Faculty Bibliography

OBJECTIVE:To determine whether medical errors, family experience, and communication processes improved after implementation of an intervention to standardize the structure of healthcare provider-family communication on family centered rounds. DESIGN/METHODS:Prospective, multicenter before and after intervention study. SETTING/METHODS:Pediatric inpatient units in seven North American hospitals, 17 December 2014 to 3 January 2017. PARTICIPANTS/METHODS:All patients admitted to study units (3106 admissions, 13171 patient days); 2148 parents or caregivers, 435 nurses, 203 medical students, and 586 residents. INTERVENTION/METHODS:Families, nurses, and physicians coproduced an intervention to standardize healthcare provider-family communication on ward rounds ("family centered rounds"), which included structured, high reliability communication on bedside rounds emphasizing health literacy, family engagement, and bidirectional communication; structured, written real-time summaries of rounds; a formal training programme for healthcare providers; and strategies to support teamwork, implementation, and process improvement. MAIN OUTCOME MEASURES/METHODS:Medical errors (primary outcome), including harmful errors (preventable adverse events) and non-harmful errors, modeled using Poisson regression and generalized estimating equations clustered by site; family experience; and communication processes (eg, family engagement on rounds). Errors were measured via an established systematic surveillance methodology including family safety reporting. RESULTS:26.5% (12.7% to 7.3%), P=0.02) increased. Trainee teaching and the duration of rounds did not change significantly. CONCLUSIONS:Although overall errors were unchanged, harmful medical errors decreased and family experience and communication processes improved after implementation of a structured communication intervention for family centered rounds coproduced by families, nurses, and physicians. Family centered care processes may improve safety and quality of care without negatively impacting teaching or duration of rounds. TRIAL REGISTRATION/BACKGROUND:ClinicalTrials.gov NCT02320175.

OBJECTIVE:To determine the early impacts of pediatric primary care parenting interventions on parent cognitive stimulation in low socioeconomic status families and whether these impacts are sustained up to 1.5 years after program completion. STUDY DESIGN/METHODS:This randomized controlled trial included assignment to 1 of 2 interventions (Video Interaction Project [VIP] or Building Blocks) or to a control group. Mother-newborn dyads were enrolled postpartum in an urban public hospital. In VIP, dyads met with an interventionist on days of well-child visits; the interventionist facilitated interactions in play and shared reading through provision of learning materials and review of videotaped parent-child interactions. In Building Blocks, parents were mailed parenting pamphlets and learning materials. We compare the trajectories of cognitive stimulation for parents in VIP and control from 6 to 54 months. RESULTS:There were 546 families that contributed data. VIP was associated with enhanced reading, parent verbal responsivity, and overall stimulation at all assessment points, with analyses demonstrating a 0.38 standard deviation increase in cognitive stimulation overall. Trajectory models indicated long-term persistence of VIP impacts on reading, teaching, and verbal responsivity. CONCLUSIONS:VIP is associated with sustained enhancements in cognitive stimulation in the home 1.5 years after completion of the program and support expansion of pediatric interventions to enhance developmental trajectories of children of low socioeconomic status. TRIAL REGISTRATION/BACKGROUND:Clinicaltrials.gov: NCT00212576.

OBJECTIVE:To examine pediatricians' attitudes towards public policies for low-income children and the advocacy efforts for the American Academy of Pediatrics (AAP). METHODS:Data from the AAP Periodic Survey in October 2014-March 2015 were used. Respondents ranked 1) Attitudes toward government programs, and 2) Attitudes toward AAP policies on: income support, housing, education, job training, food, and healthcare. Results were analyzed by age, gender, practice location, practice region, type of practice setting, and percent of patients with economic hardship. RESULTS:Response rate =47% (n=650). Most respondents reported that for children, the government should guarantee health insurance (88.9%), food and shelter (90.0%). The majority also reported that the government should guarantee health insurance (68.9%) and food and shelter (63.9%) for every citizen and to take care of people who cannot take care of themselves. There is variation among the level of support based on practice setting. In multivariable analyses related to supporting the role of government for children and citizens, not being from the Northeast was associated with lower odds of support of both children and citizens; primary care practices in rural areas were less supportive of government involvement related to all citizens but similar for children; and those <40 and 50-59 were more supportive of government guaranteeing enough to eat and a place to sleep for children. Over 55% support the AAP advocating for income support, housing, education and access to healthcare. CONCLUSIONS:Pediatricians strongly support government policies that impact child poverty and the provision of basic needs to families. This support should be used to inform professional organizations, advocates and policy-makers focused on children and families.

