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Appropriate calibration of clinical reasoning is critical to becoming a competent physician. Lack of follow-up after transitions of care can present a barrier to calibration. This study aimed to implement structured feedback about clinical reasoning for residents performing overnight admissions, measure the frequency of diagnostic changes, and determine how feedback impacts learners’ self-efficacy. Trainees shared feedback via a structured form within their electronic health record’s secure messaging system. Forms were analyzed for diagnostic changes. Surveys evaluated comfort with sharing feedback, self-efficacy in identifying and mitigating cognitive biases’ negative effects, and perceived educational value of night admissions—all of which improved after implementation. Analysis of 544 forms revealed a 43.7% diagnostic change rate spanning the transition from night-shift to day-shift providers; of the changes made, 29% (12.7% of cases overall) were major changes. This study suggests that structured feedback on clinical reasoning for overnight admissions is a promising approach to improve residents’ diagnostic calibration, particularly given how often diagnostic changes occur.

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 As of this writing, I-PASS Study Group members have directly worked with more than 50 hospitals to facilitate implementation of I-PASS. To further disseminate I-PASS, Study Group members delivered hundreds of academic presentations, including plenaries at scientific meetings, workshops, and institutional Grand Rounds. Some 3,563 individuals, representing more than 500 institutions in the 50 states in the United States, the District of Columbia, Puerto Rico, and 57 other countries, have requested access to I-PASS materials. Most recently, the I-PASSSM 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 explore medical students’ experiences working with frequently rotating pediatric inpatient attending physicians. Methods: We performed a qualitative study using focus groups and individual interviews of medical students who rotated on the general pediatric inpatient service at Children’s Hospital Colorado. The majority of inpatient pediatric attending physicians worked 1-week blocks. We used a semistructured interview guide and analyzed data using the constant comparative method. In accordance with the grounded theory method, codes were developed using an iterative approach, and major themes were identified. Analysis indicated theoretical saturation was achieved. We created a theory that arose from analysis of the data. Results: Twenty-seven medical students participated. Data analysis yielded 6 themes: learning climate, continuity, student resilience, opportunity to progress, growth into a physician, and evaluation. In the learning climate, the emotional environment was often stressful, although students valued exposure to different patient care and teaching styles. Senior resident continuity promoted student function; lack of continuity with attending physicians inhibited relationship development. Students were resilient in adjusting to changing faculty with different expectations. In the context of frequently rotating faculty, students had difficulty showing improvement to a single attending physician after feedback, which limited students’ opportunities to progress. Students perceived summative evaluation as less meaningful in the absence of having a relationship with their attending physicians. Conclusions: Medical students valued exposure to different patient care and teaching styles. However, frequently changing attending physicians caused students stress and limited students’ perceived ability to achieve and show professional growth.

Objective To explore pediatric interns' perspectives on the educational value of general pediatric ward rounds, in particular their rounding experiences with and without an attending physician. Methods Qualitative study using individual interviews of pediatric interns (2013–2014) rotating on 2 general pediatric inpatient services at different institutions with different rounding team structures. In accordance with grounded theory methodology, data were analyzed using the constant comparative method. Codes were built using an iterative approach and organized into themes. Results Twenty pediatric interns participated in 25 interviews. Data analysis yielded 4 themes: what is being learned; learning environment on rounds; learning and work; and ways of learning. Senior residents generally taught practical aspects of patient care and attending physicians taught broader concepts with references to the medical literature. Rounds without an attending physician were perceived as less formal and promoted collaborative discussions with senior residents. Interns were more uncomfortable during rounds with an attending physician but appreciated how that facilitated their learning. Although patient care tasks provided opportunities for experiential learning, interns frequently perceived them to impede learning during rounds. Intern learning during ward rounds occurred via self-directed learning, interactive learning, and through caring for patients. Brief, clinically relevant teaching pearls and questioning clinical reasoning in a respectful manner were helpful. Conclusions Interns learn different content and learn in different ways depending on the presence or absence of an attending physician at rounds. There might be educational value from rounding with teams that include and do not include an attending physician.

Introduction Hemolytic uremic syndrome is a thrombotic microangiopathy. Clopidogrel, a recently developed platelet aggregation inhibitor, has not been previously reported as a treatment for this illness. Our study's objective was to explore the efficacy and safety of clopidogrel in children with diarrhea associated hemolytic uremic syndrome. Materials and Methods We performed a retrospective chart review of all children (≤ 18 years) hospitalized with diarrhea associated hemolytic uremic syndrome. Outcomes in clopidogrel treated children were described. In subgroup analysis, outcomes were compared to those untreated with platelet aggregation inhibitors. Results Of 72 children with diarrhea associated hemolytic uremic syndrome, 88% were treated with platelet aggregation inhibitors (clopidogrel 56%, sulfinpyrazone 19%, dipyridamole 13%). The median age of clopidogrel treated children was 5 years; 40% were male. Initial median hemoglobin, platelet count, and serum creatinine were 10.1 g/dL, 53 × 10 3 /μL, and 2.3 mg/dL respectively. Clopidogrel (median dose 1 mg/kg/d) was given for a median of 4 days (range 1–15). Other therapies included erythropoietin (98%), red blood cell transfusions (80%), diuretics (58%), anti-hypertensive agents (45%), and dialysis (33%). The median hospital length of stay was 9 days (range 3–26). Three children had bleeding complications (epistaxis/hematemesis). The risk of chronic kidney disease was 5% and death 2.5%. In subgroup analysis, median duration of dialysis was 11 days in thirteen clopidogrel treated children compared to 21 days in five untreated patients ( P = 0.04). Conclusions Children with diarrhea associated hemolytic uremic syndrome treated with clopidogrel have outcomes comparable to untreated patients. Bleeding complications may occur.

