Background: The use of telehealth and remote exam devices for children with medical complexity (CMC) allows providers to engage with CMC in their home environment and alleviate caregiver burdens with in-person visits. The authors' objective was to increase the percentage of telehealth visits in which a remote exam device was used in a complex care center from 0% to 50% over a six-month period. Methods: This improvement work targeted a pediatric complex care center. The multidisciplinary quality improvement team developed key drivers to design Plan-Do-Study-Act cycles. Key drivers included access to device, timely identification of patients with devices, ease of connection, strong provider coaching, and caregivers and providers who were knowledgeable and motivated in using the device. Interventions focused on increasing distribution of devices, streamlining the scheduling process, establishing a device registry, education for caregivers and providers on using the device successfully, translating materials into common languages, and providing remote Internet connections. The primary outcome measure was the percentage of telehealth visits completed using the remote exam device. The researchers also tracked the number of devices distributed. The active intervention period was June 2021 to December 2021, with continued data collection through April 2022. Results: The median percentage of telehealth visits using the remote exam device increased from 0% to 43% over the intervention period with non-special cause variation in device utilization in the subsequent four months. The most impactful intervention focused on increasing device distribution. Conclusion: Quality improvement methods were used to increase the utilization of an in-home remote exam device for CMC.

The Pediatric Hospital Medicine (PHM) Fellowship Directors, recent fellowship graduates, and senior leaders in PHM have long identified training in scholarly activities as a key educational priority for fellowship training programs. We led a 2-day conference funded by the Agency for Healthcare Research and Quality to develop scholarship core competencies for PHM fellows. Participants included fellowship directors, national experts in PHM research, and representatives from key stakeholder organizations. Through engagement in large group presentations and small group iterative feedback and editing, participants created and refined a set of scholarship core competencies. After the conference, goals and objectives were edited and harmonized by conference leaders incorporating feedback from conference participants. Core competency development included 7 domains: (1) study design and execution, (2) data management, (3) principles of analytics, (4) critical appraisal of the medical literature, (5) ethics and responsible conduct of research, (6) peer review, dissemination, and funding, and (7) professionalism and leadership. Specific objectives for each goal were further organized into 3 levels to indicate core skills for all fellowship trainees (level 1), specialized and specific skills determined by fellow scholarly focus (level 2), and advanced skills for fellows interested in a clinical investigator career path (level 3). These newly developed scholarship core competencies provide a foundation for curricular development and implementation to ensure that the field continues to expand academically, given the 2-year training period and variable infrastructure across programs.

OBJECTIVES:Conflict management skills are essential for interprofessional team functioning, however existing trainings are time and resource intensive. We hypothesized that a curriculum incorporating virtual reality (VR) simulations would enhance providers' interprofessional conflict communication skills and increase self-efficacy. METHODS:We conducted a randomized controlled pilot study of the Conflict Instruction through Virtual Immersive Cases (CIVIC) curriculum among inpatient clinicians at a pediatric satellite campus. Participants viewed a 30-minute didactic presentation on conflict management and subsequently completed CIVIC (intervention group) or an alternative VR curriculum on vaccine counseling (control group), both of which allowed for verbal interactions with screen-based avatars. Three months following VR training, all clinicians participated in a unique VR simulation focused on conflict management that was recorded and scored using a rubric of observable conflict management behaviors and a Global Entrustment Scale (GES). Differences between groups were evaluated using generalized linear models. Self-efficacy was also assessed immediately pre, post, and 3 months postcurriculum. Differences within and between groups were assessed with paired independent and 2-sample t-tests, respectively. RESULTS:Forty of 51 participants (78%) completed this study. The intervention group (n = 17) demonstrated better performance on the GES (P = .003) and specific evidence-based conflict management behaviors, including summarizing team member's concerns (P = .02) and checking for acceptance of the plan (P = .02), as well as statistical improvements in 5 self-efficacy measures compared with controls. CONCLUSIONS:Participants exposed to CIVIC demonstrated enhanced conflict communication skills and reported increased self-efficacy compared with controls. VR may be an effective method of conflict communication training.

BACKGROUND Individual children’s hospitals care for a small number of patients with multisystem inflammatory syndrome in children (MIS-C). Administrative databases offer an opportunity to conduct generalizable research; however, identifying patients with MIS-C is challenging. METHODS We developed and validated algorithms to identify MIS-C hospitalizations in administrative databases. We developed 10 approaches using diagnostic codes and medication billing data and applied them to the Pediatric Health Information System from January 2020 to August 2021. We reviewed medical records at 7 geographically diverse hospitals to compare potential cases of MIS-C identified by algorithms to each participating hospital’s list of patients with MIS-C (used for public health reporting). RESULTS The sites had 245 hospitalizations for MIS-C in 2020 and 358 additional MIS-C hospitalizations through August 2021. One algorithm for the identification of cases in 2020 had a sensitivity of 82%, a low false positive rate of 22%, and a positive predictive value (PPV) of 78%. For hospitalizations in 2021, the sensitivity of the MIS-C diagnosis code was 98% with 84% PPV. CONCLUSION We developed high-sensitivity algorithms to use for epidemiologic research and high-PPV algorithms for comparative effectiveness research. Accurate algorithms to identify MIS-C hospitalizations can facilitate important research for understanding this novel entity as it evolves during new waves.

