Faculty Bibliography

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.

Background/UNASSIGNED:How health care professionals address health literacy as part of the provider-client relationship is important for prevention and promoting self-management and symptom management. Research usually focuses on patients' health literacy and fails to examine provider practices, thus leaving a gap in the literature and patient outcomes analyses. Objective/UNASSIGNED:The study tested the reliability and validity of a series of questions developed to evaluate health care provider health literacy promotion practices on an interprofessional sample. Methods/UNASSIGNED:This exploratory cross-sectional study took place between 2013 and 2015. Participants included graduate level health professions students from nursing, midwifery, medicine, pharmacy, and social work. Exploratory factor analyses with varimax rotation examined the reliability and validity of the instrument as a measure of health literacy promotion practices. Key Results/UNASSIGNED:Of the participants in the programs, 198 completed the health literacy questions in the online survey. Exploratory factor analysis showed that questions loaded on two factors connected with either individual or organizational characteristics that facilitated health literacy promotion practices. The Cronbach's alpha for the instrument was 0.95. Conclusions/UNASSIGNED:. Plain Language Summary/UNASSIGNED:We sought to develop a survey instrument people could use to assess how health care providers help patients understand their health better. After getting responses from 198 health care providers, we ran statistical tests to check the quality of the questions for measuring provider practices. We found the questions were good at evaluating provider practices around promoting patient understanding of health issues.

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.

BACKGROUND AND OBJECTIVES: Poorly designed labels and dosing tools contribute to dosing errors. We examined the degree to which errors could be reduced with pictographic diagrams, milliliter-only units, and provision of tools more closely matched to prescribed volumes. METHODS: This study involved a randomized controlled experiment in 3 pediatric clinics. English- and Spanish-speaking parents (n = 491) of children 20% deviation), and large error (>2x dose). RESULTS: We found that 83.5% of parents made >/=1 dosing error (overdosing was present in 12.1% of errors) and 29.3% of parents made >/=1 large error (>2x dose). The greatest impact on errors resulted from the provision of tools more closely matched to prescribed dose volumes. For the 2-mL dose, the fewest errors were seen with the 5-mL syringe (5- vs 10-mL syringe: adjusted odds ratio [aOR] = 0.3 [95% confidence interval: 0.2-0.4]; cup versus 10-mL syringe: aOR = 7.5 [5.7-10.0]). For the 7.5-mL dose, the fewest errors were with the 10-mL syringe, which did not necessitate measurement of multiple instrument-fulls (5- vs 10-mL syringe: aOR = 4.0 [3.0-5.4]; cup versus 10-mL syringe: aOR = 2.1 [1.5-2.9]). Milliliter/teaspoon was associated with more errors than milliliter-only (aOR = 1.3 [1.05-1.6]). Parents who received text only (versus text and pictogram) instructions or milliliter/teaspoon (versus milliliter-only) labels and tools made more large errors (aOR = 1.9 [1.1-3.3], aOR = 2.5 [1.4-4.6], respectively). CONCLUSIONS: Provision of dosing tools more closely matched to prescribed dose volumes is an especially promising strategy for reducing pediatric dosing errors.

BACKGROUND:In 2009 the I-PASS Study Group was formed by patient safety, medical education, health services research, and clinical experts from multiple institutions in the United States and Canada. When the I-PASS Handoff Program, which was developed by the I-PASS Study Group, was implemented in nine hospitals, it was associated with a 30% reduction in injuries due to medical errors and significant improvements in handoff processes, without any adverse effects on provider work flow. METHODS:To effectively disseminate and adapt I-PASS for use across specialties and disciplines, a series of federally and privately funded dissemination and implementation projects were carried out following the publication of the initial study. The results of these efforts have informed ongoing initiatives intended to continue adapting and scaling the program. RESULTS:Patient Safety Institute has developed a virtual immersion training platform, mobile handoff observational tools, and processes to facilitate further spread of I-PASS. CONCLUSION:Implementation of I-PASS has been associated with substantial improvements in patient safety and can be applied to a variety of disciplines and types of patient handoffs. Widespread implementation of I-PASS has the potential to substantially improve patient safety in the United States and beyond.

