Implementation of clinical assistants in a pediatric oncology department: An impact analysis

Bureaucratic and administrative tasks associated with health care provision have historically fallen on health care professionals, which is one among the factors contributing to low job satisfaction and lower productivity. Incorporating new professional roles that help to better respond to the needs of both patients and professionals can increase the quality and efficiency of service provision. This article aims to evaluate the impact of the clinical assistant's introduction in the Sant Joan de Déu Barcelona Children's Hospital's pediatric oncology department, in terms of (i) displacement of activity loads carried out by this new professional role and the consequent time freed up for physicians, (ii) physicians' satisfaction and (iii) efficiency of the new care model. This is an observational and retrospective study using administrative data based on the type of activity performed by clinical assistants and the measurement of the time freed up in favor of the physicians. The potential skill mix productivity increase, survey of physicians' satisfaction, and reduction in costs with the new model was analyzed. During the first year of its implementation in the pediatric oncology department, clinical assistants have performed 13,553 requests (69% of the total), representing a total saving of 266.83 hours or 6.67 workweeks of 40 hours. They performed 74% of outpatient surgical requests in the oncology department, 87% of day hospital requests and 54% of total requests in the outpatient consultations area. Physicians are overall satisfied with the new role and think they can use the time gained to do other things such as research or improving the quality of care. The role change allows reducing the cost per request by 56% in relation to the conventional model. In conclusion, the introduction of clinical assistants in the oncology department could be efficient to the extent that it displaces a significant part of the bureaucratic and administrative tasks previously performed by health care professionals and thus enables to reduce the cost of these processes. This delegation allows them to work more closely to the maximum of their competences and the physicians to have more time for higher added value clinical tasks and increase professional satisfaction.

Defining pediatric trauma center resource utilization: Multidisciplinary consensus-based criteria from the Pediatric Trauma Society

BACKGROUND

Pediatric trauma triage and transfer decisions should incorporate the likelihood that an injured child will require pediatric trauma center (PTC) resources. Resource utilization may be a better basis than mortality risk when evaluating pediatric injury severity. However, there is currently no consensus definition of PTC resource utilization that encompasses the full scope of PTC services.

METHODS

Consensus criteria were developed in collaboration with the Pediatric Trauma Society (PTS) Research Committee using a modified Delphi approach. An expert panel was recruited representing the following pediatric disciplines: prehospital care, emergency medicine, nursing, general surgery, neurosurgery, orthopedics, anesthesia, radiology, critical care, child abuse, and rehabilitation medicine. Resource utilization criteria were drafted from a comprehensive literature review, seeking to complete the following sentence: "Pediatric patients with traumatic injuries have used PTC resources if they..." Criteria were then refined and underwent three rounds of voting to achieve consensus. Consensus was defined as agreement of 75% or more panelists. Between the second and third voting rounds, broad feedback from attendees of the PTS annual meeting was obtained.

RESULTS

The Delphi panel consisted of 18 members from 15 institutions. Twenty initial draft criteria were developed based on literature review. These criteria dealt with airway interventions, vascular access, initial stabilization procedures, fluid resuscitation, blood product transfusion, abdominal trauma/solid organ injury management, intensive care monitoring, anesthesia/sedation, advanced imaging, radiologic interpretation, child abuse evaluation, and rehabilitative services. After refinement and panel voting, 14 criteria achieved the >75% consensus threshold. The final consensus criteria were reviewed and endorsed by the PTS Guidelines Committee.

CONCLUSION

This study defines multidisciplinary consensus-based criteria for PTC resource utilization. These criteria are an important step toward developing a criterion standard, resource-based, pediatric injury severity metric. Such metrics can help optimize system-level pediatric trauma triage based on likelihood of requiring PTC resources.

LEVEL OF EVIDENCE

Diagnostic Test/Criteria; Level II.

Pediatric produce prescription initiatives in the U.S.: a scoping review

BACKGROUND

To describe pediatric Produce Prescription (PRx) interventions and their study designs, outcomes, and opportunities for future research.

METHODS

A scoping review framework was used to describe PRx interventions published between January 2000 and September 2023. Articles from online databases were uploaded into Covidence. Data on study characteristics, outcomes of interest (health, food insecurity (FI), nutritional and culinary efficacy, and fruit and vegetable (F/V) consumption), and feasibility were extracted. The Mixed Methods Appraisal Tool (MMAT) was used for quality assessment.

