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Stephen RJ, Lucey K, Carroll MS, Hoge J, Maciorowski K, Jones RC, O'Connell M, Schwab C, Rojas J, Sanchez Pinto LN. Sepsis Prediction in Hospitalized Children: Clinical Decision Support Design and Deployment. Hosp Pediatr 2023; 13:751-759. [PMID: 37599646 DOI: 10.1542/hpeds.2023-007218] [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] [Indexed: 08/22/2023]
Abstract
BACKGROUND Following development and validation of a sepsis prediction model described in a companion article, we aimed to use quality improvement and safety methodology to guide the design and deployment of clinical decision support (CDS) tools and clinician workflows to improve pediatric sepsis recognition in the inpatient setting. METHODS CDS tools and sepsis huddle workflows were created to implement an electronic health record-based sepsis prediction model. These were proactively analyzed and refined using simulation and safety science principles before implementation and were introduced across inpatient units during 2020-2021. Huddle compliance, alerts per non-ICU patient days, and days between sepsis-attributable emergent transfers were monitored. Rapid Plan-Do-Study-Act (PDSA) cycles based on user feedback and weekly metric data informed improvement throughout implementation. RESULTS There were 264 sepsis alerts on 173 patients with an 89% bedside huddle completion rate and 10 alerts per 1000 non-ICU patient days per month. There was no special cause variation in the metric days between sepsis-attributable emergent transfers. CONCLUSIONS An automated electronic health record-based sepsis prediction model, CDS tools, and sepsis huddle workflows were implemented on inpatient units with a relatively low rate of interruptive alerts and high compliance with bedside huddles. Use of CDS best practices, simulation, safety tools, and quality improvement principles led to high utilization of the sepsis screening process.
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Affiliation(s)
- Rebecca J Stephen
- Department of Pediatrics, Northwestern Feinberg School of Medicine, Chicago, Illinois
- Division of Hospital Based Medicine
- Center for Quality and Safety
| | - Kate Lucey
- Department of Pediatrics, Northwestern Feinberg School of Medicine, Chicago, Illinois
- Division of Hospital Based Medicine
- Center for Quality and Safety
| | - Michael S Carroll
- Department of Pediatrics, Northwestern Feinberg School of Medicine, Chicago, Illinois
- Data Analytics and Reporting
| | | | | | | | | | | | | | - L Nelson Sanchez Pinto
- Department of Pediatrics, Northwestern Feinberg School of Medicine, Chicago, Illinois
- Division of Critical Care, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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Stephen RJ, Carroll MS, Hoge J, Maciorowski K, Jones RC, Lucey K, O'Connell M, Schwab C, Rojas J, Sanchez-Pinto LN. Sepsis Prediction in Hospitalized Children: Model Development and Validation. Hosp Pediatr 2023; 13:760-767. [PMID: 37599645 DOI: 10.1542/hpeds.2022-006964] [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] [Indexed: 08/22/2023]
Abstract
BACKGROUND AND OBJECTIVES Early recognition and treatment of pediatric sepsis remain mainstay approaches to improve outcomes. Although most children with sepsis are diagnosed in the emergency department, some are admitted with unrecognized sepsis or develop sepsis while hospitalized. Our objective was to develop and validate a prediction model of pediatric sepsis to improve recognition in the inpatient setting. METHODS Patients with sepsis were identified using intention-to-treat criteria. Encounters from 2012 to 2018 were used as a derivation to train a prediction model using variables from an existing model. A 2-tier threshold was determined using a precision-recall curve: an "Alert" tier with high positive predictive value to prompt bedside evaluation and an "Aware" tier with high sensitivity to increase situational awareness. The model was prospectively validated in the electronic health record in silent mode during 2019. RESULTS A total of 55 980 encounters and 793 (1.4%) episodes of sepsis were used for derivation and prospective validation. The final model consisted of 13 variables with an area under the curve of 0.96 (95% confidence interval 0.95-0.97) in the validation set. The Aware tier had 100% sensitivity and the Alert tier had a positive predictive value of 14% (number needed to alert of 7) in the validation set. CONCLUSIONS We derived and prospectively validated a 2-tiered prediction model of inpatient pediatric sepsis designed to have a high sensitivity Aware threshold to enable situational awareness and a low number needed to Alert threshold to minimize false alerts. Our model was embedded in our electronic health record and implemented as clinical decision support, which is presented in a companion article.
