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Elizalde A, Hammer D, Su Y, Prasun MA. Increasing teachers' confidence during health emergencies: A hands-on quality improvement program led by the school nurse. J Pediatr Nurs 2024; 77:e263-e269. [PMID: 38679506 DOI: 10.1016/j.pedn.2024.04.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 04/10/2024] [Accepted: 04/12/2024] [Indexed: 05/01/2024]
Abstract
INTRODUCTION One in four school-age children has a chronic health condition, with approximately 6% of them having multiple chronic health conditions. These students are at an elevated risk of individual health emergencies during school hours. While teachers receive online training to assist in these emergencies, they lack practicing with rescue medications. METHODS We developed a Quality Improvement (QI) program that had a) a live presentation; b) a hands-on workshop to practice using rescue medications for allergies, asthma, seizures, and diabetes; c) fliers with first-aid guidelines; and d) a web-based reference toolkit. Teachers' confidence and knowledge were measured using the Learning Self-Efficacy Scale and a knowledge questionnaire with a pre- and post-intervention survey. We also assessed their clinical skills using the rescue medications. RESULTS 129 teachers took part in this QI program. We collected 95 pre- and 81 post-surveys, with 47 matched. We saw statistically significant increases in confidence, as well as in the individual cognitive, affective, and psychomotor domains. Teachers also increased their overall knowledge. Collaterally, other district-wide improvements developed. CONCLUSION This evidence-based, hands-on QI program provided teachers the opportunity to put into practice clinical skills, increasing their confidence to help students when experiencing an individual health emergency. Furthermore, changes beyond the primary goal of this QI program were implemented, highlighting the lead role of the registered nurse as the public health advocate. IMPLICATION TO PRACTICE Laypeople benefit from hands-on training to learn clinical skills. This program serves as a basis for improving health emergencies preparedness in schools.
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Affiliation(s)
- Analía Elizalde
- Illinois State University, Mennonite College of Nursing, Normal, IL, United States of America.
| | - Denise Hammer
- Illinois State University, Mennonite College of Nursing, Normal, IL, United States of America; Mennonite College of Nursing, Illinois State University, Edwards Hall, EDW 211, Normal, IL, United States of America.
| | - Yan Su
- College of Nursing & Health Sciences, University of Massachusetts, 285 Old Westport Road, Modular Unit #5 005, Dartmouth, MA 02747-2300, United States of America.
| | - Marilyn A Prasun
- Illinois State University, Mennonite College of Nursing, Normal, IL, United States of America; Mennonite College of Nursing, Illinois State University, Edwards Hall, EDW 111B, Normal, IL, United States of America.
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Peng J, Gorham TJ, Meyer BD. Predicting Dental General Anesthesia Use among Children with Behavioral Health Conditions. JDR Clin Trans Res 2024:23800844241252817. [PMID: 38877718 DOI: 10.1177/23800844241252817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2024] Open
Abstract
OBJECTIVES To evaluate how different data sources affect the performance of machine learning algorithms that predict dental general anesthesia use among children with behavioral health conditions. STUDY DESIGN Observational study using claims data. METHODS Using Medicaid claims from Partners For Kids (2013-2019), electronic medical record data, and the Ohio Child Opportunity Index, we conducted a retrospective cohort study of 12,410 children with behavioral health diagnoses. Four lasso-regularized logistic regression models were developed to predict dental general anesthesia use, each incorporating different data sources. Lift scores, or the ratio of positive predictive value to base case prevalence, were used to compare models, and a lift score of 2.5 was considered minimally acceptable for risk prediction. RESULTS Dental general anesthesia use ranged from 3.2% to 3.9% across models, which made it difficult for the machine learning models to achieve high positive predictive value. Model performance was best when either the electronic medical record (lift = 2.59) or Ohio Child Opportunity Index (lift = 2.56), but not both (lift = 2.34) or neither (lift = 1.87), was used. CONCLUSIONS Incorporating additional data sources improved machine learning model performance, and 2 models achieved satisfactory performance. The model using electronic medical record data could be applied in hospital-based settings, and the model using the Ohio Child Opportunity Index could be more valuable in community-based settings. KNOWLEDGE TRANSFER STATEMENT Machine learning was applied to satisfactorily predict which children with behavioral health diagnoses would require dental treatment under general anesthesia. Incorporating electronic medical record data or area-level social determinants of health data, but not both, improved the performance of the machine learning predictions. The 2 highest performing models could be applied by hospitals using medical record data or by organizations using area-level social determinants of health data to risk stratify the pediatric behavioral health population.