RESULTS

19 articles met inclusion criteria. Ten studies were quantitative, five were qualitative, and four used mixed-methods. Interventions included food vouchers (n = 14) or food box/pantries (n = 5). Four studies allowed food items in addition to F/Vs. Six studies measured changes in FI and five reported a statistically significant decrease. Seven studies measured changes in F/V consumption and five reported a statistically significant increase. One study reported a statistically significant reduction in child BMI z-score. Most studies reported high feasibility. Few studies used high-quality methods.

CONCLUSIONS

Pediatric PRx interventions show promising potential to reduce FI and improve diet quality and health-related outcomes. Future studies should utilize rigorous study designs and validated assessment tools to understand the impact of pediatric PRx on health.

IMPACT

This work offers a summary of programmatic outcomes including retention, redemption, incentives, nutrition education, study design and quality limitations to help inform future work. We found positive impacts of pediatric produce prescriptions (PRx) on FI, F/V consumption, and nutritional knowledge and culinary skills. More high-quality, rigorous studies are needed to understand the best delivery and design of PRx and their impact on child behavior and health outcomes. This work provides support for the need for rigorous studies and the potential for PRx to play a role in multi-pronged strategies that address pediatric FI and diet-related disease.

Trauma-Informed Care in Pediatric Physical Therapy as a Standard Precaution: The Time Is Here

In this special communication, an overview of the research on trauma, resilience, and action items for the pediatric physical therapist (PT) is addressed. The experiences of early childhood, positive and negative, impact overall development and well-being throughout the lifespan. Childhood trauma can include exposure to abuse, neglect, violence, racism, or medical procedures. These adverse childhood experiences are associated with poor physical and mental health outcomes that can extend into adulthood and can appear in the pediatric rehabilitative realm as caregivers who become labeled noncompliant. Trauma is common and impacts all children; however, some populations, such as children with disabilities, have greater risk for experiencing adversity. An individual's trauma history is not always visible, necessitating a standard approach. Pediatric PTs must take an intentional approach to address the detrimental effects of trauma on those we serve. Many organizations recommend adopting trauma-informed care as the standard of care for all populations.

Moving toward the Development and Effective Implementation of High-Quality Guidelines in Pediatric Surgery: A Review of the Literature

Applying evidence-based guidelines can enhance the quality of patient care. While robust guideline development methodology ensures credibility and validity, methodological variations can impact guideline quality. Besides methodological rigor, effective implementation is crucial for achieving improved health outcomes. This review provides an overview of recent literature pertaining to the development and implementation of guidelines in pediatric surgery. Literature was reviewed to provide an overview of sound guideline development methodologies and approaches to promote effective guideline implementation. Challenges specific to pediatric surgery were highlighted. A search was performed to identify published guidelines relevant to pediatric surgery from 2018 to June 2023, and their quality was collectively appraised using the AGREE II instrument. High-quality guideline development can be promoted by using methodologically sound tools such as the Guidelines 2.0 checklist, the GRADE system, and the AGREE II instrument. While implementation can be promoted during guideline development and post-publication, its effectiveness may be influenced by various factors. Challenges pertinent to pediatric surgery, such as limited evidence and difficulties with outcome selection and heterogeneity, may impact guideline quality and effective implementation. Fifteen guidelines were identified and collectively appraised as suboptimal, with a mean overall AGREE II score of 58%, with applicability being the lowest scoring domain. There are identified challenges and barriers to the development and effective implementation of high-quality guidelines in pediatric surgery. It is valuable to prioritize the identification of adapted, innovative methodological strategies and the use of implementation science to understand and achieve effective guideline implementation.

Paramedics' Success and Complications in Prehospital Pediatric Intubation: A Meta-Analysis

BACKGROUND

Prehospital pediatric intubation is a potentially life-saving procedure in which paramedics are relied upon. However, due to the anatomical nature of pediatrics and associated adverse events, it is more challenging compared to adult intubation. In this study, the knowledge and attitude of paramedics was assessed by measuring their overall success rate and associated complications.

METHODS

An online search using PubMed, Scopus, Web of Science, and Cochrane CENTRAL was conducted using relevant keywords to include studies that assess success rates and associated complications. Studies for eligibility were screened. Data were extracted from eligible studies and pooled as risk ratio (RR) with a 95% confidence interval (CI).

