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Smith CJ, Raval MV, Simon MA, Henry MCW. Addressing pediatric surgical health inequities through quality improvement efforts. Semin Pediatr Surg 2023; 32:151280. [PMID: 37147217 DOI: 10.1016/j.sempedsurg.2023.151280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
Concepts of healthcare quality and health equity should be inextricably linked but are often pursued separately. Quality improvement (QI) can serve as a powerful means to eliminate health inequities by adopting an equity-focused lens to diagnose and address baseline disparities among pediatric populations using targeted interventions. QI and pediatric surgery practitioners should integrate concepts of equity at every stage of formulating a QI project including conceptualization, planning, and execution. Early adaptation of an equity conscious perspective using QI methodology can prevent exacerbation of preexisting disparities while improving overall outcomes.
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Affiliation(s)
- Charesa J Smith
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA; Northwestern Quality Improvement, Research, & Education in Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA; Northwestern Quality Improvement, Research, & Education in Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Melissa A Simon
- Department of Obstetrics and Gynecology, Center for Health Equity Transformation, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Marion C W Henry
- Division of Pediatric Surgery, Department of Surgery, University of Chicago, Chicago, Illinois, USA
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Honcoop AC, Poitevien P, Kerns E, Alverson B, McCulloh RJ. Racial and ethnic disparities in bronchiolitis management in freestanding children's hospitals. Acad Emerg Med 2021; 28:1043-1050. [PMID: 33960050 DOI: 10.1111/acem.14274] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 04/30/2021] [Accepted: 05/02/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Variation in bronchiolitis management by race and ethnicity within emergency departments (EDs) has been described in single-center and prospective studies, but large-scale assessments across EDs and inpatient settings are lacking. Our objective is to describe the association between race and ethnicity and bronchiolitis management across 37 U.S. freestanding children's hospitals from 2015 to 2018. METHODS Using the Pediatric Health Information System, we analyzed ED and inpatient visits from November 2015 to November 2018 of children with bronchiolitis 3 to 24 months old. Rates of use for specific diagnostic tests and therapeutic measures were compared across the following race/ethnicity categories: 1) non-Hispanic White (NHW), 2) non-Hispanic Black (NHB), 3) Hispanic, and 4) other. The subanalyses of ED patients only and children < 1 year old were performed. Mixed-effect logistic regression was performed to compare the adjusted odds of receiving specific test/treatment using NHW children as the reference group. RESULTS A total of 134,487 patients met inclusion criteria (59% male, 28% NHB, 26% Hispanic). Adjusted analysis showed that NHB children had higher odds of receiving medication associated with asthma (odds ratio [OR] = 1.27, 95% confidence interval [CI] = 1.22 to 1.32) and lower odds of receiving diagnostic tests (blood cultures, complete blood counts, viral testing, chest x-rays; OR = 0.78, 95% CI = 0.75 to 0.81) and antibiotics (OR = 0.58, 95% CI = 0.52 to 0.64) than NHW children. Hispanic children had lower odds of receiving diagnostic testing (OR = 0.94, 95% CI = 0.90 to 0.98), asthma-associated medication (OR = 0.92, 95% CI = 0.88 to 0.96), and antibiotics (OR = 0.74, 95% CI = 0.66 to 0.82) compared to NHW children. CONCLUSION NHB children more often receive corticosteroid and bronchodilator therapies; NHW children more often receive antibiotics and chest radiography. Given that current guidelines generally recommend supportive care with limited diagnostic testing and medical intervention, these findings among NHB and NHW children represent differing patterns of overtreatment. The underlying causes of these patterns require further investigation.
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Affiliation(s)
| | - Patricia Poitevien
- Hasbro Children's HospitalWarren Alpert Medical School Providence Rhode Island USA
| | - Ellen Kerns
- University of Nebraska Medical CenterChildren's Hospital Medical Center Omaha Nebraska USA
| | - Brian Alverson
- Hasbro Children's HospitalWarren Alpert Medical School Providence Rhode Island USA
| | - Russell J. McCulloh
- University of Nebraska Medical CenterChildren's Hospital Medical Center Omaha Nebraska USA
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Paul R, Niedner M, Brilli R, Macias C, Riggs R, Balamuth F, Depinet H, Larsen G, Huskins C, Scott H, Lucasiewicz G, Schaffer M, DeSouza HG, Silver P, Richardson T, Hueschen L, Campbell D, Wathen B, Auletta JJ. Metric Development for the Multicenter Improving Pediatric Sepsis Outcomes (IPSO) Collaborative. Pediatrics 2021; 147:peds.2020-017889. [PMID: 33795482 PMCID: PMC8131032 DOI: 10.1542/peds.2020-017889] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/22/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND A 56 US hospital collaborative, Improving Pediatric Sepsis Outcomes, has developed variables, metrics and a data analysis plan to track quality improvement (QI)-based patient outcomes over time. Improving Pediatric Sepsis Outcomes expands on previous pediatric sepsis QI efforts by improving electronic data capture and uniformity across sites. METHODS An expert panel developed metrics and corresponding variables to assess improvements across the care delivery spectrum, including the emergency department, acute care units, hematology and oncology, and the ICU. Outcome, process, and balancing measures were represented. Variables and statistical process control charts were mapped to each metric, elucidating progress over time and informing plan-do-study-act cycles. Electronic health record (EHR) abstraction feasibility was prioritized. Time 0 was defined as time of earliest sepsis recognition (determined electronically), or as a clinically derived time 0 (manually abstracted), identifying earliest physiologic onset of sepsis. RESULTS Twenty-four evidence-based metrics reflected timely and appropriate interventions for a uniformly defined sepsis cohort. Metrics mapped to statistical process control charts with 44 final variables; 40 could be abstracted automatically from multiple EHRs. Variables, including high-risk conditions and bedside huddle time, were challenging to abstract (reported in <80% of encounters). Size or type of hospital, method of data abstraction, and previous QI collaboration participation did not influence hospitals' abilities to contribute data. To date, 90% of data have been submitted, representing 200 007 sepsis episodes. CONCLUSIONS A comprehensive data dictionary was developed for the largest pediatric sepsis QI collaborative, optimizing automation and ensuring sustainable reporting. These approaches can be used in other large-scale sepsis QI projects in which researchers seek to leverage EHR data abstraction.