BACKGROUND AND OBJECTIVES Multisystem inflammatory syndrome in children (MIS-C) is a novel, severe condition following severe acute respiratory syndrome coronavirus 2 infection. Large epidemiologic studies comparing MIS-C to Kawasaki disease (KD) and evaluating the evolving epidemiology of MIS-C over time are lacking. We sought to understand the illness severity of MIS-C compared with KD and evaluate changes in MIS-C illness severity over time during the coronavirus disease 2019 pandemic compared with KD. METHODS We included hospitalizations of children with MIS-C and KD from April 2020 to May 2022 from the Pediatric Health Information System administrative database. Our primary outcome measure was the presence of shock, defined as the use of vasoactive/inotropic cardiac support or extracorporeal membrane oxygenation. We examined the volume of MIS-C and KD hospitalizations and the proportion of hospitalizations with shock over time using 2-week intervals. We compared the proportion of hospitalizations with shock in MIS-C and KD patients over time using generalized estimating equations adjusting for hospital clustering and age, with time as a fixed effect. RESULTS We identified 4868 hospitalizations for MIS-C and 2387 hospitalizations for KD. There was a higher proportion of hospitalizations with shock in MIS-C compared with KD (38.7% vs 5.1%). In our models with time as a fixed effect, we observed a significant decrease in the odds of shock over time in MIS-C patients (odds ratio 0.98, P < .001) but not in KD patients (odds ratio 1.00, P = .062). CONCLUSIONS We provide further evidence that MIS-C is a distinct condition from KD. MIS-C was a source of lower morbidity as the pandemic progressed.

Journal of Hospital MedicineVolume 18, Issue 2 p. 163-163 LEADERSHIP & PROFESSIONAL DEVELOPMENT Leadership & professional development: Using our voice to promote and redefine leadership and professional development Karen E. Jerardi MD, Med, Corresponding Author Karen E. Jerardi MD, Med karen.jerardi@cchmc.org orcid.org/0000-0002-3773-8792 @KJerardiMD Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center and University of Cincinnati School of Medicine, Cincinnati, Ohio, USA Correspondence Karen E. Jerardi, MD, Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center and University of Cincinnati School of Medicine, Cincinnati, OH, USA. Email: karen.jerardi@cchmc.org; Twitter: @KJerardiMDSearch for more papers by this authorKimberly D. Manning MD, Kimberly D. Manning MD orcid.org/0000-0002-0521-5583 Emory University School of Medicine, Atlanta, Georgia, USASearch for more papers by this author Karen E. Jerardi MD, Med, Corresponding Author Karen E. Jerardi MD, Med karen.jerardi@cchmc.org orcid.org/0000-0002-3773-8792 @KJerardiMD Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center and University of Cincinnati School of Medicine, Cincinnati, Ohio, USA Correspondence Karen E. Jerardi, MD, Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center and University of Cincinnati School of Medicine, Cincinnati, OH, USA. Email: karen.jerardi@cchmc.org; Twitter: @KJerardiMDSearch for more papers by this authorKimberly D. Manning MD, Kimberly D. Manning MD orcid.org/0000-0002-0521-5583 Emory University School of Medicine, Atlanta, Georgia, USASearch for more papers by this author First published: 30 January 2023 https://doi.org/10.1002/jhm.13049Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume18, Issue2February 2023Pages 163-163 RelatedInformation

