Faculty Bibliography

Health literacy is a foundational component of providing accessible pediatric care, influencing whether families can understand, access, and use health information. As families increasingly rely on online health resources, health literacy skills applied to digital information, or e-health literacy, has become an evolving dimension of pediatric health literacy. The concept of health literacy extends beyond an individual's abilities, intersecting with the demands placed on individuals by healthcare systems. There is a growing focus on organizational health literacy (OHL), which reflects how effectively systems support equitable communication, but this remains infrequently assessed or implemented. Limited parent, child, and adolescent health literacy is common and disproportionately affects families with lower income, minoritized racial/ethnic backgrounds, lower educational attainment, and who use languages other than English for care. Limited health literacy has been associated with decreased disease-specific knowledge, suboptimal health behaviors, and worse clinical outcomes. Although health literacy-informed strategies can improve comprehension and outcomes, best practices, such as teach-back, remain underutilized across pediatric care settings. The rapid expansion of digital tools offers new opportunities to enhance health literacy-informed communication but also introduces challenges related to equity, accuracy, and safety. Advancing pediatric health literacy requires coordinated efforts: embedding health literacy principles into institutional and national policies, integrating universal health literacy precautions into clinical workflows, expanding clinician and patient health literacy education, and advancing health literacy-focused research, including on digital interventions and artificial intelligence (AI)-supported communication. Prioritizing these efforts is essential to creating health literate-systems that enable all families to access, understand and use health information.

OBJECTIVE:The quality of discharge processes impacts adverse outcomes post hospitalization for children with medical complexity (CMC). Perspectives of caregivers at risk for communication challenges (eg, non-English speakers, those with limited health literacy, immigrants) on understandability and feasibility of discharge instructions for CMC are understudied. Our objective was to explore their perspectives on barriers and facilitators to comprehension and implementation of discharge instructions for CMC. PATIENTS AND METHODS/METHODS:In this qualitative, descriptive study, we used maximum variation sampling to enroll caregivers of CMC (N = 40) discharged from acute or intensive care units of 2 urban hospitals. English- and Spanish-speaking caregivers of CMC (Pediatric Medical Complexity Algorithm) aged 18 years or older and discharged on 1 or more daily medications were eligible. We conducted semistructured interviews, audio-recorded and transcribed interviews, and performed content analysis. Two team members applied codes from a codebook (developed based on prior literature and preliminary analyses) and identified emerging themes. RESULTS:Equal numbers of participants spoke English and Spanish (n = 20 per language) and were recruited from each hospital (n = 20 per hospital). Half (47.5%) had low health literacy; 85% were of non-US birth. Themes emerged across 4 categories: (1) clinician and medication access; (2) patient- and family-centered approaches to discharge planning and education; (3) caregiver prior experience; and (4) resources and support systems. CONCLUSIONS:Caregivers identified barriers and facilitators affecting discharge plan comprehension and implementation. Optimizing postdischarge care for CMC is complex and requires family-centered, language-concordant, and health literacy-informed processes. Future interventions should focus on systems-level changes that enhance access and account for caregiver perspectives.

OBJECTIVE:To examine whether disparities in preventable adverse events (AEs) and family experience for hospitalized children of parents with and without limited comfort with English (LCE) changed following implementation of a health literacy-informed, structured family-centered rounds intervention, Patient and Family Centered I-PASS. METHODS:Seven-center prospective before and after intervention study conducted from December 2014 to January 2017. Inclusion criteria includes parents and caregivers of hospitalized children less than 18 years old. LCE defined as parent and caregiver reporting any language other than English as the language in which they were most comfortable speaking to physicians and nurses. Preventable AE rates determined via (1) daily medical record surveillance, solicited clinician reports, hospital incident reports, and family safety interviews, followed by (2) dual-physician masked review and consensus rating. Changes assessed through multivariable mixed-effects logistic regression, controlling for complex chronic conditions, length of stay, parent race and ethnicity, education, and clustering by site. Family experience assessed via predischarge survey (6 domains, 5-point scale). Mixed-effects linear regression estimated changes in mean domain scores by language comfort. RESULTS:Of 1666 patients, 8.8% (n = 147) had parents with LCE. Preimplementation, over twice as many children of parents expressing LCE experienced preventable AEs, compared with children of parents expressing comfort with English (18.8% vs 7.6%; P = .001; adjusted odds ratio, 3.29; 95% CI, 1.48-7.31). Postimplementation, there were no significant differences between groups (6.4 vs 5.3%; P = .68; adjusted odds ratio, 1.26; 95% CI, 0.42-3.75). Some domains of family experience improved for both groups, although disparities in experience persisted in nurse communication. CONCLUSIONS:Patient safety disparities related to parental comfort with English narrowed after implementing a family-centered rounds communication intervention.

