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Tchou MJ, Hall M, Markham JL, Stephens JR, Steiner MJ, McCoy E, Aronson PL, Shah SS, Molloy MJ, Cotter JM. Changing patterns of routine laboratory testing over time at children's hospitals. J Hosp Med 2024. [PMID: 38643414 DOI: 10.1002/jhm.13372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 03/19/2024] [Accepted: 04/09/2024] [Indexed: 04/22/2024]
Abstract
BACKGROUND Research into low-value routine testing at children's hospitals has not consistently evaluated changing patterns of testing over time. OBJECTIVES To identify changes in routine laboratory testing rates at children's hospitals over ten years and the association with patient outcomes. DESIGN, SETTINGS, AND PARTICIPANTS We performed a multi-center, retrospective cohort study of children aged 0-18 hospitalized with common, lower-severity diagnoses at 28 children's hospitals in the Pediatric Health Information Systems database. MAIN OUTCOMES AND MEASURES We calculated average annual testing rates for complete blood counts, electrolytes, and inflammatory markers between 2010 and 2019 for each hospital. A > 2% average testing rate change per year was defined as clinically meaningful and used to separate hospitals into groups: increasing, decreasing, and unchanged testing rates. Groups were compared for differences in length of stay, cost, and 30-day readmission or ED revisit, adjusted for demographics and case mix index. RESULTS Our study included 576,572 encounters for common, low-severity diagnoses. Individual hospital testing rates in each year of the study varied from 0.3 to 1.4 tests per patient day. The average yearly change in hospital-specific testing rates ranged from -6% to +7%. Four hospitals remained in the lowest quartile of testing and two in the highest quartile throughout all ten years of the study. We grouped hospitals with increasing (8), decreasing (n = 5), and unchanged (n = 15) testing rates. No difference was found across subgroups in costs, length of stay, 30-day ED revisit, or readmission rates. Comparing resource utilization trends over time provides important insights into achievable rates of testing reduction.
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Affiliation(s)
- Michael J Tchou
- Department of Pediatrics, Section of Hospital Medicine, University of Colorado-Anschutz Medical Center and Children's Hospital Colorado, Aurora, Colorado, USA
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas, USA
| | - Jessica L Markham
- Department of Pediatrics, Children's Mercy Kansas City and University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - John R Stephens
- North Carolina Children's Hospital and School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Michael J Steiner
- North Carolina Children's Hospital and School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Elisha McCoy
- Department of Internal Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Department of General Pediatrics, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Paul L Aronson
- Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Samir S Shah
- Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
| | - Matthew J Molloy
- Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
| | - Jillian M Cotter
- Department of Pediatrics, Section of Hospital Medicine, University of Colorado-Anschutz Medical Center and Children's Hospital Colorado, Aurora, Colorado, USA
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李 正. [Significance and application of quality improvement in clinical medicine]. Zhongguo Dang Dai Er Ke Za Zhi 2024; 26:219-223. [PMID: 38557371 PMCID: PMC10986376 DOI: 10.7499/j.issn.1008-8830.2309009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 01/08/2024] [Indexed: 04/04/2024]
Abstract
Quality improvement is a methodology which was initially developed and employed in the field of industrial manufacturing. This approach involves implementing a series of interventions aimed at elevating the existing quality standards to a higher level. In daily medical work, there are often spontaneous quality improvements. Medical quality improvements supported by scientific methodology can evaluate medical quality more scientifically and provide objective feedback on the quality of medical work for healthcare professionals. This article provides a concise introduction to quality improvement and shows its application and significance in the field of clinical medicine through examples.
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Ropers FG, Rietveld S, Rings EHHM, Bossuyt PMM, van Bodegom-Vos L, Hillen MA. Diagnostic testing in children: A qualitative study of pediatricians' considerations. J Eval Clin Pract 2023; 29:1326-1337. [PMID: 37221991 DOI: 10.1111/jep.13867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/02/2023] [Accepted: 05/04/2023] [Indexed: 05/25/2023]
Abstract
AIMS AND OBJECTIVES Studies in adult medicine have shown that physicians base testing decisions on the patient's clinical condition but also consider other factors, including local practice or patient expectations. In pediatrics, physicians and parents jointly decide on behalf of a (young) child. This might demand more explicit and more complex deliberations, with sometimes conflicting interests. We explored pediatricians' considerations in diagnostic test ordering and the factors that influence their deliberation. METHOD We performed in-depth, semistructured interviews with a purposively selected heterogeneous sample of 20 Dutch pediatricians. We analyzed transcribed interviews inductively using a constant comparative approach, and clustered data across interviews to derive common themes. RESULTS Pediatricians perceived test-related burden in children higher compared with adults, and reported that avoiding an unjustified burden causes them to be more restrictive and deliberate in test ordering. They felt conflicted when parents desired testing or when guidelines recommended diagnostic tests pediatricians perceived as unnecessary. When parents demanded testing, they would explore parental concern, educate parents about harms and alternative explanations of symptoms, and advocate watchful waiting. Yet they reported sometimes performing tests to appease parents or to comply with guidelines, because of feared personal consequences in the case of adverse outcomes. CONCLUSION We obtained an overview of the considerations that are weighed in pediatric test decisions. The comparatively strong focus on prevention of harm motivates pediatricians to critically appraise the added value of testing and drivers of low-value testing. Pediatricians' relatively restrictive approach to testing could provide an example for other disciplines. Improved guidelines and physician and patient education could help to withstand the perceived pressure to test.