Pediatric hospital medicine (PHM) has experienced incredible growth in the last 20 years, including the creation of >50 PHM fellowships since the first program in 2003. In 2013, a National Pediatric Hospital Medicine Leaders Conference concluded that the best path forward for the field would be subspecialty certification with a 2-year accredited fellowship.1 This process culminated in formal recognition of PHM as a subspecialty by the American Board of Medical Specialties in 2016 and the first American Board of Pediatrics (ABP) certification examination in 2019.2,3 Also, in 2019, the Accreditation Council for Graduate Medical Education (ACGME) published requirements for PHM fellowships and began accrediting programs.4 Established PHM fellowships and programs in development now need to implement standardized curricular components to improve the consistency and educational quality of training and be compliant with ACGME accreditation requirements.During the initial period of PHM fellowship expansion, before American Board of Medical Specialties recognition of PHM as a subspecialty, PHM fellowship program directors (PDs) mobilized and formed a national PHM Fellowship Directors’ Council to oversee the evolution of PHM fellowships and provide a community for collaboration and development of shared resources. In 2014, the council created subcommittees to address areas of need within PHM fellowship programs. These included the curriculum subcommittee, which was composed of both new and established PDs as well as 2 community hospitalist representatives, all with specific interest and skills in curriculum development. Between 2014 and 2016, the council, led by the curriculum subcommittee, created a standardized 2-year fellowship curricular framework to reflect the competencies of pediatric hospitalists and meet future board certification requirements.5,6 This curricular framework was developed through an iterative process, with input from stakeholders representing fellowship PDs, fellowship graduates, and leaders in PHM and within medical education at large as well as clinical experts from a variety of practice settings, including community, internal medicine-pediatric, and newborn and/or neonatal hospitalists. The council recognized that, despite the curricular framework, the breadth and depth of PHM could still result in different program areas of emphasis and varied educational experiences. Therefore, the council set out to standardize the goals and objectives for each curricular component so that fellows and program leaders could have a common understanding of the learning goals for each educational experience.In this article, we (1) describe the method by which the council’s curriculum subcommittee developed standardized goals and objectives for PHM fellowship curricular components and (2) discuss how these goals and objectives can be used by programs to guide the education and assessment of fellows.The council has been committed to a scholarly, organized, collaborative method in their process of fellowship curriculum development, and, therefore, Kern et al’s7 Six-Step Approach to curriculum development was used as a guide (Fig 1). For steps 1 and 2, the general and targeted needs assessment, we identified a rationale for our curriculum rooted in patient, institutional, and societal needs, with input from key stakeholders, as previously noted.5,6 Kern et al’s7 step 3, creation of goals and objectives, is crucial in directing choice of curriculum content, identifying effective learning methods, and enabling the evaluation of learners and curriculum.In July 2017, at the annual PHM Fellowship Directors’ Council meeting, the curriculum subcommittee was tasked with developing goals and objectives for each component of its newly proposed 2-year PHM curricular framework. The subcommittee prioritized goals and objectives for the core clinical requirements (hospital medicine, complex care, comanagement, assessment and stabilization of the critically ill child, newborn care, and community hospital medicine) and systems and scholarship requirements (improvement science and patient safety, medical education, leadership, business administration, and advocacy). Curriculum subcommittee members organized into pairs or small groups to address each curriculum component. Clinical and translational research, also a component of the systems and scholarship domain, was addressed separately by the 2019 Pediatric Hospital Medicine Fellowship Research Training Conference, which convened to develop research-specific goals and objectives for PHM fellowships.At the outset of this project, curriculum subcommittee cochairs organized a faculty development session for the subcommittee members regarding the scholarly approach to curriculum design. A curriculum subcommittee member and 1 subcommittee cochair with advanced training and graduate degrees in education reviewed the relationships among competency-based postgraduate medical education, ACGME milestones, and Entrustable Professional Activities (EPAs). Additionally, the session reviewed goals and objectives within the context of Kern et al’s7,8 conceptual framework for curriculum design and Bloom et al’s9,10 taxonomy as a model for classifying cognitive processes of thinking and learning. These educational resources were also made available via shared cloud folders for subcommittee members to reference throughout the process. The curriculum subcommittee cochairs designed a template for each group to use when drafting the goals and objectives (Fig 2). The template was organized by ACGME core competency domains (patient care [PC], medical knowledge [MK], systems-based practice, practice-based learning and improvement, professionalism, and interpersonal and communication skills [ICSs]). Within each core competency, authors defined an overarching goal, followed by individual learning objectives mapped to knowledge-skills-attitude (KSA) domains and subspecialty and/or PHM-specific EPAs. PHM EPAs served as the guide for what should be expected of an independently practicing pediatric hospitalist.11In October 2017, the curriculum subcommittee issued a call for content from the PHM Fellowship Directors’ Council to gather existing goals and objectives from individual institutions (Fig 3). Twenty-three sets of goals and objectives for various PHM fellowship rotations were shared from 12 different PHM fellowship programs across the country. These shared resources, together with the published PHM Core Competencies,5 were used to draft the goals and objectives for each assigned curricular component. First drafts then underwent peer review by another curriculum subcommittee small group (eg, members assigned to work on the hospital medicine rotation reviewed the complex care rotation draft and vice versa). The original small group authors then incorporated suggested edits and forwarded second drafts to current and former leaders within the PHM Fellowship Directors’ Executive Council. The executive council members provided feedback before the 2018 annual PHM Fellowship Directors’ Council meeting.During the July 2018 PHM Fellowship Directors’ Council meeting, the curriculum subcommittee delivered a faculty development session on competency-based medical education and writing effective goals and objectives for all 77 PDs in attendance. The curriculum subcommittee then elicited specific verbal and written feedback on each set of goals and objectives from all the PDs via an evaluation form (Supplemental Information). The evaluation form prompted PDs to review specific characteristics for each objective: SMART format,8 appropriate action verb from Bloom’s taxonomy9, appropriate ACGME core competency, correct KSA designation, and accurate EPA mapping. The form also included free-text options for additional comments and feedback. After the July 2018 PD meeting, the curriculum subcommittee small groups updated their working drafts on the basis of the feedback obtained from the larger PD council.In December 2018, expert reviewers outside the council were identified on the basis of national reputation as a PHM leader or content expertise relevant to a specific curriculum domain (Supplemental Table 1). The expert pool included experienced hospitalists from geographically diverse institutions of varying sizes. In the spring of 2019, each draft of goals and objectives underwent review by at least 2 expert reviewers (with the exception of 1 rotation [care and stabilization of the critically ill child], which only underwent review by 1 expert) to allow for multiple perspectives. After the expert review, the original authors developed their final drafts, which were disseminated to the PHM fellowship PDs at the annual PHM Fellowship Directors’ meeting in July 2019. The final product was a collection of peer-reviewed goals and objectives for the 12 PHM fellowship core components in the proposed curricular framework, mapped to KSA domains and EPAs (see Supplemental Tables 2 through 7 for a sample of hospital medicine goals and objectives). The completed goals and objectives are available in an online repository accessible to all PHM fellowship PDs.We present an innovative, collaborative approach to developing peer-reviewed, evidence-informed curricular goals and objectives for PHM fellowships that align with ACGME Core Competencies, pediatric subspecialty EPAs, and PHM-specific EPAs. Before ABP and ACGME recognition, during a time of rapid growth of our field, the PHM fellowship PDs created a grassroots council to develop resources quickly and methodically, ensuring that PHM fellowship programs are well equipped to train future generations of pediatric hospitalists. Since 2008, the council has committed to collaborating with one another and key stakeholders in the PHM community to establish fellowship standards, with the ultimate goal of producing effective training programs and highly competent pediatric hospitalists. In doing so, the PDs were able to define what training in our specialty should look like, providing recommendations for the ACGME as they defined the formal requirements for PHM training. For example, the 2-year fellowship curriculum the council developed in 2016 was adopted, with few exceptions, as the standard for ACGME program requirements. The council now has standardized goals and objectives for each required curricular component that have been thoroughly vetted by the national PHM Fellowship Directors’ Council as well as other PHM leaders and remain available for any PHM program to use or adapt to meet their program and learner needs. To our knowledge, although pediatric emergency medicine has published their collaborative approach to identifying essential requirements for administrating and managing a pediatric emergency medicine fellowship program,12 no other established subspecialty has committed to standardizing goals and objectives for their fellowship curricula.Previous literature reveals that clear goals and objectives increase the quality of an educational experience, and, therefore, we anticipate that these standardized goals and objectives will serve as a tool to facilitate high-quality educational experiences for fellows.13,14 With the widespread adoption of competency-based medical education and the emergence of EPAs,15 we wanted to ensure our goals and objectives aligned with the ACGME Core Competencies, the PHM Core Competencies,5 and the PHM EPAs.11 EPAs describe what activities clinicians should be trusted to do by integrating multiple competencies,16 translate competencies into clinical practice, and provide more tangible activities that can be observed and evaluated. They also guide evaluation tools and provide an objective map for trainees of how we expect them to apply their training in clinical practice. Mapping the goals and objectives for the ACGME-required curricular elements to the ABP PHM EPAs ensures the curriculum aligns with the competencies expected of a graduating PHM fellow. This process also aided us in staying within the scope of PHM practice and avoiding extraneous expectations for fellows in an already full 2-year curriculum. Having standardized, competency-based goals and objectives is especially important for a relatively young, diverse field to ensure fellows, PDs, and fellowship faculty have a shared understanding of the expectations of trainees.We adhered to an academic approach and completed the first 3 steps in the Six-Step Approach to curriculum development by Kern et al.7 The next 2 steps, educational strategies and implementation, must be addressed by each individual program but can be guided by our shared goals and objectives. The goals and objectives were intended to be broadly applicable and could be implemented by individual programs without modification. However, the curriculum committee recognizes the need to align rotation goals and objectives with program- and institutional-level goals and objectives. Alignment of objectives optimizes the fellows’ educational experience and is required by ACGME. If a program has a focus on a particular clinical condition or a specific approach to delivering care, PHM PDs have the flexibility to add, remove, or modify objectives accordingly. The KSA domain is another area that is easily modifiable. PHM PDs may choose to keep the core content of an objective the same but shift from a knowledge-based to skill-based objective, for example. Educational strategies flow directly from goals and objectives. For the same content area, one program may have a knowledge-based objective, which it addresses through a lecture, whereas another program may have a skills-based objective, which it achieves through simulation.Finally, step 6, evaluation and feedback, will be crucial as fellowship programs implement their curricula. Evaluation will need to occur both at the individual program level and at the national level, which we expect will involve collaboration among the council, ACGME, and ABP. Our hope with curriculum standardization is that we can create high-quality, effective PHM training experiences that produce competent pediatric hospitalists across all fellowship programs and sites. Although we now have the ACGME as an accrediting body tasked with ensuring compliance and monitoring outcomes, the PHM Fellowship Directors’ Council serves an essential role because it continuously reevaluates the fellowship training experience on the basis of real-time feedback from trainees and the field of PHM.We faced challenges when pursuing this project. Although the curriculum subcommittee is composed of PDs with an interest in curriculum development, there were varying levels of experience in writing goals and objectives as well as varying fundamental knowledge about the interplay between competencies and EPAs. We attempted to mitigate this challenge through faculty development sessions, provision of medical education resources, and multifaceted feedback. Coordinating group work remotely and on a national scale was also a challenge, leading to the two-year timespan to complete the first stage of this project. Additionally, owing to the diverse nature of our field and practice settings, we were challenged to balance comprehensiveness with feasibility to attain goals and objectives of reasonable scope. Finally, our process was subject to inherent bias because we were relying on expert consensus, which could be influenced by geographic location, clinical setting, training, and/or work experience by each individual providing input and feedback throughout the process. We attempted to strengthen the validity of consensus via structured, iterative rounds of review with deliberate selection of authors and reviewers to help ensure representation across the PHM field.The PHM Fellowship Directors’ Council curriculum subcommittee plans to use a similar process to create standardized goals and objectives for curricular components falling under individualized curriculum, which includes common electives, such as infectious diseases, sedation, child abuse, and palliative care. Additionally, the ACGME requires that a curriculum must contain competency-based goals and objectives for each educational experience designed to promote progress on a trajectory to autonomous practice in their subspecialty; objectives generally should be delineated on the basis of postgraduate training level.4 In response to this, the curriculum committee has committed to creating tiered goals and objectives by fellowship year for curricular components that span the duration of the two-year fellowship (eg, hospital medicine, complex care, improvement science, and patient safety). In addition, newly published updated PHM Core Competencies17 are available to inform future reiterations of our goals and objectives. Finally, we hope to collaborate with the PHM Fellowship Directors’ assessment committee as they work to develop standardized, competency-based assessment tools that align with our competency-based goals and objectives.With an innovative, collaborative approach, the PHM fellowship PDs have developed a set of standardized goals and objectives for PHM fellowship programs that align with PHM Core Competencies, EPAs, and ACGME requirements and supplement the PHM fellowship curricular framework. We anticipate the goals and objectives will facilitate high-quality educational experiences across fellowship programs, while allowing for adaptation to suit individual program needs.We thank the PHM PDs’ executive council and curriculum subcommittee for their significant contribution to this project: Helen Rhim, Valeriy Chorny, Rebecca Tenney-Soeiro, Nancy Chen, Michelle Hofmann, Allison Markowsky, Scott Carney, Sarah Denniston, Kim O’Hara, Navita Kumar, Joyee Vachani, Tony Tarchichi, Jeremiah Cleveland, Mikelle Key-Solle, Ann Allen, Kathryn McLeod, Nisha Gupta, Rebecca Purtell, Ann Marshburn, Steve Marek, Jeri Kessenich, Erin Knoebel, Miranda Kane, Whitney Browning, Stephen Pishko, Lauren Solan, John Andrake, and Shiela Liewehr.

