Priorities for Pediatric Patient Safety Research

Infection Associated With Invasive Devices in Pediatric Health Care: A Meta-analysis

CONTEXT

Indwelling invasive devices inserted into the body for extended are associated with infections.

OBJECTIVE

This study aimed to estimate infection proportion and rates associated with invasive devices in pediatric healthcare.

DATA SOURCES

Medline, CINAHL, Embase, Web of Science, Scopus, Cochrane CENTRAL, clinical trial registries, and unpublished study databases were searched.

STUDY SELECTION

Cohort studies and trials published from January 2011 to June 2022, including (1) indwelling invasive devices, (2) pediatric participants admitted to a hospital, (3) postinsertion infection complications, and (4) published in English, were included.

DATA EXTRACTION

Meta-analysis of observational studies in epidemiology guidelines for abstracting and assessing data quality and validity were used.

MAIN OUTCOMES AND MEASURES

Device local, organ, and bloodstream infection (BSIs) pooled proportion and incidence rate (IR) per-1000-device-days per device type were reported.

RESULTS

A total of 116 studies (61 554 devices and 3 632 364 device-days) were included. The highest number of studies were central venous access devices associated BSI (CVAD-BSI), which had a pooled proportion of 8% (95% confidence interval [CI], 6-11; 50 studies) and IR of 0.96 per-1000-device-days (95% CI, 0.78-1.14). This was followed by ventilator-associated pneumonia in respiratory devices, which was 19% (95% CI, 14-24) and IR of 14.08 per-1000-device-days (95%CI, 10.57-17.58).

CONCLUSIONS

Although CVAD-BSI and ventilator associated pneumonia are well-documented, there is a scarcity of reporting on tissue and local organ infections. Standard guidelines and compliance initiatives similar to those dedicated to CVADs should be implemented in other devices in the future.

Navigating quality and safety in your health system: understanding the alphabet soup

Entering any new healthcare system today requires thorough knowledge about its quality and safety structure and culture. Learning that language is generally the first step in gaining a better understanding of how systems function. This overview of common mnemonics in the quality and safety world will provide the reader with better comprehension of their quality systems within their institutions. Healthcare providers should understand how patient safety organizations were established and the importance of our safety event classification system, along with the ability to recognize gaps in care that highlight opportunities for improvement. In addition, this review provides explanations of error prevention tools used every day to help new colleagues communicate better and share situational awareness to keep patients safe. Lastly, utilization of standard quality improvement tools can facilitate quality improvement projects and assist all healthcare systems to become highly reliable organizations.

Journey to STEEEP healthcare: A focus on systems through a patient's experience

Healthcare systems continue to struggle with providing safe, timely, effective, efficient, equitable and patient-centered (STEEEP) care. Upon audit by clinicians, treatment processes such as those completed following clinical pathways appear to manage care safely. However, when reviewing the treatment process through the patient and/or their family's lens, the experience is quite different. This article will use a vignette detailing care provided in a primary care physician's office along with the patient's outpatient testing experience to reveal opportunities for improvement, a glimpse into the patient's experience and share methods for achieving STEEEP healthcare.

Family role in paediatric safety incidents: a retrospective study protocol

INTRODUCTION

Healthcare-associated harm is an international public health issue. Children are particularly vulnerable to this with 15%-35% of hospitalised children experiencing harm during medical care. While many factors increase the risk of adverse events, such as children's dependency on others to recognise illness, children have a unique protective factor in the form of their family, who are often well placed to detect and prevent unsafe care. However, families can also play a key role in the aetiology of unsafe care.We aim to explore the role of families, guardians and parents in paediatric safety incidents, and how this may have changed during the pandemic, to learn how to deliver safer care and codevelop harm prevention strategies across healthcare settings.

METHODS AND ANALYSIS

This will be a retrospective study inclusive of an exploratory data analysis and thematic analysis of incident report data from the Learning from Patient Safety Events service (formerly National Reporting and Learning System), using the established PatIent SAfety classification system. Reports will be identified by using specific search terms, such as *parent* and *mother*, to capture narratives with explicit mention of parental involvement, inclusive of family members with parental and informal caregiver responsibilities.Paediatricians and general practitioners will characterise the reports and inter-rater reliability will be assessed. Exploratory descriptive analysis will allow the identification of types of incidents involving parents, contributing factors, harm outcomes and the specific role of the parents including inadvertent contribution to or mitigation of harm.

ETHICS AND DISSEMINATION

This study was approved by Cardiff University Research Ethics Committee (SMREC 22/32). Findings will be submitted to a peer-reviewed journal, presented at international conferences and presented at stakeholder workshops.

Developing a machine learning model to detect diagnostic uncertainty in clinical documentation

BACKGROUND AND OBJECTIVE

Diagnostic uncertainty, when unrecognized or poorly communicated, can result in diagnostic error. However, diagnostic uncertainty is challenging to study due to a lack of validated identification methods. This study aims to identify distinct linguistic patterns associated with diagnostic uncertainty in clinical documentation.

DESIGN, SETTING AND PARTICIPANTS

This case-control study compares the clinical documentation of hospitalized children who received a novel uncertain diagnosis (UD) diagnosis label during their admission to a set of matched controls. Linguistic analyses identified potential linguistic indicators (i.e., words or phrases) of diagnostic uncertainty that were then manually reviewed by a linguist and clinical experts to identify those most relevant to diagnostic uncertainty. A natural language processing program categorized medical terminology into semantic types (i.e., sign or symptom), from which we identified a subset of these semantic types that both categorized reliably and were relevant to diagnostic uncertainty. Finally, a competitive machine learning modeling strategy utilizing the linguistic indicators and semantic types compared different predictive models for identifying diagnostic uncertainty.