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Affiliation(s)
- J Peng
- IT Research & Innovation, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - T J Gorham
- IT Research & Innovation, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - B D Meyer
- Division of Pediatric Dentistry, The Ohio State University and Nationwide Children's Hospital, Columbus, OH, USA
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Gorham TJ, Tumin D, Groner J, Allen E, Retzke J, Hersey S, Liu SB, Macias C, Alachraf K, Smith AW, Blount T, Wall B, Crickmore K, Wooten WI, Jamison SD, Rust S. Predicting emergency department visits among children with asthma in two academic medical systems. J Asthma 2023; 60:2137-2144. [PMID: 37318283 DOI: 10.1080/02770903.2023.2225603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 06/11/2023] [Indexed: 06/16/2023]
Abstract
Objective: To develop and validate a predictive algorithm that identifies pediatric patients at risk of asthma-related emergencies, and to test whether algorithm performance can be improved in an external site via local retraining.Methods: In a retrospective cohort at the first site, data from 26 008 patients with asthma aged 2-18 years (2012-2017) were used to develop a lasso-regularized logistic regression model predicting emergency department visits for asthma within one year of a primary care encounter, known as the Asthma Emergency Risk (AER) score. Internal validation was conducted on 8634 patient encounters from 2018. External validation of the AER score was conducted using 1313 pediatric patient encounters from a second site during 2018. The AER score components were then reweighted using logistic regression using data from the second site to improve local model performance. Prediction intervals (PI) were constructed via 10 000 bootstrapped samples.Results: At the first site, the AER score had a cross-validated area under the receiver operating characteristic curve (AUROC) of 0.768 (95% PI: 0.745-0.790) during model training and an AUROC of 0.769 in the 2018 internal validation dataset (p = 0.959). When applied without modification to the second site, the AER score had an AUROC of 0.684 (95% PI: 0.624-0.742). After local refitting, the cross-validated AUROC improved to 0.737 (95% PI: 0.676-0.794; p = 0.037 as compared to initial AUROC).Conclusions: The AER score demonstrated strong internal validity, but external validity was dependent on reweighting model components to reflect local data characteristics at the external site.
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Affiliation(s)
- Tyler J Gorham
- Information Technology Research & Innovation, Nationwide Children's Hospital, Columbus, OH, USA
| | - Dmitry Tumin
- Department of Pediatrics, Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Judith Groner
- Division of Primary Care Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA
- Department of Pediatrics, The Ohio State University, Columbus, OH, USA
| | - Elizabeth Allen
- Division of Primary Care Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA
- Department of Pediatrics, The Ohio State University, Columbus, OH, USA
| | - Jessica Retzke
- Division of Primary Care Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA
- Department of Pediatrics, The Ohio State University, Columbus, OH, USA
| | - Stephen Hersey
- Division of Primary Care Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA
- Department of Pediatrics, The Ohio State University, Columbus, OH, USA
| | - Swan Bee Liu
- Information Technology Research & Innovation, Nationwide Children's Hospital, Columbus, OH, USA
| | - Charlie Macias
- Quality Improvement Services, Nationwide Children's Hospital, Columbus, OH, USA
| | - Kamel Alachraf
- Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Aimee W Smith
- Department of Psychology, East Carolina University, Greenville, NC, USA
| | | | | | | | - William I Wooten
- Department of Pediatrics, Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Shaundreal D Jamison
- Department of Pediatrics, Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Steve Rust
- Information Technology Research & Innovation, Nationwide Children's Hospital, Columbus, OH, USA
