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Kassie AM, Eakin E, Abate BB, Endalamaw A, Zewdie A, Wolka E, Assefa Y. The use of positive deviance approach to improve health service delivery and quality of care: a scoping review. BMC Health Serv Res 2024; 24:438. [PMID: 38589897 PMCID: PMC11003118 DOI: 10.1186/s12913-024-10850-2] [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: 11/16/2023] [Accepted: 03/11/2024] [Indexed: 04/10/2024] Open
Abstract
BACKGROUND Quality has been a persistent challenge in the healthcare system, particularly in resource-limited settings. As a result, the utilization of innovative approaches is required to help countries in their efforts to enhance the quality of healthcare. The positive deviance (PD) approach is an innovative approach that can be utilized to improve healthcare quality. The approach assumes that solutions to problems are already available within the community and identifying and sharing those solutions can help others to resolve existing issues. Therefore, this scoping review aimed to synthesize the evidence regarding the use of the PD approach in healthcare system service delivery and quality improvement programs. METHODS Articles were retrieved from six international databases. The last date for article search was June 02, 2023, and no date restriction was applied. All articles were assessed for inclusion through a title and/or abstract read. Then, articles that passed the title and abstract review were screened by reading their full texts. In case of duplication, only the full-text published articles were retained. A descriptive mapping and evidence synthesis was done to present data with the guide of the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for Scoping Reviews checklist and the results are presented in text, table, and figure formats. RESULTS A total of 125 articles were included in this scoping review. More than half, 66 (52.8%), of the articles were from the United States, 11(8.8%) from multinational studies, 10 (8%) from Canada, 8 (6.4%) from the United Kingdom and the remaining, 30 (24%) are from other nations around the world. The scoping review indicates that several types of study designs can be applied in utilizing the PD approach for healthcare service and quality improvement programs. However, although validated performance measures are utilized to identify positive deviants (PDs) in many of the articles, some of the selection criteria utilized by authors lack clarity and are subject to potential bias. In addition, several limitations have been mentioned in the articles including issues in operationalizing PD, focus on leaders and senior managers and limited staff involvement, bias, lack of comparison, limited setting, and issues in generalizability/transferability of results from prospects perspective. Nevertheless, the limitations identified are potentially manageable and can be contextually resolved depending on the nature of the study. Furthermore, PD has been successfully employed in healthcare service and quality improvement programs including in increasing surgical care quality, hand hygiene practice, and reducing healthcare-associated infections. CONCLUSION The scoping review findings have indicated that healthcare systems have been able to enhance quality, reduce errors, and improve patient outcomes by identifying lessons from those who exhibit exceptional practices and implementing successful strategies in their practice. All the outcomes of PD-based research, however, are dependent on the first step of identifying true PDs. Hence, it is critical that PDs are identified using objective and validated measures of performance as failure to identify true PDs can subsequently lead to failure in identifying best practices for learning and dissemination to other contextually similar settings.
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Affiliation(s)
- Ayelign Mengesha Kassie
- School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, Australia.
- School of Nursing, College of Health Sciences, Woldia University, Woldia, Ethiopia.