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Affiliation(s)
- Fabienne G Ropers
- Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Sophie Rietveld
- Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Edmond H H M Rings
- Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
- Department of Pediatrics, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Patrick M M Bossuyt
- Amsterdam University Medical Centers, University of Amsterdam, Epidemiology & Data Science, Amsterdam, The Netherlands
- Amsterdam Public Health, Methodology, Amsterdam, The Netherlands
| | - Leti van Bodegom-Vos
- Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Marij A Hillen
- Amsterdam University Medical Centers, location AMC, Amsterdam Public Health, Medical Psychology, Amsterdam, The Netherlands
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Marschner MN, Chandran MM, Colyer LG. Artificially Elevated Tacrolimus Concentrations Obtained From a Venous Catheter Previously Used for Tacrolimus Administration in a Pediatric Patient. J Pharm Pract 2023; 36:1264-1267. [PMID: 35689341 DOI: 10.1177/08971900221107841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Intravenous (IV) administration of calcineurin inhibitors, cyclosporine (CsA) and tacrolimus (TAC), has been associated with spuriously high serum concentrations collected from central venous catheters (CVCs) used for medication administration, secondary to reversible adsorption of medication to the catheter. Thus, therapeutic drug monitoring of IV CsA and TAC via CVCs previously exposed to these agents should be interpreted cautiously and ideally avoided. The duration of this effect is poorly characterized and the risk for extension of this effect to unexposed lumens of the same central catheter remains uncertain. We describe a case of a pediatric patient with artificially elevated serum TAC concentrations obtained from previously exposed and unexposed lumens of a central catheter, 27 days after last IV TAC administration.
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Affiliation(s)
- Magda N Marschner
- Department of Pharmacy, Children's Hospital Colorado, Aurora, CO, USA
| | - Mary M Chandran
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Lindsay G Colyer
- Department of Pharmacy, Children's Hospital Colorado, Aurora, CO, USA
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King B, Patel RM. Using Quality Improvement to Improve Value and Reduce Waste. Clin Perinatol 2023; 50:489-506. [PMID: 37201993 DOI: 10.1016/j.clp.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Value is defined as health outcomes achieved per dollar spent. Addressing value in quality improvement (QI) efforts can help optimize patient outcomes while reducing unnecessary spending. In this article, we discuss how QI focused on reducing morbidities frequently reduces costs, and how proper cost accounting can help demonstrate improvements in value. We provide examples of high-yield opportunities for value improvement in neonatology and review the literature associated with these topics. Opportunities include reducing neonatal intensive care admissions for low-acuity infants, sepsis evaluations in low-risk infants, unnecessary total parental nutrition use, and utilization of laboratory and imaging.
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Affiliation(s)
- Brian King
- Department of Pediatrics, University of Pittsburg School of Medicine.
| | - Ravi M Patel
- Emory University School of Medicine and Children's Healthcare of Atlanta, 2015 Uppergate Drive, NE, Atlanta, GA 30322, USA
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Rabbani N, Ma SP, Li RC, Winget M, Weber S, Boosi S, Pham TD, Svec D, Shieh L, Chen JH. Targeting repetitive laboratory testing with electronic health records-embedded predictive decision support: A pre-implementation study. Clin Biochem 2023; 113:70-77. [PMID: 36623759 PMCID: PMC9936847 DOI: 10.1016/j.clinbiochem.2023.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 12/07/2022] [Accepted: 01/05/2023] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Unnecessary laboratory testing contributes to patient morbidity and healthcare waste. Despite prior attempts at curbing such overutilization, there remains opportunity for improvement using novel data-driven approaches. This study presents the development and early evaluation of a clinical decision support tool that uses a predictive model to help providers reduce low-yield, repetitive laboratory testing in hospitalized patients. METHODS We developed an EHR-embedded SMART on FHIR application that utilizes a laboratory test result prediction model based on historical laboratory data. A combination of semi-structured physician interviews, usability testing, and quantitative analysis on retrospective laboratory data were used to inform the tool's development and evaluate its acceptability and potential clinical impact. KEY RESULTS Physicians identified culture and lack of awareness of repeat orders as key drivers for overuse of inpatient blood testing. Users expressed an openness to a lab prediction model and 13/15 physicians believed the tool would alter their ordering practices. The application received a median System Usability Scale score of 75, corresponding to the 75th percentile of software tools. On average, physicians desired a prediction certainty of 85% before discontinuing a routine recurring laboratory order and a higher certainty of 90% before being alerted. Simulation on historical lab data indicates that filtering based on accepted thresholds could have reduced ∼22% of repeat chemistry panels. CONCLUSIONS The use of a predictive algorithm as a means to calculate the utility of a diagnostic test is a promising paradigm for curbing laboratory test overutilization. An EHR-embedded clinical decision support tool employing such a model is a novel and acceptable intervention with the potential to reduce low-yield, repetitive laboratory testing.
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Affiliation(s)
- Naveed Rabbani
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA; Stanford Center for Biomedical Informatics Research, Stanford University School of Medicine, Stanford, CA, USA.