RESULTS

Thirty-eight studies involving 14,207 pediatrics undergoing intubation by paramedics were included in this study. The prevalence of success rate was 82.5% (95% CI, 0.745-0.832) for overall trials and 77.2% (95% CI, 0.713-0.832) success rate after the first attempt. By subgrouping the patients according to using muscle relaxants during intubation, the group that used muscle relaxants showed a high overall successful rate of 92.5% (95% CI, 0.877-0.973) and 79.9% (95% CI, 0.715-0.994) success rate after the first attempt, more than the group without muscle relaxant which represent 78.9% (95% CI, 0.745-0.832) overall success rate and 73.3% (95% CI, 0.616-0.950) success rate after first attempt.

CONCLUSION

Paramedics have a good overall successful rate of pediatric intubation with a lower complication rate, especially when using muscle relaxants.

Legacy in paediatrics: A concept analysis

AIM

To provide an analysis of legacy and legacy-oriented interventions in paediatric healthcare.

DESIGN

Walker and Avant's method of concept analysis.

METHODS

Using Walker and Avant's method, three defining attributes of the concept were determined, followed by antecedents, consequences, and empirical referents of legacy.

RESULTS

In paediatrics, legacy is co-authored in relationships, has the capability to outlive the person or event it represents, and elicits the essence of a person or experience. Receiving legacy-oriented interventions are not a prerequisite for having a legacy, nor is death.

CONCLUSION

Engaging in purposeful, individualized legacy-oriented interventions can improve coping in paediatric patients, families, and providers. By understanding the concept of legacy, providers are better equipped to provide care honouring the unique personhood, relationships, and strengths of children and families in even the most dire circumstances.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Understanding the scope and purpose of legacy in paediatrics assists providers in improving patient- and family-centred outcomes by designing interventions that facilitate long-term coping in patients facing a loss of or significant change in health, normalcy, or life.

IMPACT

Legacy-oriented interventions are provided at most children's hospitals in the United States, yet no widespread consensus on foundation or scope has been determined. This concept analysis provides evidence-based guidelines for policy and practice in creating legacy for and with children, providing opportunities to improve quality of care for young patients and their families around the world.

REPORTING METHOD

N/A.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Disparities in Patient Family Social Determinants of Health in a Large Urban Pediatric Health System

INTRODUCTION

This analysis sought to identify disparities in social determinants of health (SDOH) outcomes at a Texas pediatric hospital.

METHODS

This retrospective study used electronic health records of pediatric patients families surveyed August -December 2022. Outcomes for health literacy, social support, food, transportation, energy, digital, and housing insecurity, and tobacco exposure were analyzed across demographic categories.

RESULTS

Among 15,294 respondents to the survey (mean child age, 8.73 years; 43.68% Hispanic, 29.73% non-Hispanic White, 18.27% non-Hispanic Black, 6.79% other race/ethnicity; 53.95% male), 50.25% of respondents reported at least one SDOH, whereas 23.39% reported two or more SDOH. The most prevalent SDOH was lack of social support (3,456, 23.91%). Hispanic, non-Hispanic Black, and other race/ethnicity respondents, non-English speakers, and public insurance users had higher odds of reporting almost all SDOH in logistic regression models adjusted for age, race/ethnicity, language, gender, and insurance type.

DISCUSSION

Race/ethnicity, language, and insurance type disparities were identified for all SDOH.

The Imperative of Ethics in Everyday Clinical Pediatrics

Clinical ethics is the dimension of bioethics devoted to analyzing competing values and obligations in clinical care, seeking the optimal balance between competing duties. Competence in clinical ethics is particularly important in our current scientific and social environment, where disharmony and challenges between value systems are common and the medical profession suffers from self-imposed risks to integrity and coherence. The ability to bring ethical analysis into the challenges of everyday clinical practice is a crucial component in resolving values conflicts and protecting the clinician-patient relationship that is the heart of our profession.

Shared Decision-Making in Pediatrics

This article briefly reviews a 4-step process for implementing shared decision-making (SDM) in pediatrics. The authors address difficulties with determining whether SDM should occur and comment on how the SDM process relates to, and may be conflated with, other decision-making models that leverage similar patient-centered and family-centered communication strategies.