RESULTS

Our cohort included 242 UD-labeled patients and 932 matched controls with a combination of 3070 clinical notes. The best-performing model was a random forest, utilizing a combination of linguistic indicators and semantic types, yielding a sensitivity of 89.4% and a positive predictive value of 96.7%.

CONCLUSION

Expert labeling, natural language processing, and machine learning methods combined with human validation resulted in highly predictive models to detect diagnostic uncertainty in clinical documentation and represent a promising approach to detecting, studying, and ultimately mitigating diagnostic uncertainty in clinical practice.

Parent Perception of Child Safety following Admission to a Neonatal Unit

OBJECTIVE

Parent partnership is a key aspect of neonatal hospital care. However, there is a lack of information regarding parents' perception of neonatal safety. This study explores parents' opinions on safety during their child's hospitalization to identify points for improvement.

STUDY DESIGN

We used a questionnaire, validated by the Spanish National Healthcare Authorities, on perception of safety with respect to hospital health care.

RESULTS

Thirty-seven parents of 20 newborns treated in the neonatal intensive care unit (NICU) and 139 parents of newborns in intermediate care (IC) participated in this study. With regard to overall perception of safety, more than 96% of parents felt "very safe" or "fairly safe." In the NICU, an area for improvement detected was to ask parents more often their opinion about the care or treatment provided to their child. In IC, three points for improvement were identified from the group of parents whose child was admitted directly to IC: the consistency of the information received, the request for consent for procedures, and the request for an opinion on their child's care and treatment. Only four parents reported that their child suffered an incident. Regarding incident management, parents were not completely satisfied with the information they received.

CONCLUSION

To the best of our knowledge, this is the first study of parent perception of patient safety in a neonatal unit using a validated questionnaire. Our findings suggest that parents can provide valuable information on neonatal safety, which can then be used to identify areas for improvement.

KEY POINTS

· There is a lack of information regarding parents' perception of neonatal safety.. · This study explores parent's opinion about safety of their child during the hospitalization.. · Our findings suggest that parents can provide valuable information to identify improvement areas..

A Customized Triggers Program: A Children's Hospital's Experience in Improving Trigger Usability

BACKGROUND

Despite the growth of patient safety programs across the United States, errors and adverse events remain a source of patient harm. Many hospitals rely on retrospective voluntary reporting systems; however, there are opportunities to improve patient safety using novel tools like trigger programs.

METHODS

Children's National Hospital developed a unique pediatric triggers program that offers customized, near real-time reports of potential safety events. Our team defined a measure to quantify clinical utility of triggers, termed "trigger signal," as the percentage of cases that represent true adverse or near-miss events (numerator) per total triggers activated (denominator). Our key driver diagram focused on unifying the program structure, increasing data analytics, promoting organizational awareness, and supporting multidisciplinary end user engagement. Using the model for improvement, we aimed to double overall trigger signal from 8% to 16% and sustain for 12 months.

RESULTS

The trigger signal increased from 8% to 41% and sustained during the coronavirus disease 2019 pandemic. A balancing measure of time to implement a new trigger decreased. Key interventions to increase trigger signal were change in the program structure, increasing stakeholder engagement, and development of self-service reports for end users.

CONCLUSIONS

Children's National Hospital's triggers program highlights successful evolution of an iterative, customized approach to increase clinical utility that hospitals can implement to impact real-time patient care. This triggers program requires an iterative, customized approach rather than a "1-size-fits-all," static paradigm to add a new dimension to current patient safety programs.

Identifying research priorities with children, youth, and families: A scoping review

Increased patient advocacy has resulted in a shift toward more active patient engagement in the research. A scoping review was conducted to explore the literature on healthcare research priority settings wherein children, youths, or their families were involved in the priority-setting process. Six databases including MEDLINE, CINAHL, PsycINFO, Embase, Web of Science, and Global Health and the James Lind Alliance website were searched up until September 2019. All primary studies involving children (<18 years of age) or families in developing research priorities in health care were included. All retrieved references were uploaded into Covidence, and two independent reviewers screened the search results. Descriptive thematic analysis was used to identify common themes. A total of 30 studies with 4247 participants were included. Less than half of the participants (n = 1237, (33%) were pediatric patients and their families. A total of 455 research priorities were identified. Three common themes emerged: (i) quality of care delivery, (ii) self-efficacy in health behaviors, and (iii) community engagement in care. This scoping review revealed priority research health topics from the perspectives of children, youths, or their families. The findings may be used as a foundation for future research to improve the health outcomes of children, youths, or their families according to their identified priorities.

Diagnosis Code and Health Care Utilization Patterns Associated With Diagnostic Uncertainty

BACKGROUND AND OBJECTIVES

Diagnostic uncertainty is challenging to identify and study in clinical practice. This study compares differences in diagnosis code and health care utilization between a unique cohort of hospitalized children with uncertain diagnoses (UD) and matched controls.

PATIENTS AND METHODS

This case-control study was conducted at Cincinnati Children's Hospital Medical Center. Cases were defined as patients admitted to the pediatric hospital medicine service and having UDs during their hospitalization. Control patients were matched on age strata, biological sex, and time of year. Outcomes included type of diagnosis codes used (ie, disease- or nondisease-based) and change in code from admission to discharge. Differences in diagnosis codes were evaluated using conditional logistic regression. Health care utilization outcomes included hospital length of stay (LOS), hospital transfer, consulting service utilization, rapid response team activations, escalation to intensive care, and 30-day health care reutilization. Differences in health care utilization were assessed using bivariate statistics.