| | - Stephen P Ma
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Ron C Li
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Marcy Winget
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Susan Weber
- Technology and Digital Solutions, Stanford University School of Medicine, Stanford, CA, USA
| | - Srinivasan Boosi
- Technology and Digital Solutions, Stanford University School of Medicine, Stanford, CA, USA
| | - Tho D Pham
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - David Svec
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Lisa Shieh
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Jonathan H Chen
- Stanford Center for Biomedical Informatics Research, Stanford University School of Medicine, Stanford, CA, USA; Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA; Division of Hospital Medicine, Stanford University School of Medicine, Stanford, CA, USA; Clinical Excellence Research Center, Stanford University School of Medicine, Stanford, CA, USA
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Obiagwu PN, Morrow B, McCulloch M, Argent A. Burden and severity of deranged electrolytes and kidney function in children seen in a tertiary hospital in Kano, northern Nigeria. PLoS One 2023; 18:e0283220. [PMID: 36930619 PMCID: PMC10022757 DOI: 10.1371/journal.pone.0283220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 03/03/2023] [Indexed: 03/18/2023] Open
Abstract
INTRODUCTION Derangement in serum electrolytes and kidney function is often overlooked, especially in resource-constrained settings, and associated with increased risk of morbidity and mortality. This study aimed to describe the burden of derangements in serum electrolytes and kidney function in children presenting to a tertiary hospital in Nigeria. METHODS The laboratory records of all children who had serum electrolytes urea and creatinine ordered on their first presentation to hospital between January 1 and June 30, 2017 were retrospectively reviewed. Basic demographic data including admission status (inpatient or outpatient) were recordedandserum levels of sodium, potassium, chloride and bicarbonate were assessed for derangements usingnormal values from established reference ranges. Results of repeat samples were excluded. Kidney function was classified based on the serum creatinine relative to normal values for age and sex. RESULTS During the study period, 1909 children (60.3% male); median (IQR) age 42 (11.9) months had serum chemistry and 1248 (65.4%) were admitted. Results of their first samples were analyzed. Electrolyte derangements were present in 78.6% of the samples most commonly hyponatraemia (41.1%), low bicarbonate(37.2%), hypochloraemia (33.5%) and hypokalemia(18.9%). Azotaemia was found in 20.1% of the results. Elevated serum creatinine levels were found in 399 children (24.7%), 24.1% of those being in the severe category. Children aged 5 years and younger accounted for 76.4% of those with derangement in kidney function. One hundred and eight outpatients (17.8%) had deranged kidney function. CONCLUSION Deranged serum electrolytes and kidney function were common in this cohort.
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Affiliation(s)
- Patience N. Obiagwu
- Department of Paediatrics, Aminu Kano Teaching Hospital and Bayero University, Kano, Nigeria
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- * E-mail:
| | - Brenda Morrow
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Mignon McCulloch
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Andrew Argent
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Johnson SC, Bigus E, Thompson PL, Bundy DG, Amaya MI. Deimplementation of Polycythemia Screening in Asymptomatic Infants in a Level 1 Nursery. Pediatr Qual Saf 2022; 7:e533. [PMID: 35369422 PMCID: PMC8970080 DOI: 10.1097/pq9.0000000000000533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 11/04/2021] [Indexed: 11/28/2022] Open
Abstract
Polycythemia (venous hematocrit >65%) is rare in healthy newborns (incidence: 0.4%–5%), with serious outcomes (stroke, bowel ischemia) of unknown incidence in asymptomatic infants. No national guidelines address screening or management of asymptomatic infants with polycythemia. Our nursery screened “high risk” (HR) newborns (small for gestational age, large for gestational age, twin, infant of diabetic mother) with poor adherence and low yield. We aimed to decrease polycythemia screening of asymptomatic HR infants by 80% within 6 months.
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Rooholamini SN, Jennings B, Zhou C, Kaiser SV, Garber MD, Tchou MJ, Ralston SL. Effect of a Quality Improvement Bundle to Standardize the Use of Intravenous Fluids for Hospitalized Pediatric Patients: A Stepped-Wedge, Cluster Randomized Clinical Trial. JAMA Pediatr 2022; 176:26-33. [PMID: 34779837 PMCID: PMC8593833 DOI: 10.1001/jamapediatrics.2021.4267] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
IMPORTANCE Given that hypotonic maintenance intravenous fluids (IVF) may cause hospital-acquired harm, in November 2018, the American Academy of Pediatrics released a clinical practice guideline recommending the use of isotonic IVF for patients aged 28 days to 18 years without contraindications. No recommendations were made regarding laboratory monitoring; however, unnecessary laboratory tests may contribute to health care waste and harm patients. OBJECTIVE To examine the effect of a quality improvement intervention bundle on (1) increasing the mean proportion of hours per hospital day with exclusive isotonic IVF use to at least 80% and (2) decreasing the mean proportion of hospital days with laboratory tests obtained. DESIGN, SETTING, AND PARTICIPANTS This stepped-wedge, cluster randomized clinical trial (Standardization of Fluids in Inpatient Settings [SOFI]) was sponsored by a national quality improvement collaborative and was conducted across 106 US pediatric hospitals. The SOFI intervention period was from September 2019 to March 2020. INTERVENTIONS Hospital sites were exposed to educational materials, a clinical algorithm and order set for IVF use, electronic medical record interventions to reduce laboratory testing, and "harms of overtesting" cards. MAIN OUTCOMES AND MEASURES Primary outcomes were mean proportion of hours per hospital day receiving exclusive isotonic IVF and mean proportion of hospital days with laboratory test values obtained. Secondary measures included total IVF duration per hospital day, daily patient weight measurement while receiving IVF, serum sodium testing, and adverse events. Baseline data were collected for 2 months; intervention period data, 7 months. Outcomes were analyzed using linear mixed-effects regression models. RESULTS A total of 106 hospitals were randomly assigned to 1 of 3 intervention start dates (wedges), and 100 hospitals (94%) completed the study. In total, 5215 hospitalizations were reviewed before the intervention, and 6724 hospitalizations were reviewed after the intervention. Prior to interventions, the mean (SD) proportion of hours per day with exclusive isotonic IVF use was 88.5% (31.7%). Interventions led to an absolute increase of 5.4% (95% CI, 3.9%-6.9%) above baseline in exclusive isotonic IVF use but did not change the proportion of hospital days during which a laboratory test value was obtained (estimated difference, 0.1%; 95% CI, -1.5% to 1.7%; P = .90), IVF use duration (estimated difference, -1.2%; 95% CI, -2.9% to 0.4%), serum sodium testing, or adverse events. There was an absolute increase of 4.4% (95% CI, 2.6%-6.2%) in the mean proportion of hospital days with a patient weight measurement while receiving IVF. CONCLUSIONS AND RELEVANCE In this stepped-wedge, cluster randomized clinical trial, an intervention bundle significantly improved the use of isotonic maintenance IVF without a concomitant increase in adverse events or electrolyte testing. Further work is required to deimplement laboratory testing. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03924674.
