Linda A. Waggoner-Fountain

Adequacy of information transferred at resident sign-out (inhospital handover of care): a prospective survey

Background: During sign-out (handover of care), information and responsibility about patients is transferred from one set of caregivers to another. Few residency training programmes formally teach resident physicians how to sign out or assess their ability to sign out, and little research has examined the sign-out process. Objective: To characterise the effectiveness of the sign-out process between resident physicians on an acute care ward. Design/methods: Resident physicians rotating on a paediatric acute care ward participated in a prospective study. Immediately after an on-call night, they completed a confidential survey characterising their night on call, the adequacy of the sign-out they received, and where they went to get information they had not received during sign-out. Results: 158 of 196 (81%) potential surveys were collected. On 49/158 surveys (31%), residents indicated something happened while on call they were not adequately prepared for. In 40/49 instances residents did not receive information during sign-out that would have been helpful, and in 33/40 the situation could have been anticipated and discussed during sign-out. The quality of sign-out (assessed using a five-point Likert scale from 1 = inadequate to answer call questions to 5 =  adequate to answer call questions) on the nights when something happened the resident was not adequately prepared for were significantly different than the nights they felt adequately prepared (mean (SD) score 3.58 (0.92) and 4.48 (0.70); p = 0.001). There were no significant differences in: how busy the nights were; numbers of patients on service at the beginning of the call shift; numbers of admissions during a call shift; numbers of transfers to an intensive care unit; whether residents were “cross-covering” or were members of the general ward team; or whether the resident had cared for the patient previously. Conclusion: Although sign-out between resident physicians is a frequent activity, there are many times when important information is not transmitted. Analysis of these “missed opportunities” can be used to help develop an educational programme for resident physicians on how to sign out more effectively.

Kawasaki Syndrome Masquerading as Bacterial Lymphadenitis

We present two case reports of older children who initially presented with cervical lymphadenitis and who were eventually diagnosed and treated for Kawasaki syndrome (KS). Both children presented with unilateral cervical lymphadenopathy and fever and later developed additional clinical features of KS, including cardiac aneurysms in one of the patients. Of the five KS clinical criteria which accompany fever for 5 days, cervical lymphadenopathy of ≥1.5 cm is the least commonly found. Both patients were treated as having bacterial adenitis prior to the diagnosis of KS. We hope to illustrate that in the case of atypical cervical lymphadenitis, KS should be carefully considered in the differential diagnosis.

Collaborating With Physicians to Redesign a Sign-Out Tool

Physician sign-out is a mechanism for transferring patient information from one group of hospital care-givers to another at shift changes. Support tools are critical to the success of sign-out. To ensure that a tool is effective, designers must collaborate with end users, but collaboration can be difficult when working with users who are busy and have irregular schedules. In this article, we report on a collaborative effort between physicians and engineers to redesign a sign-out support tool. Strategies included focus groups, interviews, “on-the-fly” feedback, and an iterative design process, which engaged end users in the design process. Task analysis methods enabled us to quantify the differences in functionality between the original tool and the prototype.

Supporting the Characterization of Sign-Out in Acute Care Wards

Physician sign-out is a mechanism for transferring patient information, responsibility, and/or authority between care givers at a shift change. Despite being an important process, little research has examined the content and process of conducting sign-out. This paper describes the development and application of a support tool used to study and analyze physician sign-out. The tool supports the identification and analysis of 10 types of patient information, five types of physician communication, and three sources of distraction to physicians. The tool was applied during observations of sign-out on acute care pediatric wards to form a baseline of the current sign-out process and the information exchanged between physicians to identify areas in need of procedural support and training interventions.

Characterization of Sign-Out in Pediatric Acute Care Wards to Inform Process Improvement

Physician sign-out is a mechanism for transferring patient information, responsibility, and authority from one set of hospital caregivers to another at shift changes. This project characterized the information exchanged between physicians during 15 sign-outs, and analyzed data from 158 post-call resident surveys. Ten categories of patient information were developed to characterize the exchanged information. Of the ten categories of patient information, no single category was discussed for every patient. The information critically important to discuss during sign-out was often the least covered, as residents discussed the patients current physical condition for only 35% of the patients, current medications for only 63% of patients, and contingency plans for possible scenarios for only 17.7% of patients. On average, residents discussed 14 patients during each sign-out, with the average sign-out lasting 35 minutes (2:28 minutes/patient). Of the total sign-out duration, approximately 23% of the time was spent discussing matters not related to patient care. Of the time spent “on-task”, 32.2% was spent on patient background, which could be obtained from other data sources. Very little time was spent discussing information which may not be available elsewhere, such as what actions, both planned and contingency, should occur overnight. Such information only received 12.1% of the sign-out time. 49 out of 158 resident surveys (31.0%) revealed that residents experienced an event while on call that they were unprepared to handle. Of those cases, 82% were the result of missing information. These data create a baseline understanding of sign-out which should be used to inform potential process and training improvements to ensure that the appropriate information is discussed for each patient.

