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Purpose The purpose of this study is to outline a process-oriented psychology informed view of the impact of ever-increasing acuity within an adult inpatient system and conceptualise how an integrated therapies team (ITT) can work with the chaos that this brings. Design/methodology/approach A reflective scientist-practitioner based approach was used over a two-year period. Findings Several factors lead to “chaos” in an inpatient unit, including societal inequality, the trauma and adversity it creates and the impact of this at a systemic, interpersonal and intrapersonal level. Chaos is one means of coping and can dominate inpatient working, whereas understanding the underlying distress is often marginalised. Developing an ITT can support working with chaos. The ITT holds the therapeutic perspective for the wider multi-disciplinary team (MDT) and therapeutic and facilitation skills are central to how it operates. Processing the chaos and working with the underlying distress is its overarching function. Practical implications Developing an ITT offers a robust structure for evolving inpatient MDT working to cope with increasing acuity in a psychologically informed way. Social implications The chaos in question is often viewed as patients’ issue but from a collectivist perspective it is something that all members of society are responsible for. Originality/value To the best of the authors’ knowledge, this is the first paper to conceptualise the chaos on an inpatient ward as a process needed by the system as a way of coping and propose the addition of an ITT to inpatient working.

Background: Due to advances in medical care, including nutrition and hydration, children with neurological impairment are surviving longer. Many of these children are fed using a commercial formula via an enteral feeding tube. However, families are now becoming more interested in administering blended diet via their child's gastrostomy in a bid to reduce often significant gastrointestinal symptoms including reflux, constipation, gagging and retching post fundoplication. Aims: To describe the process undertaken by the authors' short-life working group to create safe, robust pathways to enable children to have access to blended diet while in the acute hospital setting. Methods: A multidisciplinary team short-life working group was established, which consisted of representatives from nursing, dietetics and catering. Following this a scoping exercise was undertaken to assess what practices were carried out in other health boards, prior to the creation of documentation. Conclusion: In conjunction with senior management and the Central Legal Office, the authors' short life working group has created safe, robust documentation and pathways to enable children in a large tertiary paediatric centre to access blended diet while in the acute setting. Due to the recent COVID-19 pandemic the pilot study to trial these documents within the neurology ward was delayed, however this work is ongoing. Furthermore, the authors will be looking to train nursing staff within ward areas to administer blended diet within the ward setting.

Objective Goals of care discussions are crucial in helping parents navigate complex medical decisions and shown to improve quality of care. Little is known about whether physicians elicit or address parents’ goals during a child's hospitalization. The purpose of this study was to understand the current practice of goal setting at the beginning of hospitalization by exploring the perspectives of parents of hospitalized children and their hospital physicians. Methods A qualitative study with semi-structured interviews was conducted from 2018 to 2019 at a 361-bed quaternary suburban freestanding children's hospital. Twenty-seven parents of hospitalized children and sixteen pediatric hospital medicine faculty were matched to participate. Data was analyzed using modified grounded theory, with themes identified through constant comparative approach. Results Five themes were identified: 1) Majority of hospitalized children's parents want to share their goals with physicians. 2) Parents and physicians share the same underlying goal of getting the child better to go home. 3) Parents of children with chronic diseases identified non-hospital goals that were not addressed. 4) Physicians do not explicitly elicit but rather assume what parents’ goals of care are. 5) Factors related to patient, parent, and physician were identified as barriers to goal setting. Conclusions Physicians may not consistently elicit parents’ goals of care for their hospitalized children at the start of hospitalization. Parents desire their physicians to explicitly ask about their goals and involve them in goal setting during hospitalization. Strategies were identified by parents and physicians to improve goal setting with parents of hospitalized children.

Background Remote clinics, where patients attend appointments over telephone or video calls, are increasingly replacing traditional in-person consultations. In the UK, gastroenterology clinics have generally occurred in hospital outpatient departments, and uptake of remote clinics had been slow, before accelerating in the COVID-19 pandemic. Aims This literature review aimed to assess the use, advantages and disadvantages of remote clinics in adult and paediatric gastroenterology. Methods A literature search was carried out for articles in English published since 2000. Findings Four articles were identified, two on adult and two on paediatric gastroenterology services. Benefits highlighted included high patient satisfaction with and preference for remote clinics, owing to reduced travel time and cost. Services reported reduced nonattendance rates compared with in-person clinics. Authors and patients cautioned that remote clinics should not entirely replace face-to-face contact, which has advantages for visual assessment and building clinician–patient relationships. Conclusions Remote clinics are effective for gastroenterology services. Further research is recommended to capture the qualitative experience of the patients, families and nurses involved in these remote clinics.