RESULTS

Our final cohort included 240 UD cases and 911 matched controls. Compared with matched controls, UD cases were 8 times more likely to receive a nondisease-based diagnosis code (odds ratio [OR], 8.0; 95% confidence interval [CI], 5.7-11.2) and 2.5 times more likely to have a change in their primary International Classification of Disease, 10th revision, diagnosis code between admission and discharge (OR, 2.5; 95% CI, 1.9-3.4). UD cases had a longer average LOS and higher transfer rates to our main hospital campus, consulting service use, and 30-day readmission rates.

CONCLUSIONS

Hospitalized children with UDs have meaningfully different patterns of diagnosis code use and increased health care utilization compared with matched controls.

Children's falls inside the inpatient setting: A qualitative study of parent perceptions and the implications for falls prevention messaging

PURPOSE

To explore how parents understand their children's falls during hospitalization and how they perceive hospital interventions and messaging related to fall risk and prevention.

DESIGN AND METHODS

Semi-structured interviews were conducted to explore parent-caregiver descriptions of their children's falls during hospitalization. Prospective purposive sampling was used to identify eligible participants. Interviews were conducted with the parent-caregiver who was present at the time of the fall event. Themes were coded both inductively and deductively using a constant comparative method.

RESULTS

Twelve parent-child groupings participated. Three themes emerged: parental knowledge of risk, parent sense of threat to the identity of the child, and age differences in perception of level of controllability of risk.

CONCLUSIONS

Falls prevention education is usually delivered as a straightforward presentation of generic factual information about risk factors, with the assumption that families need more information. Findings from this study challenge this approach. This study indicates that parent-caregivers have fairly high levels of knowledge about children's fall risks; parent-caregiver beliefs about the controllability of falls may differ based on age of the child; finally, as has been found in previous studies of adult falls, parent-caregivers may perceive hospital falls prevention measures as a source of potential threat to their child''s already vulnerable social identity.

PRACTICE IMPLICATIONS

Involving the parent-caregiver in the fall risk assessment and collaborative development of falls prevention interventions may increase family alliance with health advice and reduce the incidence of falls in hospitalized children.

Electronic surveillance of patient safety events using natural language processing

Objective

We describe our approach to surveillance of reportable safety events captured in hospital data including free-text clinical notes. We hypothesize that a) some patient safety events are documented only in the clinical notes and not in any other accessible source; and b) large-scale abstraction of event data from clinical notes is feasible.

Materials and Methods

We use regular expressions to generate a training data set for a machine learning model and apply this model to the full set of clinical notes and conduct further review to identify safety events of interest. We demonstrate this approach on peripheral intravenous (PIV) infiltrations and extravasations (PIVIEs).

Results

During Phase 1, we collected 21,362 clinical notes, of which 2342 were reviewed. We identified 125 PIV events, of which 44 cases (35%) were not captured by other patient safety systems. During Phase 2, we collected 60,735 clinical notes and identified 440 infiltrate events. Our classifier demonstrated accuracy above 90%.

Conclusion

Our method to identify safety events from the free text of clinical documentation offers a feasible and scalable approach to enhance existing patient safety systems. Expert reviewers, using a machine learning model, can conduct routine surveillance of patient safety events.

Quality measurement and surveillance platforms in critically ill children: A scoping review

BACKGROUND/AIM

The objective of this study was to describe current surveillance platforms which support routine quality measurement in paediatric critical care.

METHOD

Scoping review. The search strategy consisted of a traditional database and grey literature search as well as expert consultation. Surveillance platforms were eligible for inclusion if they collected measures of quality in critically ill children.

RESULTS

The search strategy identified 21 surveillance platforms, collecting 57 unique outcome (70%), process (23%), and structural (7%) quality measures. Hospital-associated infections were the most commonly collected outcome measure across all platforms (n = 11; 52%). In general, case definitions were not harmonised across platforms, with the exception of nationally mandated hospital-associated infections (e.g., central line-associated blood stream infection). Data collection relied on manual coding. Platforms typically did not provide an evidence-based rationale for measures collected, with no identifiable reports of co-designed, consensus-derived measures or consumer involvement in measure selection or prioritisation.

CONCLUSIONS

Quality measurement in critically ill children lacks uniformity in definition which limits local and international benchmarking. Current surveillance activities for critically ill children focus heavily on outcome measurement, with process, structural, and patient-reported measures largely overlooked. Long-term outcome measures were not routinely collected. Harmonisation of paediatric intensive care unit quality measures is needed and can be achieved using prioritisation and consensus/co-design methods.

Patient, Caregiver, and Clinician Participation in Prioritization of Research Questions in Pediatric Hospital Medicine

IMPORTANCE

The research agenda in pediatric hospital medicine has seldom considered the perspectives of young people, parents and caregivers, and health care professionals. Their perspectives may be useful in identifying questions on topics for research.

OBJECTIVE

To prioritize unanswered research questions in pediatric hospital medicine from the perspectives of young people, parents/caregivers, and health care professionals.

DESIGN, SETTING, AND PARTICIPANTS

Between August 4, 2020, and August 19, 2021, two online surveys and a virtual workshop were conducted, using modified Delphi technique and nominal group technique. Young people, parents/caregivers, and health care professionals with experiences in pediatric hospital medicine in Canada were included.

