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Santoro SL, Howe YJ, Krell K, Skotko BG, Co JPT. Health Surveillance in a Down Syndrome Specialty Clinic: Implementation of EHR-integrations during the COVID pandemic. J Pediatr 2022; 255:58-64.e6. [PMID: 37081778 PMCID: PMC9617631 DOI: 10.1016/j.jpeds.2022.10.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 10/13/2022] [Accepted: 10/16/2022] [Indexed: 11/05/2022]
Abstract
Objective To address gaps in routine recommended care for children with Down syndrome, through quality improvement during the COVID-19 pandemic. Study design A retrospective chart review of patients with Down syndrome was conducted. Records of visits to the Massachusetts General Hospital Down Syndrome Program were assessed for adherence to five components of the 2011 American Academy of Pediatrics (AAP) Clinical Report, “Health Supervision for Children with Down Syndrome.” The impact of two major changes was analyzed using statistical process control charts: a planned intervention of integrations to the electronic health record (EHR) for routine health maintenance with age-based logic based on a diagnosis of Down syndrome, created and implemented in July 2020; and a natural disruption in care due to the COVID-19 pandemic, starting in March 2020. Results From December 2018 to March 2022, 433 patients with Down syndrome had 940 visits. During the COVID-19 pandemic, adherence to the audiology component decreased (58% to 45%, p <0.001); composite adherence decreased but later improved. Ophthalmology evaluation remained stable. Improvement in adherence to three components (TSH, hemoglobin, sleep study ever) in July 2020 coincided with EHR-integrations. Total adherence to the 5 AAP guideline components was higher for follow-up visits compared with new patient visits (69% and 61%, respectively; p < 0.01). Conclusion The COVID-19 pandemic influenced adherence to components of the AAP Health supervision for children with Down syndrome but improvements in adherence coincided with implementation of our intervention, and re-opening after the COVID-19 pandemic. As each primary care pediatrician cares for 1–2 patients with Down syndrome (1), for many children the current care model involves a primary care physician providing health supervision for children with Down syndrome following the American Academy of Pediatrics’ (AAP) Clinical Report.(2–4)
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Affiliation(s)
- Stephanie L Santoro
- Down Syndrome Program, Division of Medical Genetics and Metabolism, Department of Pediatrics, Massachusetts General Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA.
| | - Yamini J Howe
- Department of Pediatrics, Harvard Medical School, Boston, MA; Lurie Center for Autism, Massachusetts General Hospital, Boston, MA
| | - Kavita Krell
- Down Syndrome Program, Division of Medical Genetics and Metabolism, Department of Pediatrics, Massachusetts General Hospital, Boston, MA
| | - Brian G Skotko
- Down Syndrome Program, Division of Medical Genetics and Metabolism, Department of Pediatrics, Massachusetts General Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - John Patrick T Co
- Department of Pediatrics, Harvard Medical School, Boston, MA; Department of Pediatrics, Massachusetts General Hospital, Boston, MA
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Improving Delivery of Care through Standardized Monitoring in Children with Eosinophilic Esophagitis. Pediatr Qual Saf 2021; 6:e429. [PMID: 34345747 PMCID: PMC8322550 DOI: 10.1097/pq9.0000000000000429] [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: 08/24/2020] [Accepted: 01/04/2021] [Indexed: 12/01/2022] Open
Abstract
Introduction: Eosinophilic esophagitis (EoE) is a chronic, antigen-driven disorder for which endoscopic monitoring and multidisciplinary care are recommended to achieve histologic remission. The EoE team at our large academic center developed a quality improvement (QI) initiative aimed to reduce variability in monitoring. This QI project focused on completing 3 process metrics within 6 months of diagnosis: (1) outpatient follow-up with a gastroenterologist; (2) referral to an allergist; and (3) Follow-up esophagogastroduodenoscopy (EGD). Methods: In January 2015, our QI team developed a registry of newly diagnosed EoE patients and maintained ongoing, weekly tracking of the process measures. Interventions to increase the completion of the process metrics included educational sessions, proactive reminders to providers, and targeted communications with patient families. Missed opportunities were evaluated by more in-depth chart review and categorized as provider- or patient-driven. Results: We tracked 6-month process metrics from 2015 through 2018. During this interval, follow-up visit rates in GI improved from 77% to 86%, and the percentage of referrals placed to allergy increased from 65% to 77%. The percentage of patients completing a repeat EGD improved from 33% to 61%. Among patients without a repeated EGD, nearly 70% of those missed opportunities were provider-driven. Conclusions: In patients newly diagnosed with EoE, QI interventions, including patient registry development, implementation of a local standard of care, and creating a patient tracking system, improved adherence with national EoE monitoring guidelines.