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Affiliation(s)
| | | | - Chuan Zhou
- Department of Pediatrics, University of Washington, Seattle,Seattle Children’s Research Institute, Seattle, Washington
| | | | | | - Michael J. Tchou
- Department of Pediatrics, University of Colorado and Children’s Hospital Colorado, Aurora
| | - Shawn L. Ralston
- Department of Pediatrics, Johns Hopkins University, Baltimore, Maryland
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Haq H, Rule ARL, Coria A, Thahane LK, Duperval RM, Barnes A, Condurache T, Ferrer K, Shenoy MJ, Mendoza J, Russ CM. Pediatric Hospital Medicine and Global Health: A Fitting Niche for an Emerging Subspecialty. Am J Trop Med Hyg 2021; 105:1152-1154. [PMID: 34491222 DOI: 10.4269/ajtmh.20-1201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 07/01/2021] [Indexed: 11/07/2022] Open
Abstract
As North American hospitals serve increasingly diverse patient populations, including recent immigrants, refugees, and returned travelers, all pediatric hospitalists (PHs) require foundational competency in global health, and a subset of PHs are carving out niches focused in global health. Pediatric hospitalists are uniquely positioned to collaborate with low- and middle-income country clinicians and child health advocates to improve the health of hospitalized children worldwide. Using the 2018 WHO standards for improving the quality of care for children and adolescents worldwide, we describe how PHs' skills align closely with what the WHO and others have identified as essential elements to bring high-quality, sustainable care to children in low- and middle-income countries. Furthermore, North American global health hospitalists bring home expertise that reciprocally benefits their home institutions.
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Affiliation(s)
- Heather Haq
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas.,Baylor College of Medicine International Pediatric AIDS Initiative (BIPAI) at Texas Children's Hospital, Houston, Texas
| | - Amy R L Rule
- Perinatal Institute and Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center/University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Alexandra Coria
- Division of Pediatric Hospital Medicine, Maimonides Children's Hospital at Maimonides Medical Center, Brooklyn, New York
| | - Lineo K Thahane
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas.,Baylor College of Medicine Children's Foundation - Lesotho, Maseru, Lesotho
| | | | - Adelaide Barnes
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Tania Condurache
- School of Medicine, University of Louisville, Louisville, Kentucky
| | - Kathy Ferrer
- Children's National Hospital, Washington, District of Columbia
| | - Michelle J Shenoy
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Joanne Mendoza
- Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Christiana M Russ
- Division of Medical Critical Care, Boston Children's Hospital, Boston, Massachusetts
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11
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Schefft M, Noda A, Godbout E. Aligning Patient Safety and Stewardship: A Harm Reduction Strategy for Children. Curr Treat Options Pediatr 2021; 7:138-151. [PMID: 38624879 PMCID: PMC8273156 DOI: 10.1007/s40746-021-00227-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 06/29/2021] [Indexed: 11/30/2022]
Abstract
Purpose of review Review important patient safety and stewardship concepts and use clinical examples to describe how they align to improve patient outcomes and reduce harm for children. Recent findings Current evidence indicates that healthcare overuse is substantial. Unnecessary care leads to avoidable adverse events, anxiety and distress, and financial toxicity. Increases in antimicrobial resistance, venous thromboembolism, radiation exposure, and healthcare costs are examples of patient harm associated with a lack of stewardship. Studies indicate that many tools can increase standardization of care, improve resource utilization, and enhance safety culture to better align safety and stewardship. Summary The principles of stewardship and parsimonious care can improve patient safety for children.
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Affiliation(s)
- Matthew Schefft
- Department of Pediatrics, Division of Hospital Medicine, Children’s Hospital of Richmond at Virginia Commonwealth University Health System, Richmond, Virginia, USA
- Children’s Hospital of Richmond at VCU, 1001 E Marshall St, Richmond, VA 23298 USA
| | - Andrew Noda
- Department of Pharmacy, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Emily Godbout
- Department of Pediatrics, Division of Infectious Disease, Children’s Hospital of Richmond at Virginia Commonwealth University Health System, Richmond, Virginia, USA
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Ramazani SN, Gottfried JA, Kaissi M, Lynn J, Leonard MS, Schriefer J, Bayer ND. Improving the Timing of Laboratory Studies in Hospitalized Children: A Quality Improvement Study. Hosp Pediatr 2021; 11:670-678. [PMID: 34158310 DOI: 10.1542/hpeds.2020-005793] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES For hospitalized children and their families, laboratory study collection at night and in the early morning interrupts sleep and increases the stress of a hospitalization. To change this practice, our quality improvement (QI) study developed a rounding checklist aimed at increasing the percentage of routine laboratory studies ordered for and collected after 7 am. METHODS Our QI study was conducted on the pediatric hospital medicine service at a single-site urban children's hospital over 28 months. Medical records from 420 randomly selected pediatric inpatients were abstracted, and 5 plan-do-study-act cycles were implemented during the intervention. Outcome measures included the percentage of routine laboratory studies ordered for and collected after 7 am. The process measure was use of the rounding checklist. Run charts were used for analysis. RESULTS The percentage of laboratory studies ordered for after 7 am increased from a baseline median of 25.8% to a postintervention median of 75.0%, exceeding our goal of 50% and revealing special cause variation. In addition, the percentage of laboratory studies collected after 7 am increased from a baseline median of 37.1% to 76.4% post intervention, with special cause variation observed. CONCLUSIONS By implementing a rounding checklist, our QI study successfully increased the percentage of laboratory studies ordered for and collected after 7 am and could serve as a model for other health care systems to impact provider ordering practices and behavior. In future initiatives, investigators should evaluate the effects of similar interventions on caregiver and provider perceptions of patient- and family-centeredness, satisfaction, and the quality of patient care.