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Hersey SJ, Retzke J, Allen ED, Snyder D, Hardy C, Groner J. A Primary Care-Based Quality Improvement Project to Reduce Asthma Emergency Department Visits. Pediatrics 2023; 152:e2023061355. [PMID: 37960935 DOI: 10.1542/peds.2023-061355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/12/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Asthma exacerbation is a common and often preventable cause of Emergency Department (ED) utilization. Children eligible for Medicaid are at increased risk of poor asthma control and subsequent ED visits. In 2010, we implemented a multicomponent longitudinal quality improvement project to improve pediatric asthma care for our primary care population, which was 90% Medicaid-eligible. Our goal was to reduce asthma-related ED visits by patients ages 2 to 18 years by 3% annually. METHODS The setting was a multisite large urban high-risk primary care network affiliated with a children's hospital. We implemented 5 sequential interventions within our network of pediatric primary care centers to increase: use of asthma action plans by clinicians, primary care-based Asthma Specialty Clinic visits (extended asthma visits in the main primary care site), use of a standard asthma note at all visits, documentation of the Asthma Control Test, and step-up therapy for children with poorly controlled asthma. RESULTS At baseline in 2010, there were 21.7 asthma-related ED visits per 1000 patients per year. By 2019, asthma-related ED visits decreased to 14.5 per 1000 patients per year, a 33% decrease, with 2 center line shifts over time. We achieved and sustained our goal metrics for 4 of 5 key interventions. CONCLUSIONS We reduced ED utilization for asthma in a large, high-risk pediatric population. The interventions implemented and used over time in this project demonstrate that sustainable outcomes can be achieved in a large network of primary care clinics.
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Affiliation(s)
| | | | - Elizabeth D Allen
- Professor Emeritus, The Ohio State University College of Medicine, Columbus, Ohio
| | | | - Charles Hardy
- Center for Clinical Excellence, Nationwide Children's Hospital, Columbus, Ohio
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Greene HM, Letson MM, Spencer SP, Dolan K, Foster J, Crichton KG. Recognizing Nonaccidental Trauma in a Pediatric Tertiary Hospital: A Quality Improvement Imperative. Pediatr Qual Saf 2023; 8:e644. [PMID: 37051404 PMCID: PMC10085517 DOI: 10.1097/pq9.0000000000000644] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 02/17/2023] [Indexed: 04/14/2023] Open
Abstract
Abusive injuries can go unrecognized or improperly managed by medical providers. This study sought to standardize the nonaccidental trauma (NAT) workup and improve NAT evaluation completion for children <7 months with concerning injuries in the pediatric emergency department (PED) and inpatient settings at an urban, tertiary care children's hospital. Methods The quality improvement (QI) team created hospital guidelines for suspected NAT, including age-based recommendations (care bundle). The team embedded an order for NAT evaluation into the electronic health record (EHR). The QI team provided education on child abuse identification and evaluation across the hospital. Hospital providers received written guides focused on enhancing communication with families. Outcome measures included monthly NAT bundle use and cases between incomplete bundles in children with suspicious injuries. Chart review of incomplete bundles helped accurately identify patients who needed NAT bundles and improved accurate NAT bundle completion for appropriate patients. Results Appropriate NAT bundle completion increased from 31% during the baseline period in January 2019 to 100% in April 2020 and remained at 100% for the remainder of the study period, ending June 2021. The number of patients between missed bundles was 11 from August 2019 until March 2020, when it increased to 583. There were no missed bundles from March 2020 through June 2021. Conclusions Standardizing NAT evaluation and creating a NAT care bundle to facilitate the appropriate evaluation preceded an increase in appropriate bundle completion in patients <7 months old with possible NAT in the PED and inpatient units.