INTERVENTIONS

The established James Lind Alliance Priority Setting Partnership method was used. In phase 1, a survey collected unanswered questions regarding pediatric hospital medicine via 3 open-ended questions. Survey responses were used to develop summary questions that went through an evidence-checking process. Unanswered questions were brought to a phase 2 interim prioritization survey. The top 10 unanswered research questions in pediatric hospital medicine were established at the final priority setting workshop.

MAIN OUTCOMES AND MEASURES

Survey responses, top 10 research questions.

RESULTS

The phase 1 survey was completed by 188 participants (148 of 167 [89%] females; 17 of 167 [10%] males; mean [SD] age, 39.5 [12.4] years) and generated 495 unanswered research questions and comments, of which 58 were deemed out of scope. The remaining 437 responses were grouped into themes (eg, communication, shared decision-making, health service delivery, and health service management) and then refined to 75 unanswered research questions. Of these 75, only 4 questions had sufficient evidence. To make the number of questions in phase 2 manageable, 21 questions submitted by only 1 respondent were eliminated. Fifty unanswered research questions were included in the phase 2 survey, which was completed by 201 participants (165 of 186 [89%] females; 19 of 186 [10%] males; mean [SD] age, 40.0 [11.0] years). A short list of 16 questions-the top 10 questions from patient partners (youths, parents/caregivers) and clinicians-was presented at the final priority setting workshop and the top 10 questions were prioritized. The top 10 questions focused on the care of special inpatient populations (eg, children with medical complexity), communication, shared decision-making, support strategies in the hospital, mental health supports, shortening length of stay, and supporting Indigenous patients, parents/caregivers, and families.

CONCLUSIONS AND RELEVANCE

This patient-oriented pediatric hospital medicine priority setting partnership identified the most important unanswered research questions focused on the care of children in the hospital. These questions provide a possible roadmap for research on areas deemed important to young people, parents/caregivers, and clinicians.

Diagnostic Error in Pediatrics: A Narrative Review

A priority topic for patient safety research is diagnostic errors. However, despite the significant growth in awareness of their unacceptably high incidence and associated harm, a relative paucity of large, high-quality studies of diagnostic error in pediatrics exists. In this narrative review, we present what is known about the incidence and epidemiology of diagnostic error in pediatrics as well as the established research methods for identifying, evaluating, and reducing diagnostic errors, including their strengths and weaknesses. Additionally, we highlight that pediatric diagnostic error remains an area in need of both innovative research and quality improvement efforts to apply learnings from a rapidly growing evidence base. We propose several key research questions aimed at addressing persistent gaps in the pediatric diagnostic error literature that focus on the foundational knowledge needed to inform effective interventions to reduce the incidence of diagnostic errors and their associated harm. Additional research is needed to better establish the epidemiology of diagnostic error in pediatrics, including identifying high-risk clinical scenarios, patient populations, and groups of diagnoses. A critical need exists for validated measures of both diagnostic errors and diagnostic processes that can be adapted for different clinical settings and standardized for use across varying institutions. Pediatric researchers will need to work collaboratively on large-scale, high-quality studies to accomplish the ultimate goal of reducing diagnostic errors and their associated harm in children by addressing these fundamental gaps in knowledge.

Pediatric Trainee Perspectives on the Decision to Disclose Medical Errors

PURPOSE

The aim of the study was to describe factors that may impact pediatric trainees' willingness to disclose medical errors using clinical vignettes.

METHODS

A single-center cross-sectional anonymous survey of pediatric residents and fellows at a large urban medical center in 2019 was conducted. Trainees were provided with clinical vignettes depicting an error resulting in a serious safety event (SSE), minor safety event (MSE), and near miss safety event (NMSE) and were asked to classify the type of safety event and rate and explain their agreement or disagreement with disclosure. Survey items also evaluated trainees' personal experiences with errors and disclosure. Descriptive and correlational analyses were used to characterize responses. Qualitative content from open-ended survey questions was analyzed using the constant comparative method.

RESULTS

Of 126 trainees, 42 (33%) completed the survey. All agreed with disclosing the hypothetical error presented in the vignette resulting in an SSE (100%), with rates falling for the MSE (95%) and NMSE (7%). There were no significant associations between disclosure agreement for the vignettes and trainee demographic features, knowledge of safety events, prior personal experiences with errors, and disclosure. Four themes that emerged from qualitative analysis of trainees' rationales for disclosure or nondisclosure of the vignette errors are harm, parental preferences, ethical principles, and anticipatory guidance.

CONCLUSIONS

Trainees had high rates of disclosure for the vignette errors cases that depicted SSEs and MSEs but lower rates for NMSEs. Trainees considered the type and level of harm caused, parental preferences, upholding ethical principles, and the need for anticipatory guidance in their rationales for disclosure or nondisclosure of the vignette errors.

Research priorities for children with neurological impairment and medical complexity in high-income countries

AIM

To identify the highest-priority clinical research areas related to children with neurological impairment and medical complexity among clinicians and caregivers.

METHOD

A modified, three-stage Delphi study using online surveys and guided by a steering committee was completed. In round 1, clinicians and family caregivers suggested clinical topics and related questions that require research to support this subgroup of children. After refinement of the suggestions by the steering committee, participants contributed to 1 (family caregivers) or 2 (clinicians) subsequent rounds to develop a prioritized list.