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Affiliation(s)
| | | | - Maha Kaissi
- Department of Pediatrics, Golisano Children's Hospital
| | - Justin Lynn
- Department of Pediatrics, Golisano Children's Hospital
| | - Michael S Leonard
- Department of Pediatrics, Golisano Children's Hospital.,Department of Public Health Sciences, University of Rochester, Rochester, New York
| | - Jan Schriefer
- Department of Pediatrics, Golisano Children's Hospital
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Naureckas Li C, Sacks CA, Cummings BM, Samuels-Kalow M, Masiakos PT, Flaherty MR. Improving Pediatric Residents' Screening for Access to Firearms in High-Risk Patients Presenting to the Emergency Department. Acad Pediatr 2021; 21:710-5. [PMID: 33429102 DOI: 10.1016/j.acap.2021.01.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 12/19/2020] [Accepted: 01/02/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND/OBJECTIVE Access to a firearm is a significant risk for completed suicide or homicide. We sought to increase the rate of screening for access to firearms in patients who presented to the emergency department with suicidal or homicidal ideation or suicide attempt through the use of quality improvement methodology. METHODS Patient records were eligible for inclusion if the child was under the age of 19 and presented to the emergency room of our tertiary medical center with a diagnosis of suicidal ideation, homicidal ideation, or suicide attempt. Records were manually reviewed for demographic information and documentation of screening for access to firearms. A baseline survey of the pediatric residents was completed to identify perceived barriers to screening for access to firearms. Subsequently, three "Plan, Do, Study, Act" (PDSA) cycles consisting of a noon conference, a dedicated grand rounds, and an electronic health record template were completed. RESULTS During the baseline and study period, 501 patients met inclusion criteria. Forty-one of sixty-six (62.1%) residents completed a baseline survey and identified barriers to screening. There was no significant increase in screening following the first or second PDSA cycles. Following the third PDSA cycle, screening rates increased from 4% to 34%. CONCLUSIONS Quality improvement methodology can be used to increase the rates of screening for access to firearms in high-risk patients. Further work is necessary to identify additional strategies to further increase screening rates.
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14
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Synhorst DC, Hall M, Bettenhausen JL, Markham JL, Macy ML, Gay JC, Morse R. Observation Status Stays With Low Resource Use Within Children's Hospitals. Pediatrics 2021; 147:peds.2020-013490. [PMID: 33707196 DOI: 10.1542/peds.2020-013490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/22/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND High costs associated with hospitalization have encouraged reductions in unnecessary encounters. A subset of observation status patients receive minimal interventions and incur low use costs. These patients may contain a cohort that could safely be treated outside of the hospital. Thus, we sought to describe characteristics of low resource use (LRU) observation status hospitalizations and variation in LRU stays across hospitals. METHODS We conducted a retrospective cohort study of pediatric observation encounters at 42 hospitals contributing to the Pediatric Health Information System database from January 1, 2019, to December 31, 2019. For each hospitalization, we calculated the use ratio (nonroom costs to total hospitalization cost). We grouped stays into use quartiles with the lowest labeled LRU. We described associations with LRU stays and performed classification and regression tree analyses to identify the combination of characteristics most associated with LRU. Finally, we described the proportion of LRU hospitalizations across hospitals. RESULTS We identified 174 315 observation encounters (44 422 LRU). Children <1 year (odds ratio [OR] 3.3; 95% confidence interval [CI] 3.1-3.4), without complex chronic conditions (OR 3.6; 95% CI 3.2-4.0), and those directly admitted (OR 4.2; 95% CI 4.1-4.4) had the greatest odds of experiencing an LRU encounter. Those children with the combination of direct admission, no medical complexity, and a respiratory diagnosis experienced an LRU stay 69.5% of the time. We observed variation in LRU encounters (1%-57% of observation encounters) across hospitals. CONCLUSIONS LRU observation encounters are variable across children's hospitals. These stays may include a cohort of patients who could be treated outside of the hospital.
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Affiliation(s)
| | - Matthew Hall
- Children's Mercy Hospital, Kansas City, Missouri.,Children's Hospital Association, Lenexa, Kansas
| | | | | | - Michelle L Macy
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.,Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - James C Gay
- Vanderbilt University Medical Center, Nashville, Tennessee; and
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15
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Patel BB, Sperotto F, Molina M, Kimura S, Delgado MI, Santillana M, Kheir JN. Avoidable Serum Potassium Testing in the Cardiac ICU: Development and Testing of a Machine-Learning Model. Pediatr Crit Care Med 2021; 22:392-400. [PMID: 33332868 DOI: 10.1097/PCC.0000000000002626] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To create a machine-learning model identifying potentially avoidable blood draws for serum potassium among pediatric patients following cardiac surgery. DESIGN Retrospective cohort study. SETTING Tertiary-care center. PATIENTS All patients admitted to the cardiac ICU at Boston Children's Hospital between January 2010 and December 2018 with a length of stay greater than or equal to 4 days and greater than or equal to two recorded serum potassium measurements. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We collected variables related to potassium homeostasis, including serum chemistry, hourly potassium intake, diuretics, and urine output. Using established machine-learning techniques, including random forest classifiers, and hyperparameter tuning, we created models predicting whether a patient's potassium would be normal or abnormal based on the most recent potassium level, medications administered, urine output, and markers of renal function. We developed multiple models based on different age-categories and temporal proximity of the most recent potassium measurement. We assessed the predictive performance of the models using an independent test set. Of the 7,269 admissions (6,196 patients) included, serum potassium was measured on average of 1 (interquartile range, 0-1) time per day. Approximately 96% of patients received at least one dose of IV diuretic and 83% received a form of potassium supplementation. Our models predicted a normal potassium value with a median positive predictive value of 0.900. A median percentage of 2.1% measurements (mean 2.5%; interquartile range, 1.3-3.7%) was incorrectly predicted as normal when they were abnormal. A median percentage of 0.0% (interquartile range, 0.0-0.4%) critically low or high measurements was incorrectly predicted as normal. A median of 27.2% (interquartile range, 7.8-32.4%) of samples was correctly predicted to be normal and could have been potentially avoided. CONCLUSIONS Machine-learning methods can be used to predict avoidable blood tests accurately for serum potassium in critically ill pediatric patients. A median of 27.2% of samples could have been saved, with decreased costs and risk of infection or anemia.