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The Type 1 Diabetes Composite Score: An Innovative Metric for Measuring Patient Care Outcomes Beyond Hemoglobin A 1c. Pediatr Qual Saf 2020; 5:e354. [PMID: 33062905 PMCID: PMC7531753 DOI: 10.1097/pq9.0000000000000354] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 07/29/2020] [Indexed: 02/06/2023] Open
Abstract
Introduction Patient outcomes resulting from optimal type 1 diabetes (T1D) care have historically focused on driving a single metric, hemoglobin A1c. Our objectives were to design, build, and launch an aggregate clinical indicator that comprehensively reflects patient management status beyond hemoglobin A1c alone. This project aimed to show proof of principle that an aggregate score comprised of T1D outcome metrics could be built to track quality performance. Methods We established an electronic medical record-based diabetes registry and utilized its population health modules to design and build this diabetes care metric. Elements representing optimal diabetes management, as defined by current guidelines and expert opinion, were identified. Nine elements fall into categories of management tools, care assessments, and complications risk. The Type 1 Diabetes Composite Score (T1DCS) aggregates these outcome measures to reflect the overall diabetes care status for each patient. Higher scores suggest better management and overall improved patient health. Results We launched this metric build in November 2018 and applied the scoring to our T1D population (≈1,900 patients). The T1DCS quickly provides a summary of current diabetes management status. T1DCS viewed over the registry cohort demonstrates a normal distribution, and scores improved from March to September 2019, reflecting better care and outcomes, and illustrating the potential to track program effectiveness. Conclusions The T1DCS is a useful metric to evaluate the clinical status of T1D patients, assess the capability of a clinical program to achieve optimal diabetes outcomes, identify patient diversity opportunities, and document outcome improvement as a novel comprehensive quality measure.
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Cronin J, Heitmiller E, Shah RK. Perioperative Harm Index facilitates prioritization of improvement initiatives. J Pediatr Surg 2020; 55:1453-1456. [PMID: 31708213 DOI: 10.1016/j.jpedsurg.2019.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 10/07/2019] [Accepted: 10/08/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Perioperative services constitute a significant portion of the care delivery, the impact, and the potential risk in healthcare organizations. Tremendous attention has been paid towards hospital-acquired conditions; however perioperative services have not received similar attention. There is a need for a standardized manner to report on conditions in perioperative services which facilitates prioritization of quality improvement initiatives. MATERIALS AND METHODS Preventable harm and quality of care indicators were selected based on a review of the literature and available datasets, as well as from safety and quality measures in our organization. Metrics were derived from myriad national quality improvement initiatives and collaboratives. A structure was created to obtain the metrics in a near real-time manner and present the Perioperative Harm Index across the organization. Specific initiatives were targeted as necessitating immediate, short-term, or longer duration prioritization for improvement initiatives. RESULTS A Perioperative Harm Index was created using 11 metrics that represent the spectrum of surgical care. The metrics facilitate prioritization of improvement initiatives and have resulted in improvement projects including perioperative normothermia in neonatal intensive care unit patients having procedures in the operating room, reduction of post-operative nausea and vomiting, and decrease in surgical site infections in selected procedures. CONCLUSIONS A Perioperative Harm Index facilitates immediate shared understanding of the harm resulting from the care of surgical patients. As such, this index enables rapid and rationale prioritization for improvement activities. Our harm index is shared, is broadly generalizable, and has facilitated prioritization of improvement opportunities and appropriate allocation of improvement resources at our organization. LEVELS OF EVIDENCE Level V.
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Affiliation(s)
- Jessica Cronin
- Children's National Medical Center, Washington, DC; George Washington University School of Medicine, Washington, DC.
| | - Eugenie Heitmiller
- Children's National Medical Center, Washington, DC; George Washington University School of Medicine, Washington, DC
| | - Rahul K Shah
- Children's National Medical Center, Washington, DC; George Washington University School of Medicine, Washington, DC
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Obrynba KS, Indyk JA, Gandhi KK, Buckingham D, Kamboj MK. The diabetes care index: A novel metric to assess delivery of optimal type 1 diabetes care. Pediatr Diabetes 2020; 21:637-643. [PMID: 32173956 DOI: 10.1111/pedi.13006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 03/09/2020] [Accepted: 03/12/2020] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES The American Diabetes Association (ADA) and the International Society for Pediatric and Adolescent Diabetes (ISPAD) have outlined standards for best practices in providing optimal diabetes care to children with type 1 diabetes (T1D). Our objectives were to design a metric that evaluated delivery of optimal diabetes care and to use this metric to drive improvement within our diabetes program. METHODS Using published guidelines, we identified 11 elements of optimal diabetes care that should be reliably delivered at our institution as standard-of-care. We utilized our electronic medical record to aid in data collection and to notify staff when to deliver specific care elements (eg, lipid collection, depression screening, etc.). We designed the T1D Care Index (T1DCI), a metric which aggregates missed opportunities to deliver elements of optimal diabetes care over a given period into a cumulative score, with a lower T1DCI reflecting better care delivery and improved program performance. RESULTS Tracking the T1DCI permitted recognition of areas to focus on quality improvement efforts, guided interventions to improve processes for care delivery, and helped determine the allocation of time and resources. Interventions resulted in improvement of care delivery across some elements of care. Overall, we observed a 26% reduction in the T1DCI after 12 months of utilization. CONCLUSIONS The T1DCI is a powerful metric to evaluate the ability of our diabetes program to standardize, quantify, and monitor delivery of optimal diabetes care to children with T1D, and to drive our program toward zero missed opportunities for quality care delivery.