The Use of Telemedicine for Screening and Addressing Social Needs in a Primary Care Pediatric Population in Brooklyn, New York

The objective of this study was to analyze temporal changes in social needs (SN), comparing those who received routine annual in-person care to those receiving SN screenings through a combination of tele-social care and in-person care biannually. Our prospective cohort study used a convenience sample of patients from primary care practices. Baseline data were collected from April 2019 to March 2020. The intervention group (n = 336) received SN screening and referral telephone outreach from June 2020 to August 2021. The control group (n = 2890) was screened, in person, during routine visits at baseline and summer 2021. We used a repeated-measures logistic regression with general estimating equations to assess incremental change in individual SN for the intervention group. Food, housing, legal and benefit needs increased and peaked at the beginning of the pandemic and decreased after interventions (P < 0.001). There was a 32% decrease in the odds of food insecurity for those in the intervention group compared to the control group (adjusted OR 0.668, 95% confidence interval 0.444-1.004, P = 0.052), and a 75% decrease in the odds of housing insecurity (adjusted OR 0.247, 95% confidence interval 0.150-0.505, P < 0.001). During COVID-19, there was an increase in SN followed by a decrease after interventions were offered. Those who completed tele-social care showed greater improvements in social needs than those in routine care, with the greatest improvements in food and housing needs.

Eric Bywaters and Barbara Ansell: Founders of Modern Pediatric Rheumatology

Eric Bywaters and Barbara Ansell were, without doubt, two of the giants in the field of Rheumatology. With their keen clinical observations and their visionary development of a dedicated multidisciplinary program focusing on diagnosis, treatment, and research, they are remembered as the founders of the modern specialty of Pediatric Rheumatology.

Confidentiality in Primary Care Pediatrics

Confidentiality is a core component of adolescent health. Confidentiality is shown to be a basic human right that is in the best interest of the adolescent, addresses health inequities, and supports adolescents' developing capacity. Practical aspects of confidentiality are discussed, resources provided to navigate a changing legal landscape, and threats to confidentiality addressed. Although confidentiality can be a source of conflict with parents and caregivers, pediatric providers can use confidentiality to assist parents and caregivers in shifting from making decisions for the adolescent to supporting the adolescent in making their own health decisions, thus facilitating a healthy transition to adulthood.

Dermatologic Review in Pediatric Vascular Lesions

Vascular anomalies (VAs) can be present in any organ; however, the skin being the largest one, it is there where many of them are evident; some are visible at birth, others develop throughout life. Pediatric dermatologists are specially trained to distinguish VAs from their mimickers, which require different treatments and may harbor distinct prognoses. We resume the diagnostic and therapeutic tasks of pediatric dermatologist at our vascular anomaly clinics, as well as the differential diagnoses of mimickers of VAs.

Establishing Goals of Care in Serious and Complex Pediatric Illness

An increasing number of children are living for months and years with serious/complex illness characterized by long-term prognostic uncertainty, intensive interactions with medical systems, functional limitations, and often home medical technologies that shape the child's and family's quality of life. These families face many medical decision points that require intentional and iterative discussions about goals of care. Threats to cohesive goals of care include prognostic uncertainty, diffusion of medical responsibility, individual family context, and blended goals of care. This article offers strategies for addressing each of these challenges.

Family engagement in paediatric acute care settings: A realist review

AIM

To create a programme theory of family engagement in paediatric acute care to explicate the relationships between contexts and mechanisms of family engagement that align with family, direct care providers and healthcare organization outcomes.

DESIGN

Realist review and synthesis.

DATA SOURCES

PubMed, CINAHL, PsycINFO and Web of Science searches for the 2.5-year period (July 2019-December 2021) following our 2021 scoping review.

REVIEW METHODS

Following methods described by Pawson and Rycroft-Malone, we defined the scope of the review, searched for and appraised the evidence, extracted and synthesized study findings and developed a supporting narrative of our results.

RESULTS

Of 316 initial citations, 101 were included in our synthesis of the final programme theory. Contexts included family and direct care provider individualism, and the organizational care philosophy and environment. Mechanisms were family presence, family enactment of a role in the child's care, direct care providers facilitating a family role in the child's care, unit/organizational promotion of a family role, relationship building and mutually beneficial partnerships. Outcomes were largely family-focussed, with a paucity of organizational outcomes studied. We identified four context-mechanism-outcome configurations.

CONCLUSION

This realist review uncovered underlying contexts and mechanisms between patients, direct care providers and organizations in the family engagement process and key components of a mutually beneficial partnership. Given that successful family engagement requires direct care provider and organizational support, future research should expand beyond family outcomes to include direct care providers, particularly nurses and healthcare organization outcomes.