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16
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Coe M, Gruhler H, Schefft M, Williford D, Burger B, Crain E, Mihalek AJ, Santos M, Cotter JM, Trowbridge G, Kessenich J, Nolan M, Tchou MJ. Learning from Each Other: A Multisite Collaborative to Reduce Electrolyte Testing. Pediatr Qual Saf 2020; 5:e351. [PMID: 33134756 DOI: 10.1097/pq9.0000000000000351] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 07/23/2020] [Indexed: 12/27/2022] Open
Abstract
Supplemental Digital Content is available in the text. Inpatient electrolyte testing rates vary significantly across pediatric hospitals. Despite evidence that unnecessary testing exists, providers still struggle with reducing electrolyte laboratory testing. We aimed to reduce serum electrolyte testing among pediatric inpatients by 20% across 5 sites within 6 months.
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17
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Markham JL, Thurm CW, Hall M, Shah SS, Quinonez R, Tchou MJ, Antoon JW, Genies MC, Parlar-Chun R, Johnson DP, Shah SP, Ittel M, Brady PW. Variation in Early Inflammatory Marker Testing for Infection-Related Hospitalizations in Children. Hosp Pediatr 2020; 10:851-858. [PMID: 32948631 DOI: 10.1542/hpeds.2020-0114] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Inflammatory marker testing in children has been identified as a potential area of overuse. We sought to describe variation in early inflammatory marker (C-reactive protein and erythrocyte sedimentation rate) testing for infection-related hospitalizations across children's hospitals and to determine its association with length of stay (LOS), 30-day readmission rate, and cost. METHODS We conducted a cross-sectional study of children aged 0 to 17 years with infection-related hospitalizations using the Pediatric Health Information System. After adjusting for patient characteristics, we examined rates of inflammatory marker testing (C-reactive protein or erythrocyte sedimentation rate) during the first 2 days of hospitalization. We used k-means clustering to assign each hospital to 1 of 3 groups on the basis of similarities in adjusted diagnostic testing rates across 12 infectious conditions. Multivariable regression was used to examine the association between hospital testing group and outcomes. RESULTS We included 55 771 hospitalizations from 48 hospitals. In 7945 (14.3%), there was inflammatory marker testing in the first 2 days of hospitalization. We observed wide variation in inflammatory marker testing rates across hospitals and infections. Group A hospitals tended to perform more tests than group B or C hospitals (37.4% vs 18.0% vs 10.4%; P < .001) and had the longest adjusted LOS (3.2 vs 2.9 vs 2.8 days; P = .01). There was no significant difference in adjusted 30-day readmission rates or costs. CONCLUSIONS Inflammatory marker testing varied widely across hospitals. Hospitals with higher inflammatory testing for one infection tend to test more frequently for other infections and have longer LOS, suggesting opportunities for diagnostic stewardship.
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Affiliation(s)
- Jessica L Markham
- Department of Pediatrics, Children's Mercy Kansas City and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri;
- School of Medicine, University of Kansas, Kansas City, Kansas
| | | | - Matt Hall
- Department of Pediatrics, Children's Mercy Kansas City and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
- Children's Hospital Association, Lenexa, Kansas
| | - Samir S Shah
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Ricardo Quinonez
- Section of Pediatric Hospital Medicine, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Michael J Tchou
- Section of Pediatric Hospital Medicine, Department of Pediatrics, University of Colorado and Children's Hospital Colorado, Aurora, Colorado
| | - James W Antoon
- Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, Tennessee
- Division of Hospital Medicine, Department of Pediatrics, School of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Marquita C Genies
- Department of Pediatrics, Johns Hopkins University, Baltimore, Maryland
| | - Raymond Parlar-Chun
- Department of Pediatrics, McGovern Medical School, University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, Texas; and
| | - David P Johnson
- Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, Tennessee
- Division of Hospital Medicine, Department of Pediatrics, School of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Snehal P Shah
- Division of Hospitalist Medicine, Department of Pediatrics, Washington University in St Louis, St Louis, Missouri
| | - Molli Ittel
- Department of Pediatrics, Children's Mercy Kansas City and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
- School of Medicine, University of Kansas, Kansas City, Kansas
| | - Patrick W Brady
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Synhorst DC, Johnson MB, Bettenhausen JL, Kyler KE, Richardson TE, Mann KJ, Fieldston ES, Hall M. Room Costs for Common Pediatric Hospitalizations and Cost-Reducing Quality Initiatives. Pediatrics 2020; 145:peds.2019-2177. [PMID: 32366609 DOI: 10.1542/peds.2019-2177] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/24/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Improvement initiatives promote safe and efficient care for hospitalized children. However, these may be associated with limited cost savings. In this article, we sought to understand the potential financial benefit yielded by improvement initiatives by describing the inpatient allocation of costs for common pediatric diagnoses. METHODS This study is a retrospective cross-sectional analysis of pediatric patients aged 0 to 21 years from 48 children's hospitals included in the Pediatric Health Information System database from January 1, 2017, to December 31, 2017. We included hospitalizations for 8 common inpatient pediatric diagnoses (seizure, bronchiolitis, asthma, pneumonia, acute gastroenteritis, upper respiratory tract infection, other gastrointestinal diagnoses, and skin and soft tissue infection) and categorized the distribution of hospitalization costs (room, clinical, laboratory, imaging, pharmacy, supplies, and other). We summarized our findings with mean percentages and percent of total costs and used mixed-effects models to account for disease severity and to describe hospital-level variation. RESULTS For 195 436 hospitalizations, room costs accounted for 52.5% to 70.3% of total hospitalization costs. We observed wide hospital-level variation in nonroom costs for the same diagnoses (25%-81% for seizure, 12%-51% for bronchiolitis, 19%-63% for asthma, 19%-62% for pneumonia, 21%-78% for acute gastroenteritis, 21%-63% for upper respiratory tract infection, 28%-69% for other gastrointestinal diagnoses, and 21%-71% for skin and soft tissue infection). However, to achieve a cost reduction equal to 10% of room costs, large, often unattainable reductions (>100%) in nonroom cost categories are needed. CONCLUSIONS Inconsistencies in nonroom costs for similar diagnoses suggest hospital-level treatment variation and improvement opportunities. However, individual improvement initiatives may not result in significant cost savings without specifically addressing room costs.