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Affiliation(s)
- Kathryn S Obrynba
- Division of Endocrinology and Diabetes, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Pediatrics, The Ohio State University, Columbus, Ohio, USA
| | - Justin A Indyk
- Division of Endocrinology and Diabetes, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Pediatrics, The Ohio State University, Columbus, Ohio, USA
| | - Kajal K Gandhi
- Division of Endocrinology and Diabetes, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Pediatrics, The Ohio State University, Columbus, Ohio, USA
| | - Don Buckingham
- Quality Improvement Services, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Manmohan K Kamboj
- Division of Endocrinology and Diabetes, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Pediatrics, The Ohio State University, Columbus, Ohio, USA
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Sparks B, Salman S, Shull M, Trout A, Kiel A, Hill I, Ediger T, Boyle B. A Celiac Care Index Improves Care of Pediatric Patients Newly Diagnosed with Celiac Disease. J Pediatr 2020; 216:32-36.e2. [PMID: 31706635 DOI: 10.1016/j.jpeds.2019.09.071] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 09/12/2019] [Accepted: 09/25/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVES To describe quality improvement efforts to reduce variability in the care of children diagnosed with celiac disease through use of an institutional patient registry and a chronic care index. STUDY DESIGN An institutional patient registry tracked rates of follow-up visits and repeat serologic testing. A Celiac Care Index that included anthropometrics, biopsy expectations, dietician consultation, and baseline laboratory evaluation was developed to standardize evaluation at diagnosis. Provider education sessions communicated expectations for this standard of care and order sets within the electronic medical record simplified test collection. Data was recorded and reviewed weekly and structured communications with providers were provided biweekly. RESULTS Adherence with follow-up expectations (77%-89% P = .03) and repeat serologic testing (50%-90% P < .0001) significantly increased during the study period. Adherence with completion of the Celiac Care Index resulted in significant improvement in obtaining complete blood count (80%-98% P < .0001), iron (25%-78% P < .0001), ferritin (34%-80% P < .0001), alanine aminotransferase/aspartate aminotransferase (74%-96% P < .0001), thyroid-stimulating hormone (64%-90% P < .0001), vitamin D (36%-83% P < .0001), and hepatitis B immune status (30%-80% P < .0001). Iron deficiency demonstrated by low ferritin levels was common (41%) and a high rate of nonimmunity to hepatitis B (70%) was detected. CONCLUSIONS The Celiac Care Index improved adherence with published care recommendations and reduced variability in baseline evaluation at diagnosis. Laboratory test results indicate further studies are needed to evaluate these recommendations.
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Affiliation(s)
- Brandon Sparks
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Riley Hospital for Children at IU Health, Indianapolis, IN.
| | - Salman Salman
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, OH
| | - Mary Shull
- Digestive Health Institute, Children's Hospital Colorado, Denver, CO
| | - Anne Trout
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, OH
| | - Ashley Kiel
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, OH
| | - Ivor Hill
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, OH
| | - Tracy Ediger
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, OH
| | - Brendan Boyle
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, OH
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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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Barron CL, Elmaraghy CA, Lemle S, Crandall W, Brilli RJ, Jatana KR. Clinical Indices to Drive Quality Improvement in Otolaryngology. Otolaryngol Clin North Am 2018; 52:123-133. [PMID: 30390736 DOI: 10.1016/j.otc.2018.08.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
A Pediatric Tracheostomy Care Index (PTCI) was developed by the authors to standardize care and drive quality improvement efforts at their institution. The PTCI comprises 9 elements deemed essential for safe care of children with a tracheostomy tube. Based on the PTCI scores, the number of missed opportunities per patient was tracked, and interventions through a "Plan-Do-Study-Act" approach were performed. The establishment of the PTCI has been successful at standardizing, quantifying, and monitoring the consistency and documentation of care provided at the authors' institution.
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Affiliation(s)
- Christine L Barron
- The Ohio State University College of Medicine, 370 West 9th Avenue, Columbus, OH 43210, USA
| | - Charles A Elmaraghy
- Department of Pediatric Otolaryngology, Nationwide Children's Hospital, 555 South 18th Street, Suite 2A, Columbus, OH 43205, USA; Department of Otolaryngology-Head and Neck Surgery, Wexner Medical Center at Ohio State University, 915 Olentangy River Road, Columbus, OH 43212, USA
| | - Stephanie Lemle
- Quality Improvement Services, Nationwide Children's Hospital, 700 Children's Drive, Suite 2A, Columbus, OH 43205, USA
| | - Wallace Crandall
- Quality Improvement Services, Nationwide Children's Hospital, 700 Children's Drive, Suite 2A, Columbus, OH 43205, USA; Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Ohio State University College of Medicine, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - Richard J Brilli
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Ohio State University College of Medicine, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - Kris R Jatana
- Department of Pediatric Otolaryngology, Nationwide Children's Hospital, 555 South 18th Street, Suite 2A, Columbus, OH 43205, USA; Department of Otolaryngology-Head and Neck Surgery, Wexner Medical Center at Ohio State University, 915 Olentangy River Road, Columbus, OH 43212, USA.
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