IMPACT

The final programme theory of family engagement in paediatric acute care provides a roadmap for clinicians to develop complex interventions to engage families and evaluate their impact. The components of our final programme theory reflect family engagement concepts that have been evolving for decades.

PATIENT OR PUBLIC CONTRIBUTION

The team conducting this review included members from the practice setting (JT & KG). In the future, as we and others use this model in practice, we will seek input for refinement from clinicians, patients and caregivers.

Pediatric interventional bronchoscopy: from early limitations to achievable opportunities

PURPOSE OF REVIEW

The rapid evolution of bronchoscopy equipment and technologies, from the introduction of the 1.1 mm flexible cryoprobe to the use of navigational and robotic bronchoscopy, has afforded unprecedented opportunities for pediatric advanced diagnostic and interventional bronchoscopy. While there is growing interest among pediatric pulmonologists to incorporate these new techniques into their practice, the current pediatric landscape is characterized by few practicing interventional bronchoscopists, scant published literature, and no formal training programs.

RECENT FINDINGS

While the majority of the published literature consists of case reports and small case series, the increased application of new techniques is starting to yield larger and more structured studies that will be able to provide more objective commentary on the proposed indications, safety, and efficacy of such techniques in the pediatric population.

SUMMARY

For many decades, progress in pediatric advanced diagnostic and interventional bronchoscopy was slow and deliberate, limited by the lack of appropriately sized equipment and experienced interventional bronchoscopists. The current opportunities afforded require equal, or perhaps even more, vigilance as pediatric pulmonologists employ new equipment and technologies and define new practices and standards of care. Importantly, this review is meant to serve as a general conspectus of pediatric advanced diagnostic and interventional bronchoscopy and not a consensus guideline for the performance of advanced or even routine bronchoscopy in the pediatric population. For technical standards of pediatric bronchoscopy, refer to existing guidelines [1,2] .

A quality improvement approach to improving recognition of Māori tamariki (children) and assessing barriers to culturally responsive care in a paediatric ward setting

BACKGROUND

Health inequity persists in Aotearoa (New Zealand) and internationally amongst most indigenous peoples. To address these health inequities, countries need to contend with the ramifications of entrenched historical, cultural and systemic failures. Within Aotearoa part of the solution to rectifying persistent health inequities lies in shifting everyday healthcare practices towards a more culturally responsive, patient-centred approach that utilises Māori knowledge and principles. Although the need for culturally responsive services in healthcare settings is clearly evident, most practitioners struggle with the challenge of creating a culturally safe environment. Further to these challenges, there are issues related to accurate recognition of ethnicity within the time constraints of an overwrought hospital environment. Within this environment, the correct identification of ethnicity is a fundamental step in the process of moving towards culturally responsive and more inclusive care.

METHOD

The research was concerned with indigenous Māori patients being consistently and correctly identified so that they might receive culturally appropriate interaction and treatment. The research specifically focused on the impact of introducing a customised sticker prompt on the front cover of clinical notes of Māori tamariki (children) to assist with correct ethnicity identification. Surveys were conducted on the paediatric ward over a 3-week period, prior to and during the intervention to evaluate the effect of the customised stickers. This study sought to (1) assess the efficacy of a sticker to improve recognition of Māori tamariki (children), (2) examine key barriers to identifying ethnicity and (3) identify wider impacts of a sticker prompt on clinical practice.

RESULTS

Results showed wide ranging positive impacts on clinical practice and culturally responsive care. Sixty-four per cent of participants indicated that the stickers were a useful tool to improve identification of Māori tamariki. Respondents reported increased accuracy of identifying patients by ethnicity, as well as improved awareness of existing ethnicity documentation, and increased engagement regarding cultural needs and ethnicity.

CONCLUSIONS

This study identified that sticker prompts are a useful tool for healthcare workers to improve recognition and awareness of ethnicity and to increase dialogue around cultural needs. The stickers led to increased consideration of the wider elements of holistic wellbeing and therefore improved culturally responsive care for Māori tamariki.