RESULTS

A diverse international expert panel consisting of 49 clinicians and 12 family caregivers provided 601 responses. Responses were distilled into 26 clinical topics comprising 126 related questions. The top clinical topics prioritized for research were irritability and pain, child mental health, disorders of tone, polypharmacy, sleep, aspiration, behavior, dysautonomia, and feeding intolerance. The clinician expert panel also prioritized 10 specific research questions.

INTERPRETATION

Study findings support a research agenda for children with neurological impairment and medical complexity focused on addressing clinical questions, prioritized by an international group of clinicians and caregivers.

Diagnostic error in the pediatric hospital: a narrative review

INTRODUCTION

Diagnostic error is a prevalent type of medical error that is associated with considerable patient harm and increased medical costs. The majority of literature guiding the current understanding of diagnostic error in the hospital setting is from adult studies. However, there is research to suggest this type of error is also prevalent in the pediatric specialty.

OBJECTIVES

The primary objective of this study was to define the current understanding of diagnostic error in the pediatric hospital through a structured literature review.

METHODS

We searched PubMed and identified studies focusing on three aspects of diagnostic error in pediatric hospitals: the incidence or prevalence, contributing factors, and related interventions. We used a tiered review, and a standardized electronic form to extract data from included articles.

RESULTS

Fifty-nine abstracts were screened and 23 full-text studies were included in the final review. Seventeen of the 23 studies focused on the incidence or prevalence, with only 3 studies investigating the utility of interventions. Most studies took place in an intensive care unit or emergency department with very few studies including only patients on the general wards. Overall, the prevalence of diagnostic error in pediatric hospitals varied greatly and depended on the measurement technique and specific hospital setting. Both healthcare system factors and individual cognitive factors were found to contribute to diagnostic error, with there being limited evidence to guide how best to mitigate the influence of these factors on the diagnostic process.

CONCLUSION

The general knowledge of diagnostic error in pediatric hospital settings is limited. Future work should incorporate structured frameworks to measure diagnostic errors and examine clinicians' diagnostic processes in real-time to help guide effective hospital-wide interventions.

Evaluation of an Educational Outreach and Audit and Feedback Program to Reduce Continuous Pulse Oximetry Use in Hospitalized Infants With Stable Bronchiolitis: A Nonrandomized Clinical Trial

IMPORTANCE

National guidelines recommend against continuous pulse oximetry use for hospitalized children with bronchiolitis who are not receiving supplemental oxygen, yet guideline-discordant use remains high.

OBJECTIVES

To evaluate deimplementation outcomes of educational outreach and audit and feedback strategies aiming to reduce guideline-discordant continuous pulse oximetry use in children hospitalized with bronchiolitis who are not receiving supplemental oxygen.

DESIGN, SETTING, AND PARTICIPANTS

A nonrandomized clinical single-group deimplementation trial was conducted in 14 non-intensive care units in 5 freestanding children's hospitals and 1 community hospital from December 1, 2019, through March 14, 2020, among 847 nurses and physicians caring for hospitalized children with bronchiolitis who were not receiving supplemental oxygen.

INTERVENTIONS

Educational outreach focused on communicating details of the existing guidelines and evidence. Audit and feedback strategies included 2 formats: (1) weekly aggregate data feedback to multidisciplinary teams with review of unit-level and hospital-level use of continuous pulse oximetry, and (2) real-time 1:1 feedback to clinicians when guideline-discordant continuous pulse oximetry use was discovered during in-person data audits.

MAIN OUTCOMES AND MEASURES

Clinician ratings of acceptability, appropriateness, feasibility, and perceived safety were assessed using a questionnaire. Guideline-discordant continuous pulse oximetry use in hospitalized children was measured using direct observation of a convenience sample of patients with bronchiolitis who were not receiving supplemental oxygen.

RESULTS

A total of 847 of 1193 eligible clinicians (695 women [82.1%]) responded to a Likert scale-based questionnaire (71% response rate). Most respondents rated the deimplementation strategies of education and audit and feedback as acceptable (education, 435 of 474 [92%]; audit and feedback, 615 of 664 [93%]), appropriate (education, 457 of 474 [96%]; audit and feedback, 622 of 664 [94%]), feasible (education, 424 of 474 [89%]; audit and feedback, 557 of 664 [84%]), and safe (803 of 847 [95%]). Sites collected 1051 audit observations (range, 47-403 per site) on 709 unique patient admissions (range, 31-251 per site) during a 3.5-month period of continuous pulse oximetry use in children with bronchiolitis not receiving supplemental oxygen, which were compared with 579 observations (range, 57-154 per site) from the same hospitals during the baseline 4-month period (prior season) to determine whether the strategies were associated with a reduction in use. Sites conducted 148 in-person educational outreach and aggregate data feedback sessions and provided real-time 1:1 feedback 171 of 236 times (72% of the time when guideline-discordant monitoring was identified). Adjusted for age, gestational age, time since weaning from supplemental oxygen, and other characteristics, guideline-discordant continuous pulse oximetry use decreased from 53% (95% CI, 49%-57%) to 23% (95% CI, 20%-25%) (P < .001) during the intervention period. There were no adverse events attributable to reduced monitoring.

CONCLUSIONS AND RELEVANCE

In this nonrandomized clinical trial, educational outreach and audit and feedback deimplementation strategies for guideline-discordant continuous pulse oximetry use among hospitalized children with bronchiolitis who were not receiving supplemental oxygen were positively associated with clinician perceptions of feasibility, acceptability, appropriateness, and safety. Evaluating the sustainability of deimplementation beyond the intervention period is an essential next step.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04178941.