Journal of Hospital MedicineVolume 16, Issue 4 p. 251-253 Perspectives in Hospital Medicine Striking While the Iron Is Hot: Using the Updated PHM Competencies in Time-Variable Training Benjamin Kinnear MD, MEd, Corresponding Author Benjamin Kinnear MD, MEd kinneabn@ucmail.uc.edu Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OhioCorresponding Author: Benjamin Kinnear, MD, MEd; Email: kinneabn@ucmail.uc.edu; Telephone: 314-541-4667; Twitter: @Midwest_MedPeds.Search for more papers by this authorNivedita Srinivas MD, Nivedita Srinivas MD Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University School of Medicine, Stanford, CaliforniaSearch for more papers by this authorKaren Jerardi MD, MEd, Karen Jerardi MD, MEd Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OhioSearch for more papers by this author Benjamin Kinnear MD, MEd, Corresponding Author Benjamin Kinnear MD, MEd kinneabn@ucmail.uc.edu Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OhioCorresponding Author: Benjamin Kinnear, MD, MEd; Email: kinneabn@ucmail.uc.edu; Telephone: 314-541-4667; Twitter: @Midwest_MedPeds.Search for more papers by this authorNivedita Srinivas MD, Nivedita Srinivas MD Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University School of Medicine, Stanford, CaliforniaSearch for more papers by this authorKaren Jerardi MD, MEd, Karen Jerardi MD, MEd Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OhioSearch for more papers by this author First published: 17 March 2021 https://doi.org/10.12788/jhm.3611Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume16, Issue4April 2021Pages 251-253 RelatedInformation