OBJECTIVE: To describe infant activity at 3 months old and to test the efficacy of a primary care-based child obesity prevention intervention on promoting infant activity in low-income Hispanic families. METHODS: This study was a randomized controlled trial (n = 533) comparing a control group of mother-infant dyads receiving standard prenatal and pediatric primary care with an intervention group receiving "Starting Early," with individual nutrition counseling and nutrition and parenting support groups coordinated with prenatal and pediatric visits. Outcomes included infant activity (tummy time, unrestrained floor time, time in movement-restricting devices). Health literacy was assessed using the Newest Vital Sign. RESULTS: Four hundred fifty-six mothers completed 3-month assessments. Infant activity results were: 82.6% ever practiced tummy time; 32.0% practiced tummy time on the floor; 34.4% reported unrestrained floor time; 56.4% reported >/=1 h/d in movement-restricting devices. Inadequate health literacy was associated with reduced tummy time and unrestrained floor time. The intervention group reported more floor tummy time (OR 2.16, 95% CI 1.44-3.23) and unrestrained floor time (OR 1.69, 95% CI 1.14-2.49) compared to controls. No difference in the time spent in movement-restricting devices was found. CONCLUSIONS: Tummy time and unrestrained floor time were low. Primary care-based obesity prevention programs have potential to promote these activities.

OBJECTIVE: Hispanic parents in the United States are disproportionately affected by low health literacy and limited English proficiency (LEP). We examined associations between health literacy, LEP, and liquid medication dosing errors in Hispanic parents. METHODS: Cross-sectional analysis of data from a multisite randomized controlled experiment to identify best practices for the labeling/dosing of pediatric liquid medications (SAFE Rx for Kids study); 3 urban pediatric clinics. Analyses were limited to Hispanic parents of children aged 20% dose deviation. Predictor variables included health literacy (Newest Vital Sign) (limited = 0-3; adequate = 4-6) and LEP (speaks English less than "very well"). RESULTS: A total of 83.1% made dosing errors (mean [SD] errors per parent = 2.2 [1.9]). Parents with limited health literacy and LEP had the greatest odds of making a dosing error compared to parents with adequate health literacy who were English proficient (trials with errors per parent = 28.8 vs 12.9%; adjusted odds ratio = 2.2 [95% confidence interval 1.7-2.8]). Parents with limited health literacy who were English proficient were also more likely to make errors (trials with errors per parent = 18.8%; adjusted odds ratio = 1.4 [95% confidence interval 1.1-1.9]). CONCLUSIONS: Dosing errors are common among Hispanic parents; those with both LEP and limited health literacy are at particular risk. Further study is needed to examine how the redesign of medication labels and dosing tools could reduce literacy- and language-associated disparities in dosing errors.

BACKGROUND AND OBJECTIVE: Effective communication with primary care physicians is important yet incompletely understood for Spanish-speaking parents. We predicted lower satisfaction among Spanish-speaking compared to English-speaking Latino and non-Latino parents. METHODS: Cross-sectional analysis at 2-month well visits within the Greenlight study at 4 pediatric resident clinics. Parents reported satisfaction with 14 physician communication items using the validated Communication Assessment Tool (CAT). High satisfaction was defined as "excellent" on each CAT item. Mean estimations compared satisfaction for communication items among Spanish- and English-speaking Latinos and non-Latinos. We used generalized linear regression modeling, adjusted for parent age, education, income, and clinic site. Among Spanish-speaking parents, we compared visits conducted in Spanish with and without an interpreter, and in English. RESULTS: Compared to English-speaking Latino (n = 127) and non-Latino parents (n = 432), fewer Spanish-speaking parents (n = 303) reported satisfaction with 14 communication items. No significant differences were found between English-speaking Latinos and non-Latinos. Greatest differences were found in the use of a greeting that made the parent comfortable (59.4% of Spanish-speaking Latinos endorsing "excellent" vs 77.5% English-speaking Latinos, P < .01) and discussing follow-up (62.5% of Spanish-speaking Latinos vs 79.8% English-speaking Latinos, P < .01). After adjusting for parent age, education, income, and study site, Spanish-speaking Latinos were still less likely to report high satisfaction with these communication items. Satisfaction was not different among Spanish-speaking parents when the physician spoke Spanish versus used an interpreter. CONCLUSIONS: Satisfaction with physician communication was associated with language but not ethnicity. Spanish-speaking parents less frequently report satisfaction with communication, and innovative solutions to enhance communication quality are needed.