Identifying Conditions With High Prevalence, Cost, and Variation in Cost in US Children's Hospitals

IMPORTANCE

Identifying high priority pediatric conditions is important for setting a research agenda in hospital pediatrics that will benefit families, clinicians, and the health care system. However, the last such prioritization study was conducted more than a decade ago and used International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes.

OBJECTIVES

To identify conditions that should be prioritized for comparative effectiveness research based on prevalence, cost, and variation in cost of hospitalizations using contemporary data at US children's hospitals.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study of children with hospital encounters used data from the Pediatric Health Information System database. Children younger than 18 years with inpatient hospital encounters at 45 tertiary care US children's hospitals between January 1, 2016, and December 31, 2019, were included. Data were analyzed from March 2020 to April 2021.

MAIN OUTCOMES AND MEASURES

The condition-specific prevalence and total standardized cost, the corresponding prevalence and cost ranks, and the variation in standardized cost per encounter across hospitals were analyzed. The variation in cost was assessed using the number of outlier hospitals and intraclass correlation coefficient.

RESULTS

There were 2 882 490 inpatient hospital encounters (median [interquartile range] age, 4 [1-12] years; 1 554 024 [53.9%] boys) included. Among the 50 most prevalent and 50 most costly conditions (total, 74 conditions), 49 (66.2%) were medical, 15 (20.3%) were surgical, and 10 (13.5%) were medical/surgical. The top 10 conditions by cost accounted for $12.4 billion of $33.4 billion total costs (37.4%) and 592 815 encounters (33.8% of all encounters). Of 74 conditions, 4 conditions had an intraclass correlation coefficient (ICC) of 0.30 or higher (ie, major depressive disorder: ICC, 0.49; type 1 diabetes with complications: ICC, 0.36; diabetic ketoacidosis: ICC, 0.33; acute appendicitis without peritonitis: ICC, 0.30), and 9 conditions had an ICC higher than 0.20 (scoliosis: ICC, 0.27; hypertrophy of tonsils and adenoids: ICC, 0.26; supracondylar fracture of humerus: ICC, 0.25; cleft lip and palate: ICC, 0.24; acute appendicitis with peritonitis: ICC, 0.21). Examples of conditions high in prevalence, cost, and variation in cost included major depressive disorder (cost rank, 19; prevalence rank, 10; ICC, 0.49), scoliosis (cost rank, 6; prevalence rank, 38; ICC, 0.27), acute appendicitis with peritonitis (cost rank, 13; prevalence rank, 11; ICC, 0.21), asthma (cost rank, 10; prevalence rank, 2; ICC, 0.17), and dehydration (cost rank, 24; prevalence rank, 8; ICC, 0.18).

CONCLUSIONS AND RELEVANCE

This cohort study found that major depressive disorder, scoliosis, acute appendicitis with peritonitis, asthma, and dehydration were high in prevalence, costs, and variation in cost. These results could help identify where future comparative effectiveness research in hospital pediatrics should be targeted to improve the care and outcomes of hospitalized children.

Health Literacy-Related Safety Events: A Qualitative Study of Health Literacy Failures in Patient Safety Events

Introduction

Communication failures are the leading root cause of safety events. Although much communication research focuses on the healthcare team, there is little focus on communication with patients and families. It is not known what deficits in health literate patient communication lead to patient safety events. We aimed to identify themes of health literacy-related safety events to describe the impact of health literate communication on patient safety.

Methods

The safety events were entered into a system-wide self-reported safety event collection database. A patient safety specialist trained in health literacy prospectively tagged events for health literacy. The authors retrospectively queried the database for all health literacy tagged events during 9 months (September 2017-May 2018). The authors reviewed and independently coded health literacy-associated safety events. Qualitative content analysis of events facilitated by software (NVivo) was completed to identify the health literacy-related safety event themes.

Results

Health literacy events comprised 4% (152/3911) of self-reported safety events during the 9 months. Main themes of the health literacy safety events related to (1) medication; (2) system processes; and (3) discharge/transition. Subthemes of each of the events further described the event types. Health literacy-associated safety events encompass all safety event outcomes (near miss, precursor, and serious safety events).

Conclusions

Health literacy-related safety events occur in the healthcare environment. This review characterizing health literacy-related safety events prioritizes areas to implement health literate safety practices. Many opportunities exist to address communication-related safety events around medication, system processes, and discharge using health literate best practices.

Health Measurement Model-Bringing a Life Course Perspective to Health Measurement: The PRISM Model

Health is a multidimensional concept that is challenging to measure, and in the rapidly evolving developmental changes that occur during the first 21 years of human life, requires a dynamic approach to accurately capture the transitions, and overall arc of a complex process of internal and external interactions. We propose an approach that integrates a lifecourse framework with a layered series of assessments, each layer using a many to many mapping, to converge on four fundamental dimensions of health measurement-Potential, Adaptability, Performance, and Experience. The four dimensions can conceptually be mapped onto a plane with each edge of the resulting quadrilateral corresponding to one dimension and each dimensions assessment calibrated against a theoretical ideal. As the plane evolves over time, the sequential measurements will form a volume. We term such a model the Prism Model, and describe conceptually how single domain assessments can be built up to generate the holistic description through the vehicle of a layer of Exemplar Cases. The model is theoretical but future work can use the framework and principles to generate scalable and adaptable applications that can unify and improve the precision of serial measurements that integrate environmental and physiologic influences to improve the science of child health measurement.