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Affiliation(s)
- Raina Paul
- Division of Emergency Medicine, Advocate Children's Hospital, Park Ridge, Illinois;
| | - Matthew Niedner
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, School of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Richard Brilli
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio
| | - Charles Macias
- Division of Pediatric Emergency Medicine, Rainbow Babies and Children’s Hospital and Case Western Reserve University, Cleveland, Ohio
| | - Ruth Riggs
- Children’s Hospital Association, Lenexa, Kansas
| | - Frances Balamuth
- Department of Pediatrics, University of Pennsylvania and Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Holly Depinet
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio,Department of Pediatrics, School of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Gitte Larsen
- Pediatric Critical Care, Department of Pediatrics, Primary Children’s Hospital, Salt Lake City, Utah
| | - Charlie Huskins
- Division of Pediatric Infectious Diseases, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - Halden Scott
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado,Section of Pediatric Emergency Medicine, Children’s Hospital Colorado, Aurora, Colorado
| | | | - Melissa Schaffer
- Department of Pediatrics, Upstate Medical University, Syracuse, New York
| | | | - Pete Silver
- Department of Pediatrics, Zucker School of Medicine at Hofstra, Cohen Children’s Medical Center, East Garden City, New York
| | | | - Leslie Hueschen
- Section of Pediatric Emergency Medicine, Department of Pediatrics, University of Missouri-Kansas City and Children’s Mercy Hospital, Kansas City, Missouri
| | | | - Beth Wathen
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado,Section of Pediatric Emergency Medicine, Children’s Hospital Colorado, Aurora, Colorado
| | - Jeffery J. Auletta
- Divisions of Hematology, Oncology, and Blood and Marrow Transplant and Infectious Diseases, Department of Pediatrics, Nationwide Children’s Hospital and College of Medicine, The Ohio State University, Columbus, Ohio
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Zhang GX, Chen KJ, Zhu HT, Lin AL, Liu ZH, Liu LC, Ji R, Chan FSY, Fan JKM. Preventable Deaths in Multiple Trauma Patients: The Importance of Auditing and Continuous Quality Improvement. World J Surg 2021; 44:1835-1843. [PMID: 32052106 DOI: 10.1007/s00268-020-05423-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Management errors during pre-hospital care, triage process and resuscitation have been widely reported as the major source of preventable and potentially preventable deaths in multiple trauma patients. Common tools for defining whether it is a preventable, potentially preventable or non-preventable death include the Advanced Trauma Life Support (ATLS®) clinical guideline, the Injury Severity Score (ISS) and the Trauma and Injury Severity Score (TRISS). Therefore, these surrogated scores were utilized in reviewing the study's trauma services. METHODS Trauma data were prospectively collected and retrospectively reviewed from January 1, 2018, to December 31, 2018. All cases of trauma death were discussed and audited by the Hospital Trauma Committee on a regular basis. Standardized form was used to document the patient's management flow and details in every case during the meeting, and the final verdict (whether death was preventable or not) was agreed and signed by every member of the team. The reasons for the death of the patients were further classified into severe injuries, inappropriate/delayed examination, inappropriate/delayed treatment, wrong decision, insufficient supervision/guidance or lack of appropriate guidance. RESULTS A total of 1913 trauma patients were admitted during the study period, 82 of whom were identified as major trauma (either ISS > 15 or trauma team was activated). Among the 82 patients with major trauma, eight were trauma-related deaths, one of which was considered a preventable death and the other 7 were considered unpreventable. The decision from the hospital's performance improvement and patient safety program indicates that for every trauma patient, basic life support principles must be followed in the course of primary investigations for bedside trauma series X-ray (chest and pelvis) and FAST scan in the resuscitation room by a person who meets the criteria for trauma team activation recommended by ATLS®. CONCLUSION Mechanisms to rectify errors in the management of multiple trauma patients are essential for improving the quality of trauma care. Regular auditing in the trauma service is one of the most important parts of performance improvement and patient safety program, and it should be well established by every major trauma center in Mainland China. It can enhance the trauma management processes, decision-making skills and practical skills, thereby continuously improving quality and reducing mortality of this group of patients.
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Affiliation(s)
- Gui-Xi Zhang
- Department of Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Ke-Jin Chen
- Department of Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Hong-Tao Zhu
- Department of Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Ai-Ling Lin
- Department of Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Zhong-Hui Liu
- Department of Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Li-Chang Liu
- Department of Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Ren Ji
- Department of Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Fion Siu Yin Chan
- Department of Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China.,Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pok Fu Lam Road, Hong Kong Special Administrative Region, China
| | - Joe King Man Fan
- Department of Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China. .,Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pok Fu Lam Road, Hong Kong Special Administrative Region, China.
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