BACKGROUND:Pediatric hospital medicine (PHM) became a subspecialty of the American Board of Pediatrics (ABP) in 2016. Starting in 2019, residency graduates are required to complete fellowship training to qualify for PHM board eligibility. These requirements pose unique challenges to internal medicine-pediatrics (med-peds) residents interested in practicing combined adult hospital medicine (HM) and PHM. OBJECTIVE:To describe the needs of med-peds residents interested in PHM fellowship training and how the current PHM training environment can meet these needs. METHODS:We conducted two cross-sectional electronic survey studies: one of med-peds residents and one of PHM fellowship program directors (FDs). Surveys were distributed to resident and FD listservs. Questions were designed using an iterative consensus process among authors. Responses were analyzed with descriptive statistics. RESULTS:Four hundred sixty-six residents responded to the resident survey. Ninety-six percent (n = 446) had considered a career in HM. Almost all (n = 456, 97.9%) respondents indicated a preference for a fellowship with both adult HM and PHM clinical training. Subspecialty designation decreased desire to pursue a career including PHM for 90.1% of respondents. Twenty-eight (58.3%) FDs responded to the FD survey. Fifteen (53.6%) programs reported being able to accommodate adult HM and PHM clinical time. CONCLUSION:The majority of resident respondents reported a desire for a PHM fellowship with clinical time in both PHM and adult HM. Approximately 30% of current US PHM fellowship programs can accommodate adult HM practice for med-peds fellows, and many other programs would be willing to explore such opportunities.

BACKGROUND Febrile infants aged 0 to 60 days are often hospitalized for a 36-to-48 hour observation period to rule out invasive bacterial infections (IBI). Evidence suggests that monitoring blood and cerebrospinal fluid (CSF) cultures for 24 hours may be appropriate for most infants. We aimed to decrease the average culture observation time (COT) from 38 to 30 hours among hospitalized infants 0 to 60 days old over 12 months. METHODS This quality improvement initiative occurred at a large children's hospital, in conjunction with development of a multidisciplinary evidence-based guideline for the management of febrile infants. We included infants aged 0 to 60 days admitted with fever without a clear infectious source. We excluded infants who had positive blood, urine, or CSF cultures within 24 hours of incubation and infants who were hospitalized for other indications (eg, bronchiolitis). Interventions included guideline dissemination, education regarding laboratory monitoring practices, standardized order sets, and near-time identification of failures. Our primary outcome was COT, defined as time between initiation of culture incubation and hospital discharge in hours. Interventions were tracked on an annotated statistical process control chart. Our balancing measure was identification of IBI after hospital discharge. RESULTS In our cohort of 184 infants aged 0 to 60 days, average COT decreased from 38 hours to 32 hours after structured guideline dissemination and order-set standardization; this decrease was sustained over 17 months. IBI was not identified in any patients after discharge. CONCLUSIONS Implementation of an evidence-based guideline through education, transparency of laboratory procedures, creation of standardized order sets, and near-time feedback was associated with shorter COT for febrile infants aged 0 to 60 days.

We read with interest “A Changing Landscape: Understanding Resident Perspectives on Pursuing Pediatric Hospital Medicine Fellowships.”1 The publication is timely, given the recent designation of Pediatric Hospital Medicine (PHM) as a subspecialty by the American Board of Medical Specialties and the American Board of Pediatrics (ABP), as well as initial accreditation of PHM fellowships by the Accreditation Council for Graduate Medical Education. Through this commentary, we seek to discuss the study findings and highlight the current landscape of PHM fellowship training as influenced by the PHM fellowship curricular framework, the ABP PHM subboard content, and the newly revised PHM Core Competencies. The authors sought to characterize categorical pediatric and combined pediatric residents’ perceptions of PHM fellowships, including barriers and facilitators to pursuing such training. In 2018, an anonymous online survey was sent to residency program directors and 23% agreed to distribute the survey. A total of 2657 residents were surveyed; 32.2% (855) responded. Study findings suggest that although many residents saw value in PHM fellowships, they also reported concerns. A majority of respondents cited potential for higher future earnings and opportunity to gain new skills in both clinical and scholarly domains as important factors encouraging them to pursue fellowship. Specifically, half of respondents stated that they would value training in each of the following areas: medical education, quality improvement, hospital administration, research, and clinical medicine. However, a majority reported that they were “somewhat” or “less likely” to pursue a position in PHM after PHM fellowship became required for board eligibility. Personal and financial factors, including family obligations, forfeited earnings while in fellowship, and existing educational debt, influenced the decision to pursue fellowship for some. The authors …

Laboratory results were notable for normal white blood cell and platelet counts and a metabolic panel with normal sodium and albumin. In fl ammatory markers were elevated with a C-reactive protein (CRP) level of 14 mg/dL, an erythrocyte sedimentation rate (ESR) of 110 mm/hour, and mild elevations of ferritin, D-dimer, and fi brinogen levels. The patient ’ s troponin level was within normal limits, and his B-type natriuretic peptide (BNP) level was mildly elevated. A urinalysis was notable for small protein, negative nitrite results, small leukocyte esterase, and 30 to 50 white blood cells per high-powered fi eld. A blood culture, a urine culture, and serologies for SARS-CoV-2 were obtained.