The development of a web-based resident sign-out training program

Patient sign-out is a mechanism for transferring information, responsibility, and/or authority from one set of caregivers to another. Little research has addressed what information should be communicated during sign-out and how sign-out should be conducted and evaluated. As hospital residents conduct many sign-outs and have limited time in general, targeted web-based training and evaluation have the potential to enhance Graduate Medical Education. However there are no web-based training systems for this very important skill. This paper presents the operational concept and system requirements for a web-based sign-out training system. It discusses an initial functional prototype. Results of a heuristic evaluation and an assessment of areas for improvement are presented.

Resident physicians as human information systems: sources yet seekers.

Objective To characterize question types that residents received on overnight shifts and what information sources were used to answer them. Materials and Methods Across 30 overnight shifts, questions asked of on-call senior residents, question askers’ roles, and residents’ responses were documented. External sources were noted. Results 158 of 397 questions (39.8%) related to the plan of care, 53 (13.4%) to medical knowledge, 48 (12.1%) to taskwork knowledge, and 44 (11.1%) to the current condition of patients. For 351 (88.4%) questions residents provided specific, direct answers or visited the patient. For 16 of these, residents modeled or completed the task. For 216 questions, residents used previous knowledge or their own clinical judgment. Residents solicited external information sources for 118 questions and only a single source for 77 (65.3%) of them. For the 118, most questions concerned either the plan of care or the patients current condition and were asked by interns and nurses (those with direct patient care responsibilities). Discussion Resident physicians serve as an information system and they often specifically answer the question using previous knowledge or their own clinical judgment, suggesting that askers are contacting an appropriately knowledgeable person. However, they do need to access patient information such as the plan of care. They also serve an educator role and answer many knowledge-related questions. Conclusions As synchronous verbal communications continue to be important pathways for information flow, informaticians need to consider the relationship between such communications and workflow in the development of healthcare support tools.

The pediatrics milestones assessment pilot: Development of workplace-based assessment content, instruments, and processes

Purpose To report on the development of content and user feedback regarding the assessment process and utility of the workplace-based assessment instruments of the Pediatrics Milestones Assessment Pilot (PMAP). Method One multisource feedback instrument and two structured clinical observation instruments were developed and refined by experts in pediatrics and assessment to provide evidence for nine competencies based on the Pediatrics Milestones (PMs) and chosen to inform residency program faculty decisions about learners’ readiness to serve as pediatric interns in the inpatient setting. During the 2012–2013 PMAP study, 18 U.S. pediatric residency programs enrolled interns and subinterns. Faculty, residents, nurses, and other observers used the instruments to assess learner performance through direct observation during a one-month rotation. At the end of the rotation, data were aggregated for each learner, milestone levels were assigned using a milestone classification form, and feedback was provided to learners. Learners and site leads were surveyed and/or interviewed about their experience as participants. Results Across the sites, 2,338 instruments assessing 239 learners were completed by 630 unique observers. Regarding end-of-rotation feedback, 93% of learners (128/137) agreed the assessments and feedback “helped me understand how those with whom I work perceive my performance,” and 85% (117/137) agreed they were “useful for constructing future goals or identifying a developmental path.” Site leads identified several benefits and challenges to the assessment process. Conclusions PM-based instruments used in workplace-based assessment provide a meaningful and acceptable approach to collecting evidence of learner competency development. Learners valued feedback provided by PM-based assessment.

Developing Leaders in Pediatric Graduate Medical Education: The APPD LEAD Program

From the Department of Pediatrics, University of South Alabama College of Medicine, Mobile, Alabama (Dr Trimm); Department of Medical Education, Phoenix Children’s Hospital, Phoenix, Arizona (Dr Caputo); Department of Pediatrics, Weill Cornell Medical College, New York, New York (Dr Bostwick); Departments of Pediatrics and Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin (Dr Frohna); Department of Pediatrics and Communicable Diseases, University of Michigan Health System, Ann Arbor, Michigan (Dr Haftel); Division of Infectious Diseases, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia (Dr Waggoner-Fountain); and Department of Pediatrics, University of California, Davis, Sacramento, California (Dr Li) The authors declare that they have no conflict of interest. Address correspondence to Franklin Trimm,MD, Department of Pediatrics, 1700 Center St, University of South Alabama, USAChildren’s and Women’s Hospital, Mobile, AL 36604 (e-mail: rftrimm@health.southalabama.edu).

PERTUSSIS IN PRIMARY CARE PRACTICE: Recent Advances in Diagnosis, Treatment, and Prevention

Pertussis continues to be an important vaccine-preventable disease. The recent multiple outbreaks of pertussis have heightened interest in its diagnosis, treatment, and prevention. Diagnosis remains challenging, although new diagnostic tests, including enzyme-linked immunosorbent assay of sera and polymerase chain reaction of nasopharyngeal aspirates, offer the possibility of more rapid diagnosis. Erythromycin remains the preferred antimicrobial to reduce secondary transmission of pertussis. The recent approval of acellular pertussis vaccine for the primary series of immunizations ushers in an exciting new era of pertussis prevention.