OBJECTIVES:Shared decision-making (SDM) is the pinnacle of patient-centered care and has been shown to improve health outcomes, especially for children with chronic medical conditions. However, parents perceive suboptimal involvement during hospitalization. The objective was to explore the perspectives of parents of hospitalized children and their hospital providers on facilitators and barriers to SDM in the hospital and identify strategies to increase SDM.METHODS:A qualitative study was conducted by using semistructured interviews with parents of hospitalized children with and without complex chronic conditions and their pediatric hospital medicine faculty. Parents and faculty were matched and individually interviewed on the same day. Two investigators iteratively coded transcripts and identified themes using modified grounded theory, with an additional author reviewing themes.RESULTS:Twenty-seven parents and 16 faculty participated in the interviews. Four themes emerged: (1) parents and providers value different components of SDM; (2) providers assume SDM is easier with parents of children with medical complexity; (3) factors related to providers, parents, patients, and family-centered rounds were identified as barriers to SDM; and (4) parents and providers identified strategies to facilitate SDM in the hospital.CONCLUSIONS:There is a discrepancy between parents’ and providers’ understanding of SDM, with parents most valuing their providers’ ability to actively listen and explain the medical issue and options with them. There are many barriers that exist that make it difficult for both parties to participate. Several strategies related to family-centered rounds have been identified that can be implemented into clinical practice to mitigate these barriers.

The purpose of this article is to critically assess the literature on engaging internal medicine hospitalists in antimicrobial stewardship. Few studies exist that describe hospitalist-led antimicrobial stewardship initiatives. Most studies in this review employed quasi-experimental or quality improvement methods. Across the studies included in our analysis, those with interventions that focused on single disease processes (e.g., pneumonia, UTI, SSTI) had a more robust impact on their selected outcomes. In the reviewed literature, engaging internal medicine hospitalists in antimicrobial stewardship efforts resulted in improved antimicrobial appropriateness and decreased broad-spectrum antibiotic usage. Despite being identified as key stakeholders and potential leaders in antimicrobial stewardship efforts, there is a paucity of literature to guide the best incorporation of hospitalists in this work.

Background Academic medicine needs more diverse leadership from racial/ethnic minorities, women, people with disabilities, and LGBTQIA+ physicians. Longitudinal structural support programs that bring together underrepresented in medicine (UiM) and non-UiM trainees are one approach to build leadership and scholarship capacity in diversity, equity, and inclusion (DEI). Objective To describe the creation, satisfaction with, and feasibility of a Leadership Education in Advancing Diversity (LEAD) Program and evaluate scholars' changes in self-efficacy, intended and actual behavior change, and outputs in leadership and DEI scholarship. Methods In 2017, we created the LEAD Program, a 10-month longitudinal, single institution program that provides residents and fellows (“scholars”) across graduate medical education (GME) with leadership training and mentorship in creating DEI-focused scholarship. In the first 3 cohorts (2017–2020), we assessed scholars' self-efficacy, actual and planned behavior change, and program satisfaction using IRB-approved, de-identified retrospective pre-/post-surveys. We measured scholarship as the number of workshops presented and publications developed by the LEAD scholars. We used descriptive statistics and paired 2-tailed t tests to analyze the data. Results Seventy-five trainees completed LEAD; 99% (74 of 75) completed the retrospective pre-/post-surveys. There was statistically significant improvement in scholars' self-efficacy for all learning objectives. All trainees thought LEAD should continue. LEAD scholars have created workshops and presented at local, regional, and national conferences, as well published their findings. Scholars identified the greatest benefits as mentorship, developing friendships with UiM and ally peers outside of their subspecialty, and confidence in public speaking. Conclusions LEAD is an innovative, feasible GME-wide model to improve resident and fellow self-efficacy and behaviors in DEI scholarship and leadership.