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Affiliation(s)
- David C Synhorst
- Department of Pediatrics, Children's Mercy Kansas City and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri;
| | - Matthew B Johnson
- Department of Pediatrics, Children's Mercy Kansas City and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Jessica L Bettenhausen
- Department of Pediatrics, Children's Mercy Kansas City and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Kathryn E Kyler
- Department of Pediatrics, Children's Mercy Kansas City and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Troy E Richardson
- Department of Pediatrics, Children's Mercy Kansas City and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri.,Children's Hospital Association, Lenexa, Kansas
| | - Keith J Mann
- American Board of Pediatrics, Chapel Hill, North Carolina; and
| | - Evan S Fieldston
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Matt Hall
- Department of Pediatrics, Children's Mercy Kansas City and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri.,Children's Hospital Association, Lenexa, Kansas
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19
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Lee B, Hershey D, Patel A, Pierce H, Rhee KE, Fisher E. Reducing Unnecessary Testing in Uncomplicated Skin and Soft Tissue Infections: A Quality Improvement Approach. Hosp Pediatr 2020; 10:129-137. [PMID: 31941651 DOI: 10.1542/hpeds.2019-0179] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVES Skin and soft tissue infections are common pediatric diagnoses with substantial costs. Recent studies suggest blood cultures are not useful in management of uncomplicated skin and soft tissue infections (uSSTIs). Complete blood cell count, erythrocyte sedimentation rate, and C-reactive protein are also of questionable value. We aimed to decrease these tests by 25% for patients with uSSTIs admitted to the pediatric hospital medicine service within 3 months. METHODS An interdisciplinary team led a quality improvement (QI) project. Baseline assessment included review of the literature and 12 months of medical records. Key stakeholders identified drivers that informed the creation of an electronic order set and development of a pediatric hospital medicine-emergency department collaborative QI project. The primary outcome measure was mean number of tests per patient encounter. Balancing measures included unplanned readmissions and missed diagnoses. RESULTS Our baseline-year rate was 3.4 tests per patient encounter (573 tests and 169 patient encounters). During the intervention year, the rate decreased by 35% to 2.2 tests per patient encounter (286 tests and 130 patient encounters) and was sustained for 14 months postintervention. There were no unplanned readmissions or missed diagnoses for the study period. Order set adherence was 80% (83 out of 104) during the intervention period and sustained at 87% postintervention. CONCLUSIONS Our interdisciplinary team achieved our aim, reducing unnecessary laboratory testing in patients with an uSSTI without patient harm. Awareness of local culture, creation of an order set, defining appropriate patient selection and testing indications, and implementation of a collaborative QI project helped us achieve our aim.
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Affiliation(s)
- Begem Lee
- Rady Children's Hospital-San Diego, San Diego, California; and
- Department of Pediatrics, University of California, San Diego, San Diego, California
| | - Daniel Hershey
- Rady Children's Hospital-San Diego, San Diego, California; and
- Department of Pediatrics, University of California, San Diego, San Diego, California
| | - Aarti Patel
- Rady Children's Hospital-San Diego, San Diego, California; and
- Department of Pediatrics, University of California, San Diego, San Diego, California
| | - Heather Pierce
- Rady Children's Hospital-San Diego, San Diego, California; and
- Department of Pediatrics, University of California, San Diego, San Diego, California
| | - Kyung E Rhee
- Rady Children's Hospital-San Diego, San Diego, California; and
- Department of Pediatrics, University of California, San Diego, San Diego, California
| | - Erin Fisher
- Rady Children's Hospital-San Diego, San Diego, California; and
- Department of Pediatrics, University of California, San Diego, San Diego, California
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20
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Girdwood SCT, Sellas MN, Courter JD, Liberio B, Tchou MJ, Herrmann LE, Dewan ML, Statile AM, Unaka NI. Improving the Transition of Intravenous to Enteral Antibiotics in Pediatric Patients with Pneumonia or Skin and Soft Tissue Infections. J Hosp Med 2020; 15:10-15. [PMID: 31339843 DOI: 10.12788/jhm.3253] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Despite national recommendations for early transition to enteral antimicrobials, practice variability has existed at our hospital. OBJECTIVE The aim of this study was to increase the proportion of enterally administered antibiotic doses for Pediatric Hospital Medicine patients aged >60 days admitted for uncomplicated community-acquired pneumonia or skin and soft tissue infections from 44% to 75% in eight months. METHODS This quality improvement study was conducted at a large, urban, academic children's hospital. The study population included Hospital Medicine patients aged >60 days with diagnoses of pneumonia or skin and soft tissue infections. Interventions included education on intravenous and enteral antibiotic charge differentials, documentation of transition plan, structured discussions of transition criteria, and real-time identification of failures with feedback. Our process measure was the total number of enteral antibiotic doses divided by all antibiotic doses in patients receiving enteral medications on the same day. An annotated statistical process control chart tracked the impact of interventions on the administration route of antibiotic doses over time. Additional outcome measures included antimicrobial costs per patient encounter using average wholesale prices and length of stay. RESULTS The percentage of enterally administered antibiotic doses increased from 44% to 80% within eight months. Antimicrobial costs per patient encounter and the associated standard deviation of costs for our target diagnoses decreased by 70% and 84%, respectively. Average length of stay did not change. CONCLUSIONS Standardized communication about criteria for transition from intravenous to enteral antibiotics can lead to earlier transitions for patients with pneumonia or skin and soft tissue infections, subsequently reducing costs and prescribing variability.