Sociodemographic Disparities in Ambulatory Pediatric Telemedicine Utilization During COVID-19

Objective: Few studies have examined sociodemographic disparities in ambulatory pediatric telemedicine utilization during the coronavirus disease 2019 pandemic. We aimed to (1) assess disparities in telemedicine visit completion during the first 6 weeks of the pandemic in 2020 and (2) determine if these disparities were significantly different from those present in 2019, when all visits occurred in person. Methods: We compared sociodemographic characteristics of patients with successful versus unsuccessful telemedicine visits from March 10, 2020 to April 18, 2020, using generalized linear mixed models. We performed the same analysis for in-person visits from the same period in 2019. We tested for differences across years using interaction terms in a combined 2019-2020 model. Results: Of 3,639 telemedicine visits scheduled, 3,033 (83.3%) were successful. In 2020, Black/African American race was significantly associated with lower odds of telemedicine visit success (odds ratio 0.65 [95% confidence interval 0.49-0.87]) compared with White race, after adjusting for age, gender, ethnicity, insurance type, visit timing, visit specialty, social vulnerability index, and internet access. In 2019, racial identity other than White was significantly associated with lower odds of in-person visit success than White, as was public insurance compared with private. In the full 2019-2020 model, in-person visits (2019) had lower odds of success than telemedicine visits (2020), and neither race, insurance type, nor any other sociodemographic characteristic had significant interactions with year. Conclusions: Racial disparities were evident in telemedicine utilization early in the pandemic; however, these disparities were not significantly different from those seen in 2019, when all visits were in person. Furthermore, telemedicine may improve access to care overall, despite having no significant impact on inequity. Efforts to eliminate racial disparities in ambulatory pediatric health care utilization are necessary across visit modalities.

Diagnostic Evaluation of Autism Spectrum Disorder in Pediatric Primary Care

BACKGROUND AND OBJECTIVES

Children with autism spectrum disorder (ASD) continue to experience significant delays in diagnosis and interventions. One of the main factors contributing to this delay is a shortage of developmental-behavioral specialists. Diagnostic evaluation of ASD by primary care pediatricians (PCPs) has been shown to be reliable and to decrease the interval from first concern to diagnosis. In this paper, we present the results of a primary care ASD diagnosis program in which the PCP serves as the primary diagnostician and leverages the infrastructure of the primary care medical home to support the child and family during the pre- and post-diagnostic periods, along with data on parental satisfaction with this model.

METHODS

Retrospective data from a cohort of patients evaluated through this program were analyzed to determine the mean age at diagnosis and interval from referral for evaluation to diagnosis. We used survey methodology to obtain data from parents regarding their satisfaction with the process.

RESULTS

Data from 8 of 20 children evaluated from April 2021 through May 2022 showed a median age of diagnosis of 34.5 months compared to the national average of 49 months. Mean interval from referral for evaluation to diagnosis was 3.5 months. Parental survey responses indicated high satisfaction.

CONCLUSIONS

This model was successful in shortening the interval from referral to diagnosis resulting in significant decrease of age at diagnosis compared with the national average. Widespread implementation could improve access to timely diagnostic services and improve outcomes for children with ASD.

Organisational barriers and facilitators to the implementation of best practices within paediatric forensic radiographic practice - A scoping review

INTRODUCTION

Implementation and application of evidence-based practice through legislation, international and national guidelines and local protocols is integral to the successful undertaking of forensic radiographic practice, because of its medico-legal role. This research aims to evaluate those organisational barriers and facilitators to its effective implementation.

METHODS

This scoping review was undertaken according to the JBI updated guidelines using the PCC mnemonic. A systematic search of 10 databases was undertaken to identify literature addressing the research question relating to this aspect of forensic radiography practice. Handsearching and snowballing were also included to enhance this search strategy. The search focussed on forensic imaging of paediatrics, the living and deceased.

RESULTS

Of the 301 papers initially selected, 9 articles were identified as eligible for inclusion, encompassing an international perspective. Through Inductive Content Analysis, 5 conceptual categories were developed: ineffective organisational governance, education translation, system brakes, default practice, and value-based judgement.

CONCLUSION

The results indicate that there are many complex and multifactorial organisational issues impacting upon effective implementation of best practices within paediatric forensic imaging. There is a need to address these issues, before attempting strategies for future implementation. It is essential to recognise that there can be no one-size-fits approach, but rather tailored strategies are required recognising individual needs within the multi-disciplinary scope of forensic radiographic practice.

IMPLICATIONS FOR PRACTICE

Failure to recognise and address the identified issues impacting upon effective implementation, may have significant implications on the processes and individuals involved in the forensic imaging acquisition pathway. Successful addressing of these issues may enable the professionals involved in organisational governance to create a more conducive and receptive environment for best-practice implementation.