Introduction Children with severe neurodisability and tone disorders can present with debilitating symptoms and declining growth. Gastrointestinal dystonia (GID) describes the clinical manifestations of: pain behaviour; hypertonicity; retching; vomiting; vagal phenomena; abdominal distension and straining attributable to the GI tract in the context of severe neurodisability.1Blended diet (BD) has an emerging role in the nutritional management of patients with neurodisability, however we are unaware of data pertaining to BD specifically in patients with GID. Aim A tertiary centre review of outcomes of patients with GID receiving BD. Method Patients who commenced BD between 07/2017 and 02/2020 were identified from prospectively gathered complex enteral nutrition (CEN) and specialist dietetic databases. BD was initiated with specialist paediatric dietetic support within the CEN clinic or in other clinics. Data gathered included: demographics; primary diagnosis; enteral feeding plan; fundoplication; weight standard deviation z score at 0, 6, 12 and 18 months prior to and from commencing BD; medications at 0 and 6, 12, 18 months; reasons if BD discontinued; parenteral nutrition (PN) requirement. Results 29 children met criteria for GID and commenced BD.1 18 were male. 14 had a fundoplication. Feeding method prior to BD: gastric bolus 17; gastric continuous 8; jejunal 4. Mean age BD commenced was 7 years. Follow up ranged 8 to 40 months. 25 patients continue BD to date. 4 discontinued BD within 1–2 months citing increased GI symptoms or device blockage. Of the 25 who continue BD, median weight z scores declined from -1.77 at 12 months prior to BD, -1.86 at 6 months prior, -1.94 at 0 months, then rose to -1.54 at 12 months, and -1.40 at 18 months. Mean weight z scores were maintained at -1.97 (CI -0.85 to -3.09) at 0 months, -1.97 (CI -0.27 to -3.02) at 12 months and -1.79 (CI -0.34 to -3.25) at 18 months [figure 1]. This trend was more significant in a subset of 6 patients, z score -2.06 (CI -1.46 to -2.67) at 0 months, -1.13 (CI -0.59 to -1.67) at 12 months (p = 0.018) and -0.84 (CI -0.46 to -1.21) at 18 months (p = 0.003) [figure 2]. 9 of the 25 were able to discontinue one GI medication, 4 discontinued two GI medications. Tone medications: 3 reduced; 20 unchanged; 2 increased. No patients received PN during the study. Conclusion GID represents the severest end point of gastrointestinal symptoms in neurodisability, with progressive decline often a feature. Our data show children with GID receiving BD continue to track their weight trajectory, whilst some experience significantly improved growth. No patients required trial on PN during the study. The authors advocate for BD’s role in minimizing the need for invasive treatments in GID whilst addressing symptoms and maintaining nutritional status2 and growth superiorly to formula feeds alone. Improvements in symptomatology and quality of life will be better described by prospective survey of patients commencing BD for GID. The authors are currently gathering this data. References McConnell N, et al. JPGN;66(supp2):1002; 2018 Hay J, et al. (presented BSPGHAN 2020)

Emergency physicians (EP) make clinical decisions multiple times daily. In some instances, medical errors occur due to flaws in the complex process of clinical reasoning and decision-making. Cognitive error can be difficult to identify and is equally difficult to prevent. To reduce the risk of patient harm resulting from errors in critical thinking, it has been proposed that we train physicians to understand and maintain awareness of their thought process, to identify error-prone clinical situations, to recognize predictable vulnerabilities in thinking, and to employ strategies to avert cognitive errors. The first step to this approach is to gain an understanding of how physicians make decisions and what conditions may predispose to faulty decision-making. We review the dual-process theory, which offers a framework to understand both intuitive and analytical reasoning, and to identify the necessary conditions to support optimal cognitive processing. We also discuss systematic deviations from normative reasoning known as cognitive biases, which were first described in cognitive psychology and have been identified as a contributing factor to errors in medicine. Training physicians in common biases and strategies to mitigate their effect is known as debiasing. A variety of debiasing techniques have been proposed for use by clinicians. We sought to review the current evidence supporting the effectiveness of these strategies in the clinical setting. This discussion of improving clinical reasoning is relevant to medical educators as well as practicing EPs engaged in continuing medical education.