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Affiliation(s)
- Sonya C Tang Girdwood
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Maria N Sellas
- Division of Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pharmacy, Nationwide Children's Hospital, Columbus, Ohio
| | - Joshua D Courter
- Division of Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Brianna Liberio
- Pediatric Residency Program, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Michael J Tchou
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Section of Hospital Medicine, Children's Hospital Colorado, Aurora, Colorado
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
| | - Lisa E Herrmann
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio
| | - Maya L Dewan
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Angela M Statile
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Pediatric Residency Program, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio
| | - Ndidi I Unaka
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Pediatric Residency Program, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio
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21
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Subramony A, Kocolas I, Srivastava R. Pediatric Hospitalists Improving Patient Care Through Quality Improvement. Pediatr Clin North Am 2019; 66:697-712. [PMID: 31230617 DOI: 10.1016/j.pcl.2019.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
This article reviews the industrial underpinnings of the quality improvement (QI) movement and describes how QI became integrated within the larger health care landscape, including hospital medicine. QI methodologies and a framework for using them are described. Key components that make up a successful QI clinical project are outlined, with a focus on the essential role of pediatric hospitalists and practical professional tips to be successful. QI training opportunities are reviewed with opportunities for hospitalists to get involved in QI on a national level. National QI networks are showcased, with multiple examples of advanced improvement projects that have significantly improved patient outcomes highlighted.
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Affiliation(s)
- Anupama Subramony
- Department of Pediatrics, Cohen Children's Medical Center, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 269-01 76th Avenue, New Hyde Park, NY 11040, USA.
| | - Irene Kocolas
- Division of Inpatient Medicine, Department of Pediatrics, University of Utah School of Medicine/Primary Children's Hospital, Intermountain Healthcare, 100 Mario Capecchi Drive, Salt Lake City, UT 84113, USA
| | - Raj Srivastava
- Division of Inpatient Medicine, Department of Pediatrics, University of Utah School of Medicine/Primary Children's Hospital, Healthcare Delivery Institute, Intermountain Healthcare, 5026 State Street, Murray, UT 84107, USA
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Tchou MJ, Hall M, Shah SS, Johnson DP, Schroeder AR, Antoon JW, Genies MC, Quinonez R, Miller CW, Shah SP, Brady PW. Patterns of Electrolyte Testing at Children's Hospitals for Common Inpatient Diagnoses. Pediatrics 2019; 144:e20181644. [PMID: 31171587 PMCID: PMC6615522 DOI: 10.1542/peds.2018-1644] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/11/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Overuse of laboratory testing contributes substantially to health care waste, downstream resource use, and patient harm. Understanding patterns of variation in hospital-level testing across common inpatient diagnoses could identify outliers and inform waste-reduction efforts. METHODS We conducted a multicenter retrospective cohort study of pediatric inpatients at 41 children's hospitals using administrative data from 2010 to 2016. Initial electrolyte testing was defined as testing occurring within the first 2 days of an encounter, and repeat testing was defined as subsequent testing within an encounter in which initial testing occurred. To examine if testing rates correlated across diagnoses at the hospital level, we compared risk-adjusted rates for gastroenteritis with a weighted average of risk-adjusted rates in other diagnosis cohorts. For each diagnosis, linear regression was performed to compare initial and subsequent testing. RESULTS In 497 719 patient encounters, wide variation was observed across hospitals in adjusted, initial, and repeat testing rates. Hospital-specific rates of testing in gastroenteritis were moderately to strongly correlated with the weighted average of testing in other conditions (initial: r = 0.63; repeat r = 0.83). Within diagnoses, higher hospital-level initial testing rates were associated with significantly increased rates of subsequent testing for all diagnoses except gastroenteritis. CONCLUSIONS Among children's hospitals, rates of initial and repeat electrolyte testing vary widely across 8 common inpatient diagnoses. For most diagnoses, hospital-level rates of initial testing were associated with rates of subsequent testing. Consistent rates of testing across multiple diagnoses suggest that hospital-level factors, such as institutional culture, may influence decisions for electrolyte testing.
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Affiliation(s)
- Michael J Tchou
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio;
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | - Samir S Shah
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David P Johnson
- Division of Hospital Medicine, Department of Pediatrics, School of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Alan R Schroeder
- Department of Pediatrics, School of Medicine, Stanford University, Palo Alto, California
| | - James W Antoon
- Children's Hospital, University of Illinois, University of Illinois Hospital and Health Sciences System, Chicago, Illinois
| | - Marquita C Genies
- Department of Pediatrics, Johns Hopkins University, Baltimore, Maryland
| | - Ricardo Quinonez
- Section of Pediatric Hospital Medicine, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Christopher W Miller
- Division of Pediatric Inpatient Medicine, Department of Pediatrics, University of Utah, Salt Lake City, Utah; and
| | - Snehal P Shah
- Division of Hospitalist Medicine, Department of Pediatrics, Washington University in St Louis, St Louis, Missouri
| | - Patrick W Brady
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Affiliation(s)
- David P Johnson
- Divisions of Hospital Medicine and
- Department of Pediatrics, School of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Barron L Patterson
- Department of Pediatrics, School of Medicine, Vanderbilt University, Nashville, Tennessee
- Academic General Pediatrics
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