somatic Symptoms

Breastfeeding for the Re-Hospitalized Infant

Pediatric Bathtub Drownings in Ontario from 2003 to 2022: A Case Series

The Next Frontier in Quality Improvement

Investing in a New Role to Increase Timely Morning Discharges in the Inpatient Setting

Caregivers’ Views of a Pediatric Inpatient Intervention to Address Health-Related Social Risks

Development of an Inclusive Demographic Survey for Clinical Care and Research

Seven Key Drivers of Pediatric Hospital Medicine Advancement of Diversity, Equity, and Inclusion