Objective To improve outpatient advanced care planning (ACP) for adults with congenital/pediatric heart disease followed in a pediatric heart failure (HF) and transplant clinic through quality improvement (QI) methodology. Design A one-year QI project was completed. We conducted quarterly chart reviews and incorporated feedback from the providers to direct subsequent interventions. Patients and Setting Patients ≥18 years of age seen in the HF and Transplant Clinic for follow-up visit were included in analysis. Interventions Interventions focused on five main areas: identifying and training providers to have ACP discussions, standardizing the ACP discussion, standardizing ACP and advance directive (AD) documentation in the electronic medical record, preparing providers to have ACP conversations, and preparing patients to engage in ACP and AD completion. Outcome Measures The outcome measure was percent of adults seen in the HF and Transplant Clinic per month with documented AD (goal 50%). The process measure was percent of adults seen in the HF and Transplant Clinic per month with a documented ACP discussion (goal 100%). Results At baseline, no patients had a documented ACP discussion or AD. Fifty-eight adults (mean age 20.4 ± 2.1 years) were seen from March 2016 to February 2017 for a total of 130 visits. In the final month of our study, 75% of adult encounters had a documented ACP discussion and 42% had a documented AD. Conclusions The percentage of documented ADs in adults seen in the HF and Transplant Clinic at a quaternary children's hospital improved through a QI initiative. Over 50% of patients who were engaged in an ACP discussion completed an AD, suggesting this population is receptive to ACP and AD completion.

Kombucha, a domesticated consortium of several microorganisms grown on sugared tea, has been valued as a nutritive health aid for over a millennium. In this study, three cultures of kombucha were obtained from diverse sources. Different inoculation methods were compared, and the wet and dry weights of the nascent pellicles were measured when cultured on several carbon sources. In addition, the anti-bacterial properties of the fermented kombucha teas were tested against Escherichia coli and Staphylococcus epidermis. Inoculation with macerated pellicles gave the fastest kombucha growth. The best carbon sources for growth of the nascent kombucha pellicles were sucrose, glucose, and fructose. On maltose, galactose, and lactose, not only did the kombucha pellicles grow poorly but 25% were also contaminated by common airborne molds. Good growth of the kombucha cultures was correlated with low pH of the fermented tea. Antibacterial effects of concentrated fermented teas and vinegar were similar to those of 1 mmol ampicillin against Escherichia coli or 0.01 mmol penicillin against Staphylococcus epidermis. When the pH of concentrated kombucha teas was neutralized, their bactericidal effects were no better than unfermented controls.

Background: Implicit bias pervades health care, decreases quality of care, and disproportionately affects health outcomes for persons of color. Little is known about the use of biased language in the care of seriously ill children as documented in the electronic health record (EHR). Objective: To describe the use of biased language in the EHR of critically ill pediatric patients and to assess if there is a difference based on patient demographics and clinical characteristics. Setting/Participants: A retrospective review of EHRs was conducted on patients admitted to a Pediatric Intensive Care Unit (PICU) with a palliative care consult at a large, urban academic center in the United States in 2019. Measurements: Demographics and clinical characteristics were compared between patients with and without biased language in their EHR in univariate and multivariate analyses. Frequencies of descriptor usage and health care team members using the descriptor were recorded. Exemplar quotes using biased language were recorded. Results: In 63 patients, no differences were found in demographic or clinical characteristics between patients with and without positively and negatively biased language. In adjusted analysis, there was no effect of demographics or clinical characteristics on the odds of having at least 1 instance of negatively biased language. Physicians and social workers used more biased language than other health care team members. Conclusion: Despite no statistically significant difference noted in this pilot study, linguistic biases exist in the EHR of seriously ill children, which may lead to testimonial injustice. Efforts to combat bias and racism in pediatric health care documentation may focus on revising note templates and educating across disciplines.

To complete the curriculum, learners rotating through a pediatric palliative care service are asked to submit a piece of reflective writing. Here, we share an edited version of the narrative one student submitted, accompanied by a brief consideration of the numerous benefits of reflective writing for medical trainees (including improved communication and professionalism skills, as well as increased levels of empathy and comfort when facing complex or difficult situations). Additionally, we describe how brief personal narratives may serve to reduce common misconceptions and confusion by educating patients, families, and clinicians about the reality and the role of pediatric palliative care.