| | - Elizabeth Eakin
- School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Biruk Beletew Abate
- School of Nursing, College of Health Sciences, Woldia University, Woldia, Ethiopia
| | - Aklilu Endalamaw
- School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, Australia
- College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Anteneh Zewdie
- International Institute for Primary Health Care, Ethiopia, Addis Ababa, Ethiopia
| | - Eskinder Wolka
- International Institute for Primary Health Care, Ethiopia, Addis Ababa, Ethiopia
| | - Yibeltal Assefa
- School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, Australia
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Mrosak J, Kandaswamy S, Stokes C, Roth D, Gorbatkin J, Dave I, Gillespie S, Orenstein E. The Effect of Implementation of Guideline Order Bundles Into a General Admission Order Set on Clinical Practice Guideline Adoption: Quasi-Experimental Study. JMIR Med Inform 2023; 11:e42736. [PMID: 36943348 PMCID: PMC10131941 DOI: 10.2196/42736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 11/30/2022] [Accepted: 12/01/2022] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Clinical practice guidelines (CPGs) and associated order sets can help standardize patient care and lead to higher-value patient care. However, difficult access and poor usability of these order sets can result in lower use rates and reduce the CPGs' impact on clinical outcomes. At our institution, we identified multiple CPGs for general pediatrics admissions where the appropriate order set was used in <50% of eligible encounters, leading to decreased adoption of CPG recommendations. OBJECTIVE We aimed to determine how integrating disease-specific order groups into a common general admission order set influences adoption of CPG-specific order bundles for patients meeting CPG inclusion criteria admitted to the general pediatrics service. METHODS We integrated order bundles for asthma, heavy menstrual bleeding, musculoskeletal infection, migraine, and pneumonia into a common general pediatrics order set. We compared pre- and postimplementation order bundle use rates for eligible encounters at both an intervention and nonintervention site for integrated CPGs. We also assessed order bundle adoption for nonintegrated CPGs, including bronchiolitis, acute gastroenteritis, and croup. In a post hoc analysis of encounters without order bundle use, we compared the pre- and postintervention frequency of diagnostic uncertainty at the time of admission. RESULTS CPG order bundle use rates for incorporated CPGs increased by +9.8% (from 629/856, 73.5% to 405/486, 83.3%) at the intervention site and by +5.1% (896/1351, 66.3% to 509/713, 71.4%) at the nonintervention site. Order bundle adoption for nonintegrated CPGs decreased from 84% (536/638) to 68.5% (148/216), driven primarily by decreases in bronchiolitis order bundle adoption in the setting of the COVID-19 pandemic. Diagnostic uncertainty was more common in admissions without CPG order bundle use after implementation (28/227, 12.3% vs 19/81, 23.4%). CONCLUSIONS The integration of CPG-specific order bundles into a general admission order set improved overall CPG adoption. However, integrating only some CPGs may reduce adoption of order bundles for excluded CPGs. Diagnostic uncertainty at the time of admission is likely an underrecognized barrier to guideline adherence that is not addressed by an integrated admission order set.
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Affiliation(s)
| | - Swaminathan Kandaswamy
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States
| | - Claire Stokes
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States
- Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - David Roth
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Jenna Gorbatkin
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States
| | - Ishaan Dave
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States
| | - Scott Gillespie
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States
| | - Evan Orenstein
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States
- Children's Healthcare of Atlanta, Atlanta, GA, United States
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Bowden CF, Worsley D, Esposito JM, Cutler GJ, Doupnik SK. Pediatric emergency departments' readiness for change toward improving suicide prevention: A mixed-methods study with US leaders. J Am Coll Emerg Physicians Open 2022; 3:e12839. [PMID: 36311338 PMCID: PMC9597096 DOI: 10.1002/emp2.12839] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 09/14/2022] [Accepted: 09/29/2022] [Indexed: 11/18/2022] Open
Abstract
Objective To assess pediatric emergency departments' (PEDs) current suicide prevention practices and climate for change to improve suicide prevention for youth. Methods We conducted an explanatory, sequential mixed-methods study. First, we deployed a national, cross-sectional survey of PED leaders identified through publicly available data in Fall 2020, and then we conducted follow-up interviews with those who expressed interest. The survey queried each PED's suicide prevention practices and measured readiness for change to improve suicide prevention practices using questions scored on a 5-point Likert scale. Interviews gathered further, in-depth descriptions of PEDs' practices and culture. Interviews were audio-recorded, transcribed verbatim, and analyzed using a rapid analysis approach. Results Of 135 PED directors eligible to complete the survey, 64 responded (response rate 47%). A total of 64% of PEDs had a mental health specialist available 24 hours/day, 7 days/week; 80% reported practicing mental health disposition planning, and 41% reported practicing psychiatric medication management. Altogether 91% of directors agreed or strongly agreed that their PED had a positive culture and 92% agreed/strongly agreed that their PED was ready for change. However, 31% disagreed/strongly disagreed that their PED had tools for evaluation and quality measurement. Resources needed for change (including budget, staffing, training, and facilities) varied across institutions. Interviews with our convenience sample of 21 directors revealed varying suicide prevention practices and confirmed that standardization, evaluation, and quality improvement initiatives were needed at most institutions. Leaders reported a high interest in improving care. Conclusions PED leaders reported high motivation to improve suicide prevention services for young people, and reported needing quality improvement infrastructure to monitor and guide improvement.