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Affiliation(s)
- H Michelle Greene
- Division of Emergency Medicine, Department of Pediatrics, The Ohio State University College of Medicine, and the Center for Clinical Excellence, Nationwide Children's Hospital, Columbus, Ohio
- Division of Child Abuse Pediatrics, Department of Pediatrics, The Ohio State University College of Medicine, and the Center for Clinical Excellence, Nationwide Children's Hospital, Columbus, Ohio
| | - Megan M Letson
- Division of Child Abuse Pediatrics, Department of Pediatrics, The Ohio State University College of Medicine, and the Center for Clinical Excellence, Nationwide Children's Hospital, Columbus, Ohio
| | - Sandra P Spencer
- Section of Emergency Medicine, Children's Hospital Colorado, and Department of Pediatrics University of Colorado School of Medicine, Aurora, Colorado
| | - Kevin Dolan
- Department of Quality Improvement, Center for Clinical Excellence, Nationwide Children's Hospital, Columbus, Ohio
| | - Jeanette Foster
- Department of Clinical Medical Social Work, The Ohio State University College of Social Work, and the Center for Clinical Excellence, Nationwide Children's Hospital, Columbus, Ohio
| | - Kristin G Crichton
- Division of Child Abuse Pediatrics, Department of Pediatrics, The Ohio State University College of Medicine, and the Center for Clinical Excellence, Nationwide Children's Hospital, Columbus, Ohio
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Schechter SB, Pantell MS, Parikh K, Nkoy F, McCulloh R, Fassl B, Kaiser SV. Impact of a National Quality Collaborative on Pediatric Asthma Care Quality by Insurance Status. Acad Pediatr 2021; 21:1018-1024. [PMID: 33607330 DOI: 10.1016/j.acap.2021.02.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 02/09/2021] [Accepted: 02/15/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To assess whether disparities in asthma care and outcomes based on insurance type existed before a national quality improvement (QI) collaborative, and to determine the effects of the collaborative on these disparities. METHODS Secondary analysis of data from Pathways for Improving Pediatric Asthma Care (PIPA), a national collaborative to standardize emergency department (ED) and inpatient asthma management. PIPA included children aged 2 to 17 with a diagnosis of asthma. Disparities were examined based on insurance status (public vs private). Outcomes included guideline adherence and health care utilization measures, assessed for 12 months before and 15 months after the start of PIPA. RESULTS We analyzed 19,204 ED visits and 11,119 hospitalizations from 89 sites. At baseline, children with public insurance were more likely than those with private insurance to receive early administration of corticosteroids (52.3% vs 48.9%, P= .01). However, they were more likely to be admitted (20.0% vs 19.4%, P = .01), have longer inpatient length of stay (31 vs 29 hours, P = .01), and have a readmission/ED revisit within 30 days (7.4% vs 5.6%, P = .02). We assessed the effects of PIPA on these disparities by insurance status and found no significant changes across 6 guideline adherence and 4 health care utilization measures. CONCLUSION At baseline, children with public insurance had higher asthma health care utilization than those with private insurance, despite receiving more evidence-based care. The PIPA collaborative did not affect pre-existing disparities in asthma outcomes. Future research should identify effective strategies for leveraging QI to better address disparities.
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Affiliation(s)
- Sarah B Schechter
- Department of Pediatrics, University of California, San Francisco (SB Schechter, MS Pantell, and SV Kaiser).