OBJECTIVES/OBJECTIVE:To determine impacts on social-emotional development at school entry of a pediatric primary care intervention (Video Interaction Project [VIP]) promoting positive parenting through reading aloud and play, delivered in 2 phases: infant through toddler (VIP birth to 3 years [VIP 0-3]) and preschool-age (VIP 3 to 5 years [VIP 3-5]). METHODS:Factorial randomized controlled trial with postpartum enrollment and random assignment to VIP 0-3, control 0 to 3 years, and a third group without school entry follow-up (Building Blocks) and 3-year second random assignment of VIP 0-3 and control 0 to 3 years to VIP 3-5 or control 3 to 5 years. In the VIP, a bilingual facilitator video recorded the parent and child reading and/or playing using provided learning materials and reviewed videos to reinforce positive interactions. Social-emotional development at 4.5 years was assessed by parent-report Behavior Assessment System for Children, Second Edition (Social Skills, Attention Problems, Hyperactivity, Aggression, Externalizing Problems). RESULTS:= .006). Multilevel models revealed significant VIP 0-3 linear effects and age × VIP 3-5 interactions. CONCLUSIONS:Phase VIP 0-3 resulted in sustained impacts on behavior problems 1.5 years after program completion. VIP 3-5 had additional, independent impacts. With our findings, we support the use of pediatric primary care to promote reading aloud and play from birth to 5 years, and the potential for such programs to enhance social-emotional development.

OBJECTIVE: To determine whether educational media as actually used by low-income families promotes parent-child cognitive stimulation activities. METHODS: Secondary analysis of the control group of a longitudinal cohort of mother-infant dyads enrolled post-partum in urban public hospital. Educational media exposure (via a 24-hour recall diary) and parent-child activities that may promote cognitive stimulation in the home (using StimQ) were assessed at 6, 14, 24, and 36 months. RESULTS: 149 mother-child dyads; 93.3% Latino. Mean (standard deviation) educational media exposure at 6, 14, 24, and 36 months was: 25 (40), 42 (58), 39 (49), and 39 (50) mins/day. In multilevel model analyses, prior educational media exposure had small positive relationship with subsequent total StimQ (beta=0.11, P=.03), but was non-significant (beta = 0.08, P = .09) after adjusting for confounders (child: age, gender, birth order, non-educational media exposure, language; mother: age, ethnicity, marital status, country of origin, language, depressive symptoms)Educational media did predict small increases in verbal interactions and toy provision (adjusted models, respectively: beta = 0.13, P = .02; beta = 0.11; P = .03). In contrast, more consistent relationships were seen for models of the relationship between prior StimQ (total, verbal interactions and teaching; adjusted models, respectively: beta = 0.20, P = .002; beta = 0.15, P = .006; beta = 0.20, P = .001) and predicted subsequent educational media. CONCLUSIONS: Educational media as used by this sample of low-income families does not promote cognitive stimulation activities important for early child development or activities such as reading and teaching.

BACKGROUND AND OBJECTIVES: A recent AAP policy statement recommends mL-exclusive dosing for pediatric liquid medications. Little is known about parent preferences regarding units, perceptions about moving to mL-only, and the role of health literacy and prior mL-dosing experience. METHODS: Cross-sectional analysis of data collected as part of a randomized controlled study in 3 urban pediatric clinics (SAFE-Rx for Kids study). English/Spanish-speaking parents (n=493) of children <8 years were randomized to 1 of 4 study arms and given labels/dosing tools which varied in label instruction format (text+pictogram, text-only) and units (mL-only, mL/tsp). OUTCOMES: teaspoon preference in dosing instructions, perceived difficulty with mL-only dosing. Predictor variable: health literacy (Newest Vital Sign; low[0-1], marginal[2-3], adequate[4-6]). Mediating variable: prior mL-dosing experience. RESULTS: Over two-thirds of parents had low or marginal health literacy. The majority (>70%) preferred to use mL, perceived mL-only dosing to be easy, and had prior mL-dosing experience; 11.5% had a teaspoon preference, 18.1% perceived mL-only dosing will be difficult, and 17.7% had no prior mL-dosing experience. Parents with lower health literacy had a higher odds of having a teaspoon preference (low vs. adequate: AOR=2.9[1.3-6.2]), and greater odds of perceiving difficulty with mL-only dosing (low vs. adequate: AOR=13.9[4.8-40.6]), marginal vs. adequate: AOR=7.1[2.5-20.4]). Lack of experience with mL-dosing partially mediated the impact of health literacy. CONCLUSIONS: Most parents were comfortable with mL-only dosing. Parents with low health literacy were more likely to perceive mL-only dosing to be difficult; educational efforts will need to target this group to ensure safe medication use.