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Affiliation(s)
- Cadence F. Bowden
- Division of General PediatricsClinical Futures, and PolicyLabChildren'sHospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
| | - Diana Worsley
- Division of General PediatricsClinical Futures, and PolicyLabChildren'sHospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
| | - Jeremy M. Esposito
- Department of PediatricsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Division of Emergency MedicineChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
| | - Gretchen J. Cutler
- Children's Minnesota Research InstituteChildren's MinnesotaMinneapolisMinnesotaUSA
| | - Stephanie K. Doupnik
- Division of General PediatricsClinical Futures, and PolicyLabChildren'sHospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
- Department of PediatricsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
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Jaladanki S, Schechter SB, Genies MC, Cabana MD, Rehm RS, Howell E, Kaiser SV. Strategies for sustaining high-quality pediatric asthma care in community hospitals. Health Serv Res 2022; 57:125-136. [PMID: 34382224 PMCID: PMC8763281 DOI: 10.1111/1475-6773.13870] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 07/08/2021] [Accepted: 08/01/2021] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE To identify strategies associated with sustained guideline adherence and high-quality pediatric asthma care in community hospitals. DATA SOURCES Primary qualitative data from clinicians in hospitals across the United States (collected December 2019-February 2021). STUDY DESIGN Pathways for Improving Pediatric Asthma Care (PIPA) was a national quality improvement (QI) intervention. In a prior quantitative study, data from 23 community hospitals in PIPA were analyzed to identify sites with the highest and lowest performance in sustaining improvements for 2 years. In this qualitative study, we conducted semi-structured interviews with multidisciplinary clinicians from these hospitals to identify strategies associated with sustainability. DATA COLLECTION/EXTRACTION METHODS We purposefully sampled and interviewed participants involved in clinical care of children hospitalized with asthma at the identified hospitals (those with the highest/lowest sustainability performance). We transcribed and analyzed interview data using constant comparative methods. PRINCIPAL FINDINGS Clinicians (n = 19) from five higher- and three lower-performing hospitals participated. In higher-performing hospitals, dedicated local champions more consistently provided reminders of evidence-based practices and delivered ongoing education. They also modified/developed electronic health record (EHR) tools (e.g., order sets with decision support). Higher-performing hospitals had a collaborative culture receptive to practice change and set firm expectations that evidence-based practices would be followed without exception. In lower-performing hospitals, participants described unique barriers, including delays in modifying the EHR and lack of automation of EHR tools (requiring clinicians to remember new EHR tasks without automated prompts). Barriers to sustainability for all hospitals included challenges with quality monitoring, decreasing focus of local champions over time, and ongoing difficulties developing consensus around evidence-based practices. CONCLUSIONS To better ensure sustained high-quality care for children with asthma and greater returns on QI investments, QI leaders should prioritize: designating long-term local champions to continue reminders and educational efforts and developing electronic order sets to provide ongoing decision support.
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Affiliation(s)
- Sravya Jaladanki
- Department of PediatricsUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Sarah B. Schechter
- Department of PediatricsUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Marquita C. Genies
- Department of PediatricsJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Michael D. Cabana
- Department of PediatricsAlbert Einstein College of MedicineNew YorkNew YorkUSA
| | - Roberta S. Rehm
- Department of Family Health Care NursingUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Eric Howell
- Society of Hospital MedicinePhiladelphiaPennsylvaniaUSA
| | - Sunitha V. Kaiser
- Departments of Pediatrics, Epidemiology and BiostatisticsPhilip R. Lee Institute for Health Policy Studies, University of California, San FranciscoSan FranciscoCaliforniaUSA
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Mrosak J, Kandaswamy S, Stokes C, Roth D, Dave I, Gillespie S, Orenstein E. The influence of integrating clinical practice guideline order bundles into a general admission order set on guideline adoption. JAMIA Open 2021; 4:ooab087. [PMID: 34632324 PMCID: PMC8497878 DOI: 10.1093/jamiaopen/ooab087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 08/24/2021] [Accepted: 09/22/2021] [Indexed: 11/14/2022] Open
Abstract
Objectives of this study were to (1) describe barriers to using clinical practice guideline (CPG) admission order sets in a pediatric hospital and (2) determine if integrating CPG order bundles into a general admission order set increases adoption of CPG-recommended orders compared to standalone CPG order sets. We identified CPG-eligible encounters and surveyed admitting physicians to understand reasons for not using the associated CPG order set. We then integrated CPG order bundles into a general admission order set and evaluated effectiveness through summative usability testing in a simulated environment. The most common reasons for the nonuse of CPG order sets were lack of awareness or forgetting about the CPG order set. In usability testing, CPG order bundle use increased from 27.8% to 66.6% while antibiotic ordering errors decreased from 62.9% to 18.5% with the new design. Integrating CPG-related order bundles into a general admission order set improves CPG order set use in simulation by addressing the most common barriers to CPG adoption.