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Affiliation(s)
- Rebecca J Stephen
- Department of Pediatrics, Northwestern Feinberg School of Medicine
- Divisions of Hospital-Based Medicine
- Center for Quality and Safety
| | - Michael S Carroll
- Department of Pediatrics, Northwestern Feinberg School of Medicine
- Data Analytics and Reporting
| | | | | | | | - Kate Lucey
- Department of Pediatrics, Northwestern Feinberg School of Medicine
- Divisions of Hospital-Based Medicine
- Center for Quality and Safety
| | - Megan O'Connell
- Department of Nursing, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Carly Schwab
- Department of Nursing, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Jillian Rojas
- Department of Nursing, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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Faerber JA, Xiao R, Makeneni S, Schisterman EF, Brady PW, Schondelmeyer AC, Landrigan CP, Lucey K, Lee V, Gregory PF, Prasto J, Parthasarathy P, Greenfield M, Solomon C, Brent CR, Albanowski K, Beidas RS, Bonafide CP. Sustainment of continuous pulse oximetry deimplementation: Analysis of Eliminating Monitor Overuse study data from six hospitals. J Hosp Med 2023; 18:724-729. [PMID: 37380625 PMCID: PMC10527429 DOI: 10.1002/jhm.13154] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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] [Received: 04/16/2023] [Revised: 06/01/2023] [Accepted: 06/07/2023] [Indexed: 06/30/2023]
Abstract
Using continuous pulse oximetry (cSpO2 ) to monitor children with bronchiolitis who are not receiving supplemental oxygen is a form of medical overuse. In this longitudinal analysis from the Eliminating Monitor Overuse (EMO) study, we aimed to assess changes in cSpO2 overuse before, during, and after intensive cSpO2 -deimplementation efforts in six hospitals. Monitoring data were collected during three phases: "P1" baseline, "P2" active deimplementation (all sites engaged in education and audit and feedback strategies), and "P3" sustainment (a new baseline measured after strategies were withdrawn). Two thousand and fifty-three observations were analyzed. We found that each hospital experienced reductions during active deimplementation (P2), with overall adjusted cSpO2 overuse decreasing from 53%, 95% confidence interval (CI): (49-57) to 22%, 95% CI: (19-25) between P1 and P2. However, following the withdrawal of deimplementation strategies, overuse rebounded in all six sites, with overall adjusted cSpO2 overuse increasing to 37%, 95% CI: (33-41) in P3.
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Affiliation(s)
- Jennifer A Faerber
- Data Science and Biostatistics Unit, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Rui Xiao
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Spandana Makeneni
- Data Science and Biostatistics Unit, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Enrique F Schisterman
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Patrick W Brady
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Amanda C Schondelmeyer
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Christopher P Landrigan
- Division of General Pediatrics, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Departments of Pediatrics and Medicine, and Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Kate Lucey
- Division of Hospital Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Vivian Lee
- Division of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California, USA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Polina F Gregory
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
- Division of Hospital Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Julianne Prasto
- Division of Pediatrics, Children's Hospital of Philadelphia Pediatric Care at Penn Medicine Princeton Medical Center, Plainsboro, New Jersey, USA
| | - Padmavathy Parthasarathy
- Section of Hospital Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Morgan Greenfield
- Section of Hospital Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Courtney Solomon
- Department of Pediatrics, UT Southwestern Medical Center, Dallas, Texas, USA
- Division of Pediatric Hospital Medicine, Children's Health Dallas, Dallas, Texas, USA
| | - Canita R Brent
- Section of Hospital Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kimberly Albanowski
- Section of Hospital Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Rinad S Beidas
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Evanston, Illinois, USA
| | - Christopher P Bonafide
- Section of Hospital Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Clinical Futures, a Center of Emphasis within the CHOP Research Institute, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI), University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Schondelmeyer AC, Bettencourt AP, Xiao R, Beidas RS, Wolk CB, Landrigan CP, Brady PW, Brent CR, Parthasarathy P, Kern-Goldberger AS, Sergay N, Lee V, Russell CJ, Prasto J, Zaman S, McQuistion K, Lucey K, Solomon C, Garcia M, Bonafide CP. 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. JAMA Netw Open 2021; 4:e2122826. [PMID: 34473258 PMCID: PMC8414187 DOI: 10.1001/jamanetworkopen.2021.22826] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
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.
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Affiliation(s)
- Amanda C. Schondelmeyer
- Department of Systems, Populations, and Leadership, University of Michigan School of Nursing, Ann Arbor
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Amanda P. Bettencourt
- Department of Systems, Populations, and Leadership, University of Michigan School of Nursing, Ann Arbor
| | - Rui Xiao
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Rinad S. Beidas
- Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI), University of Pennsylvania, Philadelphia
| | - Courtney Benjamin Wolk
- Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI), University of Pennsylvania, Philadelphia
| | - Christopher P. Landrigan
- Division of General Pediatrics, Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
- Division of Sleep and Circadian Disorders, Departments of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
- Division of Sleep and Circadian Disorders, Department of Neurology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Patrick W. Brady
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Canita R. Brent
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Padmavathy Parthasarathy
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Andrew S. Kern-Goldberger
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Nathaniel Sergay
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Pediatric Residency Program, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Vivian Lee
- Division of Hospital Medicine, Children’s Hospital Los Angeles, Los Angeles, California
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles
| | - Christopher J. Russell
- Division of Hospital Medicine, Children’s Hospital Los Angeles, Los Angeles, California
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles
| | - Julianne Prasto
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Division of Pediatrics, Children’s Hospital of Philadelphia Pediatric Care and Penn Medicine Princeton Medical Center, Philadelphia, Pennsylvania
| | - Sarah Zaman
- Department of Pediatrics, University of Washington School of Medicine, Seattle
- Center for Child Health, Behavior, and Development, Seattle Children’s Research Institute, Seattle, Washington
| | - Kaitlyn McQuistion
- University of Washington Pediatric Residency Program, Department of Pediatrics, University of Washington, Seattle
| | - Kate Lucey
- Division of Hospital Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Courtney Solomon
- Department of Pediatrics, UT Southwestern Medical Center, Dallas, Texas
- Division of Pediatric Hospital Medicine, Children’s Health Dallas, Texas
| | - Mayra Garcia
- Division of General and Thoracic Surgery, Children’s Health Dallas, Dallas, Texas
| | - Christopher P. Bonafide
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
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Affiliation(s)
- Kate Lucey
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; and Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Craig F Garfield
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; and Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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