Increasing Physician Reporting of Diagnostic Learning Opportunities

BACKGROUND

An estimated 10% of Americans experience a diagnostic error annually, yet little is known about pediatric diagnostic errors. Physician reporting is a promising method for identifying diagnostic errors. However, our pediatric hospital medicine (PHM) division had only 1 diagnostic-related safety report in the preceding 4 years. We aimed to improve attending physician reporting of suspected diagnostic errors from 0 to 2 per 100 PHM patient admissions within 6 months.

METHODS

Our improvement team used the Model for Improvement, targeting the PHM service. To promote a safe reporting culture, we used the term diagnostic learning opportunity (DLO) rather than diagnostic error, defined as a "potential opportunity to make a better or more timely diagnosis." We developed an electronic reporting form and encouraged its use through reminders, scheduled reflection time, and monthly progress reports. The outcome measure, the number of DLO reports per 100 patient admissions, was tracked on an annotated control chart to assess the effect of our interventions over time. We evaluated DLOs using a formal 2-reviewer process.

RESULTS

Over the course of 13 weeks, there was an increase in the number of reports filed from 0 to 1.6 per 100 patient admissions, which met special cause variation, and was subsequently sustained. Most events (66%) were true diagnostic errors and were found to be multifactorial after formal review.

CONCLUSIONS

We used quality improvement methodology, focusing on psychological safety, to increase physician reporting of DLOs. This growing data set has generated nuanced learnings that will guide future improvement work.

Quality Improvement Incorporating a Feedback Loop for Accurate Medication Reconciliation

OBJECTIVES

Medication reconciliation errors on hospital admission can lead to significant patient harm. A pediatric intermediate care unit initiated a quality improvement project and aimed to reduce errors in admission medication reconciliation by 50% in 12 months.

METHODS

From August 2017 to December 2018, a multidisciplinary team conducted a quality improvement project with plan-do-study-act methodology. Continuous data collection was achieved by reviewing medications with home caregivers within 18 hours of admission to identify errors. Cycle 1 consisted of nursing training in accurate and thorough medication history documentation. Cycle 2 was aimed at improving data collection. Cycle 3 was aimed at improving pediatric housestaff processes for medication reconciliation. In cycle 4 intervention, the reconciliation process was redesigned to incorporate the bedside nurse reviewing final medication orders with the patient's home caregivers once the medication reconciliation process was complete. Intermittent maintenance data collection continued for 12 months thereafter.

RESULTS

Cycle 1 and 2 interventions resulted in improvement in the medication reconciliation error rate from 9.8% to 4.7%. In cycle 2, the data collection rate improved from 61% to 80% of admissions sustained. Cycle 3 resulted in a further reduction in the medication error rate to 2.9%, which was sustained in cycle 4 and over the 12-month maintenance period. A patient's number of home medications did not correlate with the error rate.

CONCLUSIONS

Reductions in admission medication reconciliation errors can be achieved with staff education on medication history and process for medication reconciliation and with process redesign that incorporates active medication order review as a closed-loop communication with home caregivers.

Prioritized Agenda for Mental Health Research in Pediatric Rheumatology from the Childhood Arthritis and Rheumatology Research Alliance Mental Health Workgroup

OBJECTIVE

Mental health problems are prevalent in youth with rheumatologic disease. Gaps in knowledge exist regarding their effect, as well as strategies for detection and effective treatment. To address these gaps, the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Mental Health Workgroup developed and prioritized an agenda of research topics.

METHODS

We systematically reviewed the literature and identified 5 major research domains in further need of study: (A) mental health burden and relationship to pediatric rheumatologic disease, (B) effect of mental health disorders on outcomes, (C) mental health awareness and education, (D) mental health screening, and (E) mental health treatment. Research topics within these areas were developed by workgroup leaders and refined by the workgroup. Members were surveyed to prioritize the topics by importance, feasibility of study, and actionability.

RESULTS

Fifty-nine members (57%) completed the survey. Among the proposed research topics, 31/33 were rated as highly important and 4/33 were rated highly for importance, feasibility, and actionability. Topics rated most important related to (A) mental health burden and relationship to rheumatologic disease, and (B) the effect of mental health on outcomes. Topics rated most feasible and actionable were related to (D) mental health screening.

CONCLUSION

Addressing gaps in knowledge regarding mental health in youth with rheumatologic disease is essential for improving care. We have identified high priority research topics regarding mental health of pediatric rheumatology patients in need of further investigation that are feasible to study and believed to lead to actionable results in patient care.

Patient Safety in Ambulatory Pediatrics

Purpose of Review

The majority of patient care occurs in the ambulatory setting, and pediatric patients are at high risk of medical error and harm. Prior studies have described various safety threats in ambulatory pediatrics, and little is known about effective strategies to minimize error. The purpose of this review is to identify best practices for optimizing safety in ambulatory pediatrics.

Recent Findings

The majority of the patient safety literature in ambulatory pediatrics describes frequencies and types of medical errors. Study of effective interventions to reduce error, and particularly to reduce harm, have been limited. There is evidence that medical complexity and social context are important modifiers of risk. Telemedicine has emerged as a care delivery model with potential to ameliorate and exacerbate safety threats. Though there is variation across studies, developing a safety culture, partnerships with patients and families, and use of structured communication are strategies that support patient safety.

Summary

There is no standardized taxonomy for errors in ambulatory pediatrics, but errors related to medications, vaccines, diagnosis, and care coordination and care transitions are commonly described. Evidence-based approaches to optimize safety include standardized prescribing and medication reconciliation practices, appropriate use of decision support tools in the electronic health record, and communication strategies like teach-back. Further high-quality intervention studies in pediatric ambulatory care that assess impact on patient harm and clinical outcomes should be prioritized.