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Affiliation(s)
- Justine Mrosak
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA.,Department of Pediatric Hospital Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | | | - Claire Stokes
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA.,Department of Hematology/Oncology, Children's Healthcare of Atlanta, Atlanta, Georgia, USA, and
| | - David Roth
- Department of Medical Education, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ishaan Dave
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Scott Gillespie
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Evan Orenstein
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA.,Department of Pediatric Hospital Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
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6
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Penwill NY, Roessler De Angulo N, Pathak PR, Ja C, Elster MJ, Hochreiter D, Newton JM, Wilson KM, Kaiser SV. Changes in pediatric hospital care during the COVID-19 pandemic: a national qualitative study. BMC Health Serv Res 2021; 21:953. [PMID: 34511079 PMCID: PMC8435183 DOI: 10.1186/s12913-021-06947-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 08/20/2021] [Indexed: 11/10/2022] Open
Abstract
Background The COVID-19 pandemic has necessitated rapid changes in healthcare delivery in the United States, including changes in the care of hospitalized children. The objectives of this study were to identify major changes in healthcare delivery for hospitalized children during the COVID-19 pandemic, identify lessons learned from these changes, and compare and contrast the experiences of children’s and community hospitals. Methods We purposefully sampled participants from both community and children’s hospitals serving pediatric patients in the six U.S. states with the highest COVID-19 hospitalization rates at the onset of the pandemic. We recruited 2–3 participants from each hospital (mix of administrators, front-line physicians, nurses, and parents/caregivers) for semi-structured interviews. We analyzed interview data using constant comparative methods to identify major themes. Results We interviewed 30 participants from 12 hospitals. Participants described how leaders rapidly developed new hospital policies (e.g., directing use of personal protective equipment) and how this was facilitated by reviewing internal and external data frequently and engaging all relevant stakeholders. Hospital leaders optimized communication through regular, transparent, multi-modal, and bi-directional communication. Clinicians increased use of videoconference and telehealth to facilitate physical distancing, but these technologies may have disadvantaged non-English speakers. Due to declining volumes of hospitalized children and surges of adult patients, clinicians newly provided care for hospitalized adults. This was facilitated by developing care teams supported by adult hospitalists, multidisciplinary support via videoconference, and educational resources. Participants described how the pandemic negatively impacted clinicians’ mental health, and they stressed the importance of mental health resources and wellness activities/spaces. Conclusions We identified several major changes in inpatient pediatric care delivery during the COVID-19 pandemic, including the adoption of new hospital policies, video communication, staffing models, education strategies, and staff mental health supports. We outline important lessons learned, including strategies for successfully developing new policies, effectively communicating with staff, and supporting clinicians’ expanding scope of practice. Potentially important focus areas in pandemic recovery include assessing and supporting clinicians’ mental health and well-being, re-evaluating trainees’ skills/competencies, and adapting educational strategies as needed. These findings can help guide hospital leaders in supporting pandemic recovery and addressing future crises. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06947-7.
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Affiliation(s)
- Nicole Y Penwill
- Department of Pediatrics, University of California, San Francisco, 550 16th Street, San Francisco, CA, 94158, USA.