Pediatric hospital medicine (PHM) is the newest recognized subspecialty in pediatrics within the United States. While fellowships in PHM have been available for several years, completion of a 2-year fellowship has become a requirement for subspecialty certification. Pediatric hospitalists provide substantial teaching to trainees, and therefore, PHM fellowships must include dedicated training around teaching and medical education. The purpose of this study was to determine how current PHM fellowships prepare graduates for their roles as medical educators. Two surveys were developed from the published PHM core competencies and Entrustable Professional Activities for pediatric subspecialties. One survey was disseminated to all active PHM program directors and the second was disseminated to all PHM fellowship graduates who completed training between 2012 and 2016. Items included those related to program structure and training/assessment in medical education. A total of 21 program directors (response rate = 58%) and 46 fellowship graduates (response rate = 46%) participated in the survey. All graduates (100%) reported teaching learners in their current setting. Many (67%) fellowship programs offered formal training in medical education, and this is greater than the 50% that was previously described. Direct observation (71%) was the most common method of assessment. Most graduates reported their fellowship provided optimal training in feedback and teaching during family centered rounds but suboptimal training in other skills such as curriculum development. The results of this study highlight areas for improvement in fellowship curriculum and assessment to better prepare fellows for their roles as educators.

Journal of Hospital MedicineVolume 15, Issue 7 p. 443-444 Editorial Defining Competence in the Evolving Field of Pediatric Hospital Medicine Meghan L Fanta MD, Corresponding Author Meghan L Fanta MD meghan.fanta@cchmc.org Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio University of Cincinanati College of Medicine, Cincinnati, OhioCorresponding Author: Meghan Fanta, MD; Email: meghan.fanta@cchmc.org; Telephone: 513-803-4829; Twitter: @meghanfanta.Search for more papers by this authorJacqueline M Walker MD, MHPE, Jacqueline M Walker MD, MHPE Division of Hospital Medicine, Children's Mercy Kansas City, Kansas City, MissouriSearch for more papers by this authorKaren E Jerardi MD, MEd, Karen E Jerardi MD, MEd Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio University of Cincinanati College of Medicine, Cincinnati, OhioSearch for more papers by this author Meghan L Fanta MD, Corresponding Author Meghan L Fanta MD meghan.fanta@cchmc.org Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio University of Cincinanati College of Medicine, Cincinnati, OhioCorresponding Author: Meghan Fanta, MD; Email: meghan.fanta@cchmc.org; Telephone: 513-803-4829; Twitter: @meghanfanta.Search for more papers by this authorJacqueline M Walker MD, MHPE, Jacqueline M Walker MD, MHPE Division of Hospital Medicine, Children's Mercy Kansas City, Kansas City, MissouriSearch for more papers by this authorKaren E Jerardi MD, MEd, Karen E Jerardi MD, MEd Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio University of Cincinanati College of Medicine, Cincinnati, OhioSearch for more papers by this author First published: 01 July 2020 https://doi.org/10.12788/jhm.3404Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume15, Issue7July 2020Pages 443-444 RelatedInformation

Journal of Hospital MedicineVolume 15, Issue 5 p. 308-310 Perspectives in Hospital Medicine Pediatric Hospital Medicine Management, Staffing, and Well-being in the Face of COVID-19 Katie A Meier MD, Corresponding Author Katie A Meier MD [email protected] Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OhioCorresponding Author: Katie Meier, MD; Email: [email protected]; Telephone: 513-803-9177; Twitter: @KMeierMD.Search for more papers by this authorKaren E Jerardi MD, MEd, Karen E Jerardi MD, MEd Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OhioSearch for more papers by this authorAngela M Statile MD, MEd, Angela M Statile MD, MEd Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OhioSearch for more papers by this authorSamir S Shah MD, MSCE, MHM, Samir S Shah MD, MSCE, MHM Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio Division of Infectious Disease, Cincinnati Children's Hospital Medical Center, Cincinnati, OhioSearch for more papers by this author Katie A Meier MD, Corresponding Author Katie A Meier MD [email protected] Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OhioCorresponding Author: Katie Meier, MD; Email: [email protected]; Telephone: 513-803-9177; Twitter: @KMeierMD.Search for more papers by this authorKaren E Jerardi MD, MEd, Karen E Jerardi MD, MEd Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OhioSearch for more papers by this authorAngela M Statile MD, MEd, Angela M Statile MD, MEd Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OhioSearch for more papers by this authorSamir S Shah MD, MSCE, MHM, Samir S Shah MD, MSCE, MHM Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio Division of Infectious Disease, Cincinnati Children's Hospital Medical Center, Cincinnati, OhioSearch for more papers by this author First published: 14 April 2020 https://doi.org/10.12788/jhm.3435Citations: 21Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat No abstract is available for this article. References 1 World Health Organization. Coronavirus disease 2019 (COVID-19) Situation Report - 51. [Situation Report]. 2020. https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200311-sitrep-51-covid-19. Accessed March 26, 2020. Google Scholar 2 Centers for Disease Control and Prevention. Interim Guidance for Healthcare Facilities: Preparing for Community Transmission of COVID-19 in the United States. 2020. https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/guidance-hcf.html. Accessed March 27, 2020. Google Scholar 3Dong Y, Mo X, Hu Y, et al. Epidemiological characteristics of 2143 pediatric patients with 2019 coronavirus disease in China. Pediatrics. 2020. https://doi.org/10.1542/peds.2020-0702. 10.1542/peds.2020?0702 Google Scholar 4Cruz A, Zeichner S. COVID-19 in children: initial characterization of pediatric disease. Pediatrics. 2020;e20200834. https://doi.org/10.1542/peds.2020-0834. 10.1542/peds.2020?0834 Google Scholar 5Wu Z, McGoogan J. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention. JAMA. 2020. https://doi.org/10.1001/jama.2020.2648. 10.1001/jama.2020.2648 Google Scholar 6 James M Anderson Center of Health Systems Excellence. The Power of Learning Networks. https://www.cincinnatichildrens.org/research/divisions/j/anderson-center/learning-networks. Accessed April 2, 2020. Google Scholar 7Lai J, Ma S, Wang Y, et al. Factors Associated With Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease 2019. JAMA Netw Open. 2020; 3(3):e203976. https://doi.org/10.1001/jamanetworkopen.2020.3976. 10.1001/jamanetworkopen.2020.3976 PubMedWeb of Science®Google Scholar Citing Literature Volume15, Issue5May 2020Pages 308-310 ReferencesRelatedInformation