A roadmap for starting, growing and sustaining a comprehensive pediatric surgery service in a low resource area

The Tanzania-Oxford Children's Surgery Partnership is a longstanding capacity building and research collaboration. Over a 21-year period, this non-hierarchical partnership has worked to develop from service delivery to children surgical system strengthening in Tanzania. This has directly impacted the children's surgery and workforce by increasing the number of pediatric surgeons in the country and upskilling nurses, anesthetists, and pediatricians. Clinical skills acquisition has been complemented by the development of leadership, mentorship, and research acumen. The partnership has also delivered critical upgrading of infrastructure which has significantly increased operative volume and allowed for the provision of minimally invasive children's surgery. A children's research network has been established, with a focus on research equity and local data ownership adhering to local ethics, leading to prolific academic output. At the core of this partnership has been the recognition that achieving sustainable change requires local leadership, long-term commitment, and 'bottom-up' change. We described the historical events and steps taken by our partners to achieve the universal provision of children's surgery in Tanzania.

Identifying Risk Factors Associated with Repeated Referrals Within a Pediatric Navigation Program

Approximately 1-in-5 children have a diagnosed mental, behavioral, and/or developmental disorder or delay by age 8 in the United States. Children with such conditions often require complex, complicated diagnostic and specialty care, making them susceptible to repeated referrals and ongoing unmet healthcare needs. Patient navigation programs (PNPs) are designed to integrate care from primary care providers to community-based services, using trained navigators to help patients and their families manage referrals and connect with referred services. This study examines factors associated with repeated referrals to an active PNP to inform ongoing referral patterns and adaptations to standard navigation support within a large healthcare system in South Carolina (SC). Data is sourced from the inception of the PNP in 2017 through 2022, including 15,702 referrals. Overall, 71.07% had no repeated referrals. Children who are older, diagnosed with attention deficit disorder(s), behavioral concerns, depression, multiple referral needs, and insured by Medicaid were found to be most susceptible to repeated referrals. Conversely, children who are non-Hispanic Black, were referred at a well-child visit, and are primarily insured by private insurance or Tricare were least likely to have repeated referrals. Children who are insured by Medicaid are more likely to be younger, identify as non-Hispanic Black, Hispanic, or another race/ethnicity, and have multiple needs at time of initial referral, identifying a potentially compounded risk for those who hold multiple risk factors to experiencing repeated referrals. Findings may inform adaptations to this PNP model to adjust navigator protocol for at-risk populations and equitably optimize referral-to-service connection.

Pathologist Pediatric In-Patient Genetic Stewardship

Background: Costs for sendout genetic testing on in-patients are billed to the hospital. Turnaround times are several weeks, often extending past the inpatient hospitalization.Materials and Methods: We concurrently reviewed all sendout genetic in-patient test requests over an 18-month period, deferring those that could be obtained as an outpatient, directing the tests to less expensive laboratories with complementary testing profiles, and identifying no-charge sponsored tests.Results: Of 121 test requests, 25 were deferred, alternative less expensive laboratories were identified for 8, 16 requests were directed to sponsored tests, for a 42.3% cost saving. Of the 96 tests sent, 18 (18.8%) identified an explanatory genetic abnormality.Conclusions: Approximately 40% of the sendout genetic testing costs were reduced with prior test review. Deferment, alternative laboratories, and sponsored tests contributed to cost savings. Efficiency of diagnostic inpatient genetic testing was approximately 20%.

Pediatric epileptologist from Latin America

Experience of how to become a pediatric epileptologist in Colombia.

Airway management in paediatric emergencies outside of an intensive care setting: a quality improvement project using Lean/Six Sigma methodology

Use of a Lean/Six Sigma methodology in a quality improvement project to reduce variation and improve safety in airway management outside of the intensive care environment in a tertiary paediatric hospital.

The ethical perspectives of using animals in pediatric health

While there are ethical standards for human biomedical research, animals have historically not benefitted from the same levels of protection. Cultural shifts in response to studies demonstrating animal capacity to suffer have resulted in laws defining minimum ethical standards for the treatment of various animal populations. However, none of these pertain to service or therapy animals nor do they define ethical considerations regarding training, placement, environment, and duty limitations specific to this population. The potential for harm and inability to provide consent should raise ethical questions of animal assisted interventions (AAI), including how to best balance the risk: benefit ratio for both animal and human participants. While service animals have specific definitions, therapy and emotional support animals are much less clearly defined and therefore have far less standardized practices regarding their training, certification, and process for matching to handlers. This can lead to animals being inadequately trained to cope with the stresses of their jobs or being placed in incompatible environments. Meanwhile, service animals' duties are constant, and the animal has little ability to consent to or withdraw from participation, leading to overwork, without the opportunity to engage in activities that align with the animals' natural preferences. Emotional support animals are the least defined of these populations, receive no formal training, and are at increased risk of inadequate care, unstable housing, and abuse from handlers who may also be poorly prepared to properly handle their needs. To uphold our moral obligations to the animals that serve to improve our own mental wellness and physical independence, urgent actions are needed to improve the protections in place for these populations.