Objective To characterize Latino families' experiences with family-centered rounds at an academic children's hospital to identify areas for improvement. Methods Five focus groups of families of Latino children hospitalized on a general medical ward were conducted in Spanish by a single bilingual facilitator. Participants were recruited from a convenience sample of Spanish-speaking Latino family members present at the patients' bedside. Data were transcribed verbatim, content coded, and analyzed in Spanish for emergent themes. Results Twenty-eight Latino family members of 21 hospitalized children participated in the 5 focus groups. Most spoke only Spanish (75%), and Spanish was the preferred language of all focus group participants. Qualitative data analysis indicated that families reported positive experiences with rounds involving a Spanish-speaking provider. Thematic issues focused on family-physician communication problems, lack of family empowerment, family and provider participants for family-centered rounds, and cultural needs. Parents were dissatisfied with telephonic interpretation services and preferred a live interpreter in the absence of a fluent, bilingual physician. Many families did not feel empowered to request interpretation assistance or health information; parents often felt embarrassed as a result of their inability to understand the primary language (English) of the care providers. Some parents felt inhibited to express themselves in the presence of other family members. Addressing cultural needs (eg, chaplain support) was appreciated by families. Conclusions Spanish-speaking Latino families are not consistently receiving optimal family-centered rounds. Different strategies are needed to fully engage and empower Latino families.

OBJECTIVES: Orbital infections caused by methicillin-resistant Staphylococcus aureus may be increasing. Because Staphylococcus aureus infections have important treatment implications, our objective was to review the microbiology and antibiotic management of children hospitalized with orbital cellulitis and abscesses. PATIENTS AND METHODS: This study was a retrospective chart review of all patients admitted to a tertiary care children's hospital between 2004 and 2009 with orbital infections confirmed by a computed tomography scan. Patients with preceding surgery or trauma, anatomic eye abnormalities, malignancy, immunodeficiency, or preseptal infections were excluded. RESULTS: There were 94 children with orbital infections. A true pathogen was recovered in 31% of patients. The most commonly identified bacteria was the Streptococcus anginosus group (14 of 94 patients [15%]). Staphylococcus aureus (1 patient with methicillin-resistant Staphylococcus aureus) was identified in 9% of patients. Combination antimicrobial agents were frequently used (62%), and vancomycin use increased from 14% to 57% during the study period. Patients treated with a single antibiotic during hospitalization (n = 32), in contrast to combination therapy (n = 58), were more likely to be discharged on a single antibiotic (P < .001). Twenty-five (27%) patients were discharged on combination antibiotics. Thirteen (14%) patients were discharged on intravenous therapy. CONCLUSIONS: The Streptococcus anginosus group is an emerging pathogen in pediatric orbital infections. Although methicillin-resistant Staphylococcus aureus was uncommon, patients frequently received vancomycin and combination antibiotics. A simplified antibiotic regimen may help limit the development of resistant organisms and facilitate transition to an oral agent.

To estimate the rates of bacterial meningitis and herpes simplex virus (HSV) encephalitis in children presenting with complex febrile seizures.Health records from 2002 to 2006 of all children 6 months to 6 years with a discharge diagnosis from the Hospital for Sick Children (Toronto, ON) of febrile convulsion, meningitis, or encephalitis were reviewed. Rates of bacterial meningitis and HSV encephalitis in children presenting with complex febrile seizures were calculated.There were 390 encounters of complex febrile seizures in 366 children. Of these encounters, 75 (19%) were transferred from an outlying hospital. A history of febrile convulsions was noted in 140 (36%). Lumbar puncture was performed in 146 (37%) patients. Six patients (all but one transferred) were diagnosed with bacterial meningitis (all due to Streptococcus pneumoniae). One transferred patient was diagnosed with HSV encephalitis. In patients initially presenting to our emergency department the rates of bacterial meningitis and HSV encephalitis were 0.3% (95% confidence interval, 0.0-1.8) and 0.0% (95% confidence interval, 0.0-1.2), respectively.Given the low rate of bacterial meningitis and HSV encephalitis in children presenting with complex febrile seizures, routine lumbar puncture in these patients may be unnecessary.

Chylous ascites is a rare entity in infants. An uncommon cause of chylous ascites is intestinal malrotation. We report a case of a neonate with heterotaxia-polysplenia syndrome and intestinal malrotation who presented with chylous ascites and subsequently developed duodenal obstruction from midgut volvulus. He was successfully treated with peritoneal drainage, surgical intervention, and nutritional support. A brief overview of the association of chylous ascites, intestinal rotational anomalies and heterotaxia syndromes is discussed.

A 13-month-old boy presented to the emergency department with a three-day history of fever, cough and vomiting. The vomiting was bilious and occurred between one and10 times per day. His bowel movements were normal, and his oral intake and urine output were decreased. There were multiple ill contacts at home. There was no recent travel or animal exposures.