As health care delivery in America evolves to meet new complex demands, hospital medicine (HM) has become one of the fastest-growing specialties.1 With expanding workforce needs, the role of the advanced practice provider (APP) has evolved to meet increasing inpatient demands. The addition of APPs to adult HM teams has been described in the literature dating back to the 1990s, revealing that APPs provide a significant portion of medical services in many different settings, including HM.2–4 Because less information is known about the role of APPs in pediatric hospital medicine (PHM), we seek to describe the current state of PHM APPs and the potential positive effects that collaboration between physicians and APPs may have on the care of hospitalized children.The health care workforce composition has been changing over the last several years in response to many factors, including resident work hour reductions and projected physician shortages.5 The passage of the Patient Protection and Affordable Care Act of 2010, which created an increased demand for primary care providers and offered incentives to expand APP training programs, has resulted in an increasing number of APP graduates.6 The number of APPs per 100 physicians increased from 15.3 in 2001 to 28.2 in 2016. This trend is expected to continue, with a projection of 53.9 APPs per 100 physicians by 2030.7The field of PHM has mirrored this trend, with 41.7% of PHM divisions reporting working with APPs in 2018 compared with 33.3% in 2016. This use is still significantly smaller than adult HM groups, with 76.8% of adult HM groups and 78.6% of mixed pediatric and adult groups reporting working with APPs.8 It is anticipated that as the population of hospitalized pediatric patients with complex medical needs grows, so will the demand for pediatric hospitalists, expanding opportunities for collaboration with APPs.There are currently >270 000 licensed nurse practitioners (NPs) in the United States.9 The educational pathway for NP training begins with licensure as a registered nurse (RN), with undergraduate education and clinical training to become a generalist nurse after graduation (frequently as a bachelor of science degree in nursing, although one can also obtain a postgraduate master of science degree in nursing). RNs who subsequently train as NPs can remain generalists (eg, family NP) or may specialize in their area of experience (eg, pediatric nurse practitioner [PNP]).10 Minimum practice requirements to enter an NP program vary from no experience to ≥2 years of direct patient care. NP programs of all specialty types vary in length, from a 1-year intensive didactic and clinical program to up to 3 years, which may include earning a doctor of nursing practice degree.11 Once the program is completed, graduates must pass a national certifying examination and obtain additional licensure by their state board of nursing.12Specific NP certifications designating areas of clinical expertise first emerged in the 1970s with development of pediatric and adult acute care certifications in the 1990s to early 2000s.13 Currently, PNPs must choose between primary care or acute care certification.10 The 2012 Consensus Model for Advanced Practice Registered Nurse Regulation recommends pediatric acute care certification for NPs working in PHM.12 The training for this certification focuses on rapidly changing conditions in children who are acutely and critically ill or children with medical complexity.10 In contrast, the primary care certification focuses on long-term patient relationships to provide comprehensive care of complex and chronic conditions. Although NPs with primary care–focused certifications are not prohibited from practicing in PHM, additional training may be required.11,12There are currently >131 000 certified physician assistants (PAs) in the United States, with a small minority (1.9%) working in pediatrics. According to combined data for adult and pediatric practice, 3.5% of PAs report working in HM.14 Incoming PA students must have completed a bachelor's degree, and many programs require health care experience with hands-on patient care. A typical PA program extends over 27 continuous months, providing generalist training.15 Coursework in basic medical sciences is followed by clinical rotations in both medical and surgical disciplines, including family medicine, internal medicine, general surgery, pediatrics, obstetrics and gynecology, emergency medicine, and psychiatry. By graduation, PA students have completed at least 2000 hours of supervised clinical practice.15 PAs must pass the Physician Assistant National Certifying Exam and complete state licensure to practice.Although PAs are not required to specialize, they may choose to obtain a certification of added qualification (CAQ) in one of several specialties, including pediatrics.14 The pediatrics CAQ process requires continuing medical education focused on pediatrics practice, at least 4000 hours of pediatrics clinical experience, and passage of the pediatrics specialty examination.16 Training requirements for NPs, PAs, and physicians are depicted in Table 1.In recent studies, researchers have evaluated outcomes related to APP involvement in PHM. In 1 study comparing care provided by an independent PNP service, a physician and PNP team, and a physician and resident team for patients admitted with uncomplicated bronchiolitis, pneumonia, and asthma, the authors found no significant difference in length of stay (LOS) or adherence to clinical guidelines. Costs of care were significantly less on the independent PNP service.17 In another study comparing patient outcomes on PHM services staffed by a physician and resident team and a physician and PNP team, the authors found shorter LOS, fewer readmissions, and decreased costs on the physician and PNP team, with no statistical difference in PICU transfers between the 2 groups.18 In addition to these potential patient care advantages, physicians working with APPs report positive effects as well. Integrating APPs into resident teams can allow resident physicians to better balance patient care with protected time for education.19 APPs can serve as role models and educators for physician trainees and other members of the interprofessional team.20 This growing body of literature points to many potential advantages and opportunities for collaboration between APPs and PHM physicians.As with any significant change in health care, challenges exist when a program begins to incorporate APPs into PHM practice. During NP training, although clear educational standards for academic learning exist, there are fewer stipulations on the setting of clinical rotations. NPs graduate with a variety of hands-on training experiences that may not be specific to HM. Likewise, because PAs are trained as medical generalists, graduates may require additional training when starting a career in PHM. Although PA programs require the same core clinical rotations, graduates often have varying levels of experience based on chosen elective rotations.Recognizing the need for additional postgraduate training, programs began developing NP fellowships for a variety of specialties. Programs typically range from 6 to 12 months and allow NPs to gain additional clinical experience in their specialty of focus through mentored opportunities. Although most NP fellowships target adult specialties, pediatric postgraduate fellowships are becoming more common.21,22 Specific to HM, in a recent survey of program directors, researchers identified 11 postgraduate fellowships for APPs, mostly in adult programs; only 1 PHM APP fellowship was identified.23Because formal postgraduate training remains uncommon in PHM, consideration should be made for individual needs assessments, coupled with an appropriate orientation period to inform clear educational goals designed to meet each APP's training needs. In addition to an appreciation of the education needs of newly hired APPs, programs should be aware of individual state practice and licensure laws and billing requirements. As with all staffing decisions, workforce hiring and retainment, duty hours, and costs are additional considerations.As the field of PHM continues to grow, and the number of APP graduates increases, there will be more opportunities for collaboration with APPs in PHM. Although more research to fully characterize the scope of APP practice in PHM is needed, in newer studies, researchers indicate that involving APPs in PHM may help decrease LOS and costs, enhance patient safety, improve coordination of care, and increase staff satisfaction,17,18 indicating that positive changes and enhancements to care delivery can occur when physicians and APPs collaborate in the care of hospitalized children.