Understanding burnout in Pediatric residency through the lens of the 'Areas of worklife'

BACKGROUND AND OBJECTIVES

Burnout is a widespread problem in medicine, especially among trainees. Despite this, data on effective interventions are limited. An organizational context for burnout entitled Areas of Worklife identified six areas of the work environment that can affect burnout through mismatches between individuals expectations of that area and the reality of the work environment. This study aimed to gain a deeper understanding of pediatric residents' perspectives of the Areas of Worklife to allow programs to utilize this framework in the development of future interventions.

METHODS

Using qualitative methodology founded in grounded theory, we employed an iterative data collection by conducting semi-structured interviews, until data saturation was achieved, with 15 pediatric residents in 2018. We recorded interviews and transcribed them verbatim. Content analysis was conducted concurrently with data collection using constant comparison methods; the principal investigator and co-investigators worked jointly to generate codes and identify themes.

RESULTS

Themes were identified for the individual Areas of Worklife that represented resident perspectives and mismatches with the work environment. Overall, patient care was a central focus connecting the areas of control, reward, values, and workload; themes in these areas concentrated on resident's ability to interact with and learn from patients.

CONCLUSIONS

Residents' definitions of the Areas of Worklife can be used to identify mismatches between residents' expectations and their work environment, which can inform organizational interventions. These findings highlight the importance of a patient-focused approach to residency training, which is consistent with literature that shows patient care is a means to find meaning in their work. Resident definitions of the Areas of Worklife offer residency programs a practical approach in their battle against burnout by providing focused direction to respond to resident needs and identify tangible targets for intervention.

Real world data (RWD) in pediatrics

Unique challenges pertain when studying children, although many research principles are the same as those when studying adult populations. This truism extends to the use of real-world data (RWD). RWD are particularly relevant to pediatrics because they may potentially provide an additional source of data to inform pediatric labeling and practice patterns when clinical trials have not been or cannot be conducted. The purpose of this commentary is to provide a brief overview of the unique issues in using RWD to study the effectiveness or safety of medical therapies in children.

URM: Underrepresented or Underrecognized? A Case Study of Black Pediatric Critical Care Physicians

PURPOSE

This study explored Black physicians' experience via an antideficit lens to gain new ideas for advancing minoritized physicians in academic medicine more broadly. Increasingly, systemic racism in academic medicine is intentionally acknowledged and named. However, many solutions to tackle racism and the overall paucity of Black physicians use a deficit framing, painting Black physicians and trainees as lacking preparation, interest, or experience and qualifications. Such solutions aim to help Black people assimilate into the "White Space" of academic medicine, rather than focusing on Black people's strengths.

METHOD

This qualitative study included 15 Black physicians and trainees in pediatric critical care medicine (PCCM) from across the country who participated in semistructured interviews. Through an antideficit lens, the researchers examined the social, cultural, and structural contexts influencing the participants' individual experiences. They analyzed the data combining thematic and narrative qualitative analysis approaches, including restorying.

RESULTS

The data help promote understanding of the landscape and context in which Black PCCM physicians become successful. Achievement took on different forms for the participants. Participants described enablers of achievement that supported them through their individual journeys spanning 3 general domains-intrinsic, interpersonal, and systemic. Three additional enablers were tied specifically to participants' Black identities-harnessing Blackness as a superpower, leaning in to lead, and successfully navigating the "unwritten rules."

CONCLUSIONS

By using an antideficit framework, this study delineates and centers participants' ingenuity in cultivating repertoires of practice that enabled them to succeed, despite challenges rooted in systemic racism. Going forward, rather than focus solely on what is missing, academic medicine should try to shift systems and regularly recognize and value the knowledge, expertise, and merit Black that physicians bring. Perhaps an appropriate framing is not that Black physicians are underrepresented in medicine; maybe instead, it is that they are underrecognized.