| | - Nadia Roessler De Angulo
- Department of Pediatrics, University of California, San Francisco, 550 16th Street, San Francisco, CA, 94158, USA
| | - Priya R Pathak
- Department of Pediatrics, University of California, San Francisco, 550 16th Street, San Francisco, CA, 94158, USA
| | - Clairissa Ja
- University of California, Davis, 1 Shields Ave, Davis, CA, 95616, USA
| | - Martha J Elster
- Department of Pediatrics, University of California, San Francisco, 550 16th Street, San Francisco, CA, 94158, USA
| | - Daniela Hochreiter
- Lawrence and Memorial Hospital, 365 Montauk Ave, New London, CT, 06320, USA
| | - Jacqueline M Newton
- Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA
| | - Karen M Wilson
- The Kravis Children's Hospital at the Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1198, New York, NY, 10029, USA
| | - Sunitha V Kaiser
- Department of Pediatrics, University of California, San Francisco, 550 16th Street, San Francisco, CA, 94158, USA.,Philip R. Lee Institute for Health Policy Studies, 3333 California St, San Francisco, CA, 94118, USA
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Kerns E, McCulloh R, Fouquet S, McDaniel C, Ken L, Liu P, Kaiser S. Utilization and effects of mobile electronic clinical decision support on pediatric asthma care quality in the emergency department and inpatient setting. JAMIA Open 2021; 4:ooab019. [PMID: 33898935 PMCID: PMC8054033 DOI: 10.1093/jamiaopen/ooab019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 01/05/2021] [Accepted: 03/03/2021] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVE To determine utilization and impacts of a mobile electronic clinical decision support (mECDS) on pediatric asthma care quality in emergency department and inpatient settings. METHODS We conducted an observational study of a mECDS tool that was deployed as part of a multi-dimensional, national quality improvement (QI) project focused on pediatric asthma. We quantified mECDS utilization using cumulative screen views over the study period in the city in which each participating site was located. We determined associations between mECDS utilization and pediatric asthma quality metrics using mixed-effect logistic regression models (adjusted for time, site characteristics, site-level QI project engagement, and patient characteristics). RESULTS The tool was offered to clinicians at 75 sites and used on 286 devices; cumulative screen views were 4191. Children's hospitals and sites with greater QI project engagement had higher cumulative mECDS utilization. Cumulative mECDS utilization was associated with significantly reduced odds of hospital admission (OR: 0.95, 95% CI: 0.92-0.98) and higher odds of caregiver referral to smoking cessation resources (OR: 1.08, 95% CI: 1.01-1.16). DISCUSSION We linked mECDS utilization to clinical outcomes using a national sample and controlling for important confounders (secular trends, patient case mix, and concomitant QI efforts). We found mECDS utilization was associated with improvements in multiple measures of pediatric asthma care quality. CONCLUSION mECDS has the potential to overcome barriers to dissemination and improve care on a broad scale. Important areas of future work include improving mECDS uptake/utilization, linking clinicians' mECDS usage to clinical practice, and studying mECDS's impacts on other common pediatric conditions.
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Affiliation(s)
- Ellen Kerns
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, Nebraska, USA
- Division of Pediatric Hospital Medicine, Children's Hospital and Medical Center, Omaha, Nebraska, USA
| | - Russell McCulloh
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, Nebraska, USA
- Division of Pediatric Hospital Medicine, Children's Hospital and Medical Center, Omaha, Nebraska, USA
| | - Sarah Fouquet
- Department of Biomedical and Health Informatics, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Corrie McDaniel
- Department of Pediatrics, University of Washington, Seattle, Washington, DC, USA
| | - Lynda Ken
- Department of Pediatrics, University of Washington, Seattle, Washington, DC, USA
| | - Peony Liu
- Department of Pediatrics, Kaiser Permanente Zion Medical Center, San Diego, California, USA
| | - Sunitha Kaiser
- Departments of Pediatrics, Epidemiology and Biostatistics, University of California, San Francisco, California, USA
- Philip R. Lee Institute for Health Policy Studies, San Francisco, California, USA
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Nordstrom M, Landman G, Pfaff N, Kaiser SV. Improving Isotonic Maintenance Intravenous Fluid Use at a Tertiary Children's Hospital. Hosp Pediatr 2021; 11:374-379. [PMID: 33785518 DOI: 10.1542/hpeds.2020-003673] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Maintenance intravenous fluids (IVFs) are routinely used in the care of hospitalized children. The American Academy of Pediatrics (AAP) published clinical practice guidelines in November 2018 that recommended the use of isotonic maintenance IVF. Our primary aim was to increase the proportion of hospital days pediatric inpatients were exclusively administered isotonic maintenance IVF to ≥80% by May 2020 at our institution. METHODS We conducted a single-center quality improvement (QI) study as part of an AAP collaborative. An interdisciplinary team led QI interventions including providing targeted education to clinicians, integrating guideline recommendations into the electronic medical record, engaging hospital leaders, and providing performance data to clinicians. Our study population included children ages 28 days to 18 years admitted to inpatient wards. Our primary outcome was the proportion of hospital days with exclusive isotonic maintenance IVF use. Balancing measures included transfers to the