OBJECTIVE:Competency-based training should be paired with objective assessments. To date, there has been limited objective assessment of resident-as-teacher curricula (RATC). We sought to assess the impact of a longitudinal RATC on postgraduate year-1 (PGY1) resident teaching competency using Observed Structured Teaching Encounters (OSTEs) for the skills of 1) brief didactic teaching [DT], 2) feedback [FB], and 3) precepting [PR]. METHODS:A controlled, prospective, educational study was conducted from May 2015 to June 2016. The RATC consisted of a workshop series with reinforcement of key skills (DT, FB) during clinical rotations. Intervention residents participated in the RATC and completed OSTEs at the beginning and end of the academic year. A control group, PGY1 residents that matriculated the year previously, completed the OSTEs before starting their PGY2 year. OSTEs were reviewed by 2 blinded study personnel. We assessed reliability between raters via intraclass correlation coefficients and differences in OSTE scores via least squared mean differences (LSMD). RESULTS:In total, 92.5% (n = 37) of eligible control and 100% (n = 41) of eligible intervention residents participated. The OSTEs demonstrated excellent agreement between reviewers (DT: 0.99, FB: 0.89, PR: 0.98). A significant pre-post difference was demonstrated in the intervention group for DT (LSMD [95% confidence interval], 3.14 [2.49-3.79], P < .0001), FB (0.93 [0.49-1.37], P < .0001), and PR (0.64 [0.09-1.18], P < .022). A significant difference between the control and intervention groups was demonstrated for DT (3.00 [2.05-3.96], P < .0001). CONCLUSIONS:Skill-based OSTEs can be used to detect changes in residents' teaching competency and may represent a potential component of programmatic evaluation of resident-as-teacher curricula.

BACKGROUND AND OBJECTIVES:Workflow inefficiencies by medical teams caring for hospitalized patients may affect patient care and team experience. At our institution, complexity and clinical volume of the pediatric hospital medicine (HM) service have increased over time; however, efficient workflow expectations were lacking. We aimed to increase the percentage of HM teams meeting 3 efficiency criteria (70% nurses present for rounds, rounds completed by 11:30 am, and HM attending notes completed by 5 pm) from 28% to 80% within 1 year.METHODS:Improvement efforts targeted 5 HM teams at a large academic hospital. Our multidisciplinary team, including HM attending physicians, pediatric residents, and nurses, focused on several key drivers: shared expectations, enhanced physician and nursing buy-in and communication, streamlined rounding process, and data transparency. Interventions included (1) daily rounding expectations with prerounds huddle, (2) visible reminders, (3) complex care team scheduled rounds, (4) real-time nurse notification of rounds via electronic platform, (5) workflow redesign, (6) attending feedback and data transparency, and (7) resource attending implementation. Attending physicians entered efficiency data each day through a Research Electronic Data Capture survey. Annotated control charts were used to assess the impact of interventions over time.RESULTS:Through sequential interventions, the percentage of HM teams meeting all 3 efficiency criteria increased from 28% to 61%. Nursing presence on rounds improved, and rounds end time compliance remained high, whereas attending note completion time remained variable.CONCLUSIONS:Inpatient workflow for pediatric providers was improved by setting clear expectations and enhancing team communication; competing demands while on service contributed to difficulty in improving timely attending note completion.

Transition of care from the intensive care unit (ICU) to the ward is usually an indication of the patient's improving clinical status, but is also a time when patients are particularly vulnerable. The transition between care teams poses a higher risk of medical error, which can be mitigated by safe and complete patient handoff and medication reconciliation. ICU readmissions are associated with increased mortality as well as ICU and hospital length of stay (LOS); however tools to accurately predict ICU readmission risk are limited. While there are many mechanisms in place to carefully identify patients appropriate for transfer to the ward, the optimal timing of transfer can be affected by ICU strain, limited resources such as ICU beds, and overall hospital capacity and flow leading to suboptimal transfer times or delays in transfer. The patient and family perspectives should also be considered when planning for transfer from the ICU to the ward. During times of transition, families will meet a new care team, experience uncertainty of future care plans, and adjust to a different daily routine which can lead to increased stress and anxiety. Additionally, a subset of patients, such as those with new technology, require additional multidisciplinary support, education and care coordination which can contribute to longer hospital LOS if not addressed proactively early in the hospitalization while the patient remains in the ICU. In this review article, we describe key components of the transfer from ICU to the ward, discuss current strategies to optimize timing of patient transfers, explore strategies to partner with patients and families during the transfer process, highlight patient populations where additional considerations are needed, and identify future areas of exploration which could improve the care transition from the ICU to the ward.