Faculty Bibliography

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.

BACKGROUND:High rates of posthospitalization errors are observed in children with medical complexity (CMC). Poor parent comprehension of and adherence to complex discharge instructions can contribute to errors. Pediatrician views on common barriers and facilitators to parent comprehension and adherence are understudied. OBJECTIVE:To examine pediatrician perspectives on barriers and facilitators experienced by parents in comprehension of and adherence to inpatient discharge instructions for CMC. DESIGN, SETTINGS, AND PARTICIPANTS/METHODS:We conducted a qualitative, descriptive study of attending pediatricians (n = 20) caring for CMC in inpatient settings (United States and Canada) and belonging to listservs for pediatric hospitalists/complex care providers. We used purposive/maximum variation sampling to ensure heterogeneity (e.g., hospital, region). MAIN OUTCOME AND MEASURES/METHODS:A multidisciplinary team designed and piloted a semistructured interview guide with pediatricians who care for CMC. Team members conducted semistructured interviews via phone or video call. Interviews were audiorecorded and transcribed. We analyzed transcripts using content analysis; codes were derived a priori from a conceptual framework (based on the Pediatric Self-Management Model) and a preliminary transcript analysis. We applied codes and identified emerging themes. RESULTS:Pediatricians identified three themes as barriers and facilitators to discharge instruction comprehension and adherence: (1) regimen complexity, (2) access to the healthcare team (e.g., inpatient team, outpatient pediatrician, home nursing) and resources (e.g., medications, medical equipment), and (3) need for a family centered and health literacy-informed approach to discharge planning and education. Next steps include the assessment of parent perspectives on barriers and facilitators to discharge instruction comprehension and adherence for prents of CMC and the development of intervention strategies.

BACKGROUND AND OBJECTIVES/OBJECTIVE:Patient and Family Centered I-PASS (PFC I-PASS) emphasizes family and nurse engagement, health literacy, and structured communication on family-centered rounds organized around the I-PASS framework (Illness severity-Patient summary-Action items-Situational awareness-Synthesis by receiver). We assessed adherence, safety, and experience after implementing PFC I-PASS using a novel "Mentor-Trio" implementation approach with multidisciplinary parent-nurse-physician teams coaching sites. METHODS:Hybrid Type II effectiveness-implementation study from 2/29/19-3/13/22 with ≥3 months of baseline and 12 months of postimplementation data collection/site across 21 US community and tertiary pediatric teaching hospitals. We conducted rounds observations and surveyed nurses, physicians, and Arabic/Chinese/English/Spanish-speaking patients/parents. RESULTS:We conducted 4557 rounds observations and received 2285 patient/family, 1240 resident, 819 nurse, and 378 attending surveys. Adherence to all I-PASS components, bedside rounding, written rounds summaries, family and nurse engagement, and plain language improved post-implementation (13.0%-60.8% absolute increase by item), all P < .05. Except for written summary, improvements sustained 12 months post-implementation. Resident-reported harms/1000-resident-days were unchanged overall but decreased in larger hospitals (116.9 to 86.3 to 72.3 pre versus early- versus late-implementation, P = .006), hospitals with greater nurse engagement on rounds (110.6 to 73.3 to 65.3, P < .001), and greater adherence to I-PASS structure (95.3 to 73.6 to 72.3, P < .05). Twelve of 12 measures of staff safety climate improved (eg, "excellent"/"very good" safety grade improved from 80.4% to 86.3% to 88.0%), all P < .05. Patient/family experience and teaching were unchanged. CONCLUSIONS:Hospitals successfully used Mentor-Trios to implement PFC I-PASS. Family/nurse engagement, safety climate, and harms improved in larger hospitals and hospitals with better nurse engagement and intervention adherence. Patient/family experience and teaching were not affected.