| | - Matthew S Pantell
- Department of Pediatrics, University of California, San Francisco (SB Schechter, MS Pantell, and SV Kaiser); Philip R. Lee Institute for Health Policy Studies (MS Pantell and SV Kaiser), San Francisco, Calif; Center for Health and Community, University of California, San Francisco (MS Pantell)
| | - Kavita Parikh
- Department of Pediatrics, Children's National Medical Center (K Parikh), Washington, DC
| | - Flory Nkoy
- Department of Pediatrics, University of Utah (F Nkoy and B Fassl), Salt Lake City, Utah
| | - Russell McCulloh
- Department of Pediatrics, Children's Hospital & Medical Center (R McCulloh), Omaha, Nebr
| | - Bernhard Fassl
- Department of Pediatrics, University of Utah (F Nkoy and B Fassl), Salt Lake City, Utah
| | - Sunitha V Kaiser
- Department of Pediatrics, University of California, San Francisco (SB Schechter, MS Pantell, and SV Kaiser); Philip R. Lee Institute for Health Policy Studies (MS Pantell and SV Kaiser), San Francisco, Calif; Department of Epidemiology and Biostatistics, University of California, San Francisco (SV Kaiser)
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Ulrich L, Macias C, George A, Bai S, Allen E. Unexpected decline in pediatric asthma morbidity during the coronavirus pandemic. Pediatr Pulmonol 2021; 56:1951-1956. [PMID: 33848402 PMCID: PMC8251009 DOI: 10.1002/ppul.25406] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 03/11/2021] [Accepted: 03/29/2021] [Indexed: 02/06/2023]
Abstract
The Coronavirus disease 2019 (COVID-19) pandemic profoundly impacted health care utilization. We evaluated asthma-related emergency department (ED) and inpatient health care utilization by a county-specific Medicaid population, ages 2-18, during the COVID-19 pandemic and compared it to utilization from a 3-year average including 2017-2019. All-cause ED utilization and asthma medication fill rates were evaluated during the same timeframes. Relative to the 2017-2019 3-year average, cumulative asthma-related ED visits from January through June decreased by 45.8% (p = .03) and inpatient admission rates decreased by 50.5% (p = .03). The decline in asthma-related ED utilization was greater than the reduction of overall ED use during the same time period, suggesting that the decline involved factors specific to asthma and was not due solely to avoidance of health care facilities. Fill rates for asthma controller medications decreased during this time (p = .03) and quick relief medication fill rates had no significant change (p = .31). Multiple factors may have contributed to the decrease in acute asthma health care visits. Locally, decreased air pollution and viral exposures coincided with the "Stay-at-home" order in Ohio, and increased utilization of telehealth for assessment during exacerbations may have impacted outcomes. Identification of the cause of the decline in visit rates could spur new interventions to limit the need for ED and inpatient visits for asthma patients, leading to both economic and health-associated benefits.
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Affiliation(s)
- Lisa Ulrich
- Section of Pulmonary Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Charlie Macias
- Quality Improvement Services, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Ashish George
- Section of Pulmonary Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Shasha Bai
- Biostatistics Resource at Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Biomedical Informatics, College of Medicine, The Ohio State University, Ohio, USA
| | - Elizabeth Allen
- Section of Pulmonary Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
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Lung Transplant Index: A Quality Improvement Initiative. Pediatr Qual Saf 2019; 4:e209. [PMID: 31745512 PMCID: PMC6831041 DOI: 10.1097/pq9.0000000000000209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 08/05/2019] [Indexed: 11/25/2022] Open
Abstract
Limited long-term survival is a recognized problem in adolescent/young adult lung transplant recipients. A quality improvement (QI) initiative included the development of a Lung Transplant Index (LTI) composed of key elements that we used as a comprehensive approach to screen and identify potential harms in this at-risk patient population. Methods A single-center, uncontrolled QI study was completed from January 2014 to February 2019. The elements of the LTI are events that should have occurred within the most recent 12 months. If an element did not occur, it was counted as a missed element of preventing harm and summated later serving as the LTI score. Implementation of the LTI occurred on January 1, 2015, with a retrospective chart review of patients seen in clinic the prior year serving as baseline measures for comparison. Results The year before implementing the LTI, numerous opportunities failed to identify preventable harm in our adolescent/young adult lung transplant population. The LTI resulted in a sustained reduction of these missed opportunities without negatively influencing patient/family satisfaction with lengthening of the clinic visit. Conclusions A single-center QI initiative identified preventable harms in an adolescent/young adult lung transplant population and reduced the number of preventable harm elements not performed. Future work is needed to determine if this type of QI initiative is associated with less healthcare utilization.
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