OBJECTIVES: To determine whether parents who use a low literacy, pictogram- and photograph-based written asthma action plan have a better understanding of child asthma management compared to parents using a standard plan. METHODS: Randomized controlled study in 2 urban pediatric outpatient clinics. INCLUSION CRITERIA: English/Spanish-speaking parents of 2-12 year old asthmatic children. Parents were randomized to receive a low literacy or standard asthma action plan (American Academy of Allergy, Asthma and Immunology) for a hypothetical patient on controller and rescue medications. A structured questionnaire was used to assess whether there was an error in knowledge of 1)medications to give everyday and when sick, 2)need for spacer use, and 3)appropriate emergency response to give albuterol and seek medical help. Multiple logistic regression analyses performed adjusting for parent age, health literacy (Newest Vital Sign); child asthma severity, medications; site. RESULTS: 217 parents were randomized (109 intervention;108 control). Parents who received the low literacy plan were 1)less likely to make an error in knowledge of medications to take everyday and when sick compared to parents who received the standard plan (63.0 vs. 77.3%, p = 0.03; adjusted odds ratio [AOR] = 0.5[95% CI: 0.2-0.9]) and 2)less likely make an error regarding spacer use (14.0 vs. 51.1%, p<0.001; AOR = 0.1[0.06-0.3]). No difference in error in appropriate emergency response was seen (43.1 vs. 48.1%, p = 0.5). CONCLUSIONS: Use of a low literacy written asthma action plan was associated with better parent understanding of asthma management. Further study is needed to assess whether use of this action plan improves child asthma outcomes.

CONTEXT: Parents often manage complex instructions when their children are discharged from the inpatient setting or emergency department (ED); misunderstanding instructions can put children at risk for adverse outcomes. Parents' ability to manage discharge instructions has not been examined before in a systematic review. OBJECTIVE: To perform a systematic review of the literature related to parental management (knowledge and execution) of inpatient and ED discharge instructions. DATA SOURCES: We consulted PubMed/Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane CENTRAL (from database inception to January 1, 2017). STUDY SELECTION: We selected experimental or observational studies in the inpatient or ED settings in which parental knowledge or execution of discharge instructions were evaluated. DATA EXTRACTION: Two authors independently screened potential studies for inclusion and extracted data from eligible articles by using a structured form. RESULTS: Sixty-four studies met inclusion criteria; most (n = 48) were ED studies. Medication dosing and adherence errors were common; knowledge of medication side effects was understudied (n = 1). Parents frequently missed follow-up appointments and misunderstood return precaution instructions. Few researchers conducted studies that assessed management of instructions related to diagnosis (n = 3), restrictions (n = 2), or equipment (n = 1). Complex discharge plans (eg, multiple medicines or appointments), limited English proficiency, and public or no insurance were associated with errors. Few researchers conducted studies that evaluated the role of parent health literacy (ED, n = 5; inpatient, n = 0). LIMITATIONS: The studies were primarily observational in nature. CONCLUSIONS: Parents frequently make errors related to knowledge and execution of inpatient and ED discharge instructions. Researchers in the future should assess parental management of instructions for domains that are less well studied and focus on the design of interventions to improve discharge plan management.

OBJECTIVE: We proposed and tested a theoretical framework for how use of Teach-back could influence communication during the pediatric clinical encounter. METHODS: Audio-taped pediatric primary care encounters with 44 children with asthma were coded using the Roter Interaction Analysis System to measure patient-centered communication and affective engagement of the parent. A newly created Teach-back Loop Score measured the extent to which Teach-back occurred during the clinical encounter; parental health literacy was measured by Newest Vital Sign. Logistic regression was used to test the relationship between Teach-back and features of communication. Focus groups held separately with clinicians and parents elicited perceptions of Teach-back usefulness. RESULTS: Teach-back was used in 39% of encounters. Visits with Teach-back had more patient centered communication (p=0.01). Adjusting for parent health literacy, parent age, and child age, Teach-back increased the odds of both patient centered communication [proportional AOR (95% CI)=4.97 (4.47-5.53)]and negative affect [AOR (95% CI)=5.39 (1.68-17.31)]. Focus group themes common to clinicians and parents included: Teach-back is effective, could cause discomfort, should be used with children, and nurses should use it. CONCLUSIONS: Teach-back was associated with more patient-centered communication and increased affective engagement of parents. PRACTICE IMPLICATIONS: Standardizing Teach-back use may strengthen patient-centered communication.