Patient safety incidents reported by relatives of hospitalized children

OBJECTIVE

To know the main safety incidents reported by relatives of patients hospitalized in pediatric units.

METHODS

This is a qualitative research with exploratory-descriptive design. Data were collected between April 2016 and December 2017, in three hospitals in Porto Alegre/RS. A total of 91 semi-structured interviews were conducted with relatives of pediatric patients hospitalized in emergencies, infirmaries, and intensive care centers. The statements were transcribed in full and submitted to a thematic content analysis.

RESULTS

The category Identification of safety incidents by relatives of hospitalized pediatric patients was formulated. Eight subtopics emerged: drug therapy, hand and environment hygiene, diet therapy, risk of falls, communication, patient identification, care processes/procedures and access to the institution.

CONCLUSIONS

The family identified safety incidents in various stages of care for hospitalized children. It is necessary to think about strategies that integrate the family in the care of children, to minimize risks and complications resulting from care.

Apparent Cause Analysis: A Safety Tool

Causal analysis is a core function of safety programs. Although established protocols exist for conducting root cause analysis for serious safety events, there is limited guidance for apparent cause analysis (ACA) in health care. At our institution, through a novel facilitated ACA approach, we aim to improve safety culture and provide a clear approach to address precursor safety events and near-miss safety events. We define facilitated ACA as limited investigation (scope and duration) of a safety event that resulted in little to no harm. These investigations require fewer resources and focus on preventive strategies. Our facilitated ACA model, with an operational algorithm and structured process, was developed and implemented at our tertiary-care, freestanding, urban pediatric hospital in 2018. Sixty-four ACAs were completed, and 83% were identified with the algorithm. Process measures, including time from event reporting to ACA launch (median 3 days; interquartile range 2-6 days), are tracked. Patient safety consultants averaged 5 hours to complete a facilitated ACA. A median of 3 disciplines or departments participated in each facilitated ACA. Through an iterative process, we implemented a structured process for facilitated ACA, and the model's strength includes (1) right event, (2) right team, (3) right analysis, and (4) right action plans. This novel facilitated ACA model may support organizational cause analysis and improve safety culture with higher-reliability processes.

Development and Validation of a Predictive Model of the Risk of Pediatric Septic Shock Using Data Known at the Time of Hospital Arrival

OBJECTIVE

To derive and validate a model of risk of septic shock among children with suspected sepsis, using data known in the electronic health record at hospital arrival.

STUDY DESIGN

This observational cohort study at 6 pediatric emergency department and urgent care sites used a training dataset (5 sites, April 1, 2013, to December 31, 2016), a temporal test set (5 sites, January 1, 2017 to June 30, 2018), and a geographic test set (a sixth site, April 1, 2013, to December 31, 2018). Patients 60 days to 18 years of age in whom clinicians suspected sepsis were included; patients with septic shock on arrival were excluded. The outcome, septic shock, was systolic hypotension with vasoactive medication or ≥30 mL/kg of isotonic crystalloid within 24 hours of arrival. Elastic net regularization, a penalized regression technique, was used to develop a model in the training set.

RESULTS

Of 2464 included visits, septic shock occurred in 282 (11.4%). The model had an area under the curve of 0.79 (0.76-0.83) in the training set, 0.75 (0.69-0.81) in the temporal test set, and 0.87 (0.73-1.00) in the geographic test set. With a threshold set to 90% sensitivity in the training set, the model yielded 82% (72%-90%) sensitivity and 48% (44%-52%) specificity in the temporal test set, and 90% (55%-100%) sensitivity and 32% (21%-46%) specificity in the geographic test set.

CONCLUSIONS

This model estimated the risk of septic shock in children at hospital arrival earlier than existing models. It leveraged the predictive value of routine electronic health record data through a modern predictive algorithm and has the potential to enhance clinical risk stratification in the critical moments before deterioration.

Rapid response in the COVID-19 pandemic: a Delphi study from the European Pediatric Dialysis Working Group

BACKGROUND

COVID-19 was declared a global health emergency. Since children are less than 1% of reported cases, there is limited information to develop evidence-based practice recommendations. The objective of this study was to rapidly gather expert knowledge and experience to guide the care of children with chronic kidney disease during the COVID-19 pandemic.

METHODS

A four-round multi-center Delphi exercise was conducted among 13 centers in 11 European countries of the European Pediatric Dialysis Working Group (EPDWG) between March, 16th and 20th 2020. Results were analyzed using a mixed methods qualitative approach and descriptive statistics.

RESULTS

Thirteen COVID-19 specific topics of particular need for guidance were identified. Main themes encompassed testing strategies and results (n = 4), changes in use of current therapeutics (n = 3), preventive measurements of transmission and management of COVID-19 (n = 3), and changes in standard clinical care (n = 3). Patterns of center-specific responses varied according to regulations and to availability of guidelines.

CONCLUSIONS

As limited quantitative evidence is available in real time during the rapid spread of the COVID-19 pandemic, qualitative expert knowledge and experience represent the best evidence available. This Delphi exercise demonstrates that use of mixed methodologies embedded in an established network of experts allowed prompt analysis of pediatric nephrologists' response to COVID-19 during this fast-emerging public health crisis. Such rapid sharing of knowledge and local practices is essential to timely and optimal guidance for medical management of specific patient groups in multi-country health care systems such as those of Europe and the US.