Early-career hospitalists interested in research often face uncertainty when deciding whether to apply for grant funding. This article provides a practical guide to help early-career researchers navigate early decisions in the grant application process. We review key sources of grants (federal funding, foundations, professional societies, institutional, and commercial), as well as common types of grants (eg, pilot or seed grants, travel grants, career development awards, engagement or community partnership grants, independent research grants) that may be of interest to junior investigators. We take readers through the process of determining whether specific grants are the right fit, how to decide if they should apply, sources of grants, and how to find them. The article addresses the next steps after submission, including interpreting feedback, options for resubmission, or alternative approaches if funding is not secured. Overall, this guide aims to demystify the grant-writing process and support early-career hospitalist researchers in taking their first steps toward funded research. Several helpful tips are also provided. A future article will take readers through the process of writing components of individual grants.

OBJECTIVE:Health literacy is a critical determinant of health care outcomes, particularly in pediatric inpatient care, where hospitalists play a pivotal role. However, hospitalists often face challenges in effectively addressing health literacy with patients and caregivers. This study evaluated pediatric hospitalists' attitudes, practices, perceived effectiveness of commonly used communication techniques, and barriers to health-literate communication. METHODS:We conducted a multicenter, cross-sectional survey through the Pediatric Research in Inpatient Settings (PRIS) network from July to September 2024. The survey assessed awareness, communication practices, and barriers to health-literate communication using Likert scales and predefined options. Data were analyzed using descriptive statistics. RESULTS:A total of 55 out of 100 (55%) PRIS site leads responded. Among respondents, 67% were unaware of the universal precautions approach for health literacy, although those aware reported using it regularly (72%). All agreed that health literacy is either "extremely important" (67%) or "very important" (33%) in inpatient care. The most-frequently employed communication technique was using simple language (98%). Hospitalists viewed simple language (96%) and teach-back (87%) as the most effective strategies. Time constraints (95%), lack of patient-education materials in languages other than English (89%), and volume and complexity of information to be covered (87%) were identified as major barriers for health-literate communication. CONCLUSIONS:Pediatric hospitalists recognize the importance of health literacy, but several barriers impact consistent use of health literacy-informed communication strategies. Future work should examine the impact of organizational health literacy approaches and incorporating additional formal communication training for hospitalists.

BACKGROUND:Health literacy-informed and language-concordant written materials can promote caregiver understanding of care plans although are not commonly used in inpatient rounds. OBJECTIVES/OBJECTIVE:We sought to develop and evaluate a health literacy-informed, multilingual electronic real-time summary of rounds for hospitalized patients (the Rounds eSummary). METHODS:A multidisciplinary team developed the Rounds eSummary using health literacy, communication, and language equity best practices and multiple rounds of piloting. To generate the eSummary, clinicians completed a link with closed-ended options for various rounds components (e.g., illness severity, plan), caregiver's preferred language, and contact information. This generated an electronic PDF rounds summary (15 possible languages) emailed or texted to the family. We used descriptive statistics to analyze eSummaries (n = 437) created from October 25, 2024 to February 1, 2025. Separately, for a purposive sample of English eSummaries (n = 12) that represented different diagnoses and plans, two independent raters examined reading grade level (average of five formulas), understandability, and actionability (Patient Education Materials Assessment Tool for Printable Materials). RESULTS:Rounds eSummaries were generated in eight languages across three sites; the most common languages were English (89%), Spanish (6.2%), and Portuguese (1.8%). Plans commonly included medicines (42%), nutrition (30%), and oxygen (24%). More than half (61%) were accessed at least once by the patient/caregiver; of the eSummaries accessed, the average engagement time was 29.1 s (standard deviation 25.2). The average reading grade level was 6.8 (standard deviation 0.6, range 5.8-7.8). Overall understandability and actionability scores were 87% and 60%, respectively. CONCLUSION/CONCLUSIONS:We designed a usable Rounds eSummary that addressed language and health literacy barriers. TRIAL REGISTRATION/BACKGROUND:ClinicalTrials.gov identifier: NCT05591066.

Health literacy and language impact comprehension of and adherence to written educational materials, including those for gastrostomy tubes (g-tubes). Our objective was to evaluate the readability, understandability, actionability, content, and language availability of a national sample of written g-tube educational materials. We conducted a cross-sectional study of g-tube educational materials from top 20 children's hospitals (US News and World Report) obtained via a systematic online search and provided by the institutions. We assessed material: (1) readability, (2) understandability and actionability (Patient Education Materials Assessment Tool for Printable Materials, (3) content, and (4) language availability. Mean (standard deviation [SD]) reading grade level was 8.3 (1.9). Mean (SD) understandability and actionability scores were 81.6% (12.1%) and 65.9% (23.2%), respectively. Materials covered a mean (SD) of 46.1% (25.3%) of content items; 20% of institutions provided materials in non-English languages. Future research should examine how to improve educational materials for children with g-tubes.

OBJECTIVE:Children are susceptible to adverse drug events, especially those related to high-alert and nephrotoxic medications. This study aimed to reduce the number of days in between reported medication safety events related to high-alert and nephrotoxic medications by 5% over a 28-month period. PATIENTS AND METHODS/METHODS:This single-center quality improvement study at an urban academic institution occurred across 1 acute care and 3 intensive care units. Interventions focused on increased emphasis on these medications (targeted medication list, rounding script modifications, and provider education), review of medication orders, and rounding audits. Outcomes were the number of days in between events for high-alert and nephrotoxic medications (manual review of events from the event reporting system). Process measures included bundles related to high-alert and nephrotoxic medications (eg, knowledge and discussion of elements) observed during rounds. Metrics were analyzed using statistical process control G charts and run charts. RESULTS:The number of days in between events related to high-alert medications decreased by 10 days; a centerline shift was observed. No centerline shifts were noted for nephrotoxic medications. Special cause variation was noted with more days in between events in the final year of the study period for both high-alert and nephrotoxic medications. Mean process compliance for the high-alert bundle was 90% (monthly range, 67%-100%) and 76% (monthly range, 25%-100%) for the nephrotoxic bundle. CONCLUSIONS:Time in between high-alert medication event rates increased; process compliance varied but was unchanged overall. Future work should focus on continued tracking of metrics and incorporating additional interventions, including electronic health record changes.

Coproduction-actively collaborating with key partners and end-users toward a shared goal-challenges the traditional medical hierarchy. Each partner brings unique perspectives, knowledge, expertise, values, and preferences. In pediatric hospital medicine, coproduction involves collaborating with partners often excluded from research, clinical care, quality improvement, and medical education, including patients/families, nurses, and trainees. This article describes strategies for applying coproduction, using multiple pediatric coproduction initiatives as case examples, including efforts of the Patient and Family Centered I-PASS Study Group over the past decade to apply coproduction to studies to reduce harmful medical errors and implement family-centered rounds communication interventions. We describe how coproduction can be applied to (1) research (eg, codesigning instruments, measuring patient-reported outcomes), (2) clinical care (eg, improving treatment effectiveness, shared decision-making), (3) quality improvement (eg, measuring and improving adherence to intervention components), and (4) medical education (eg, training families, nurses, and trainees about communication, providing disease-specific education). Successful coproduction involves attention to diversity, equity, inclusion, engagement, compensation, and team management. Coproduction can lead to higher quality, safer, more equitable care, improved content development and delivery, refined methods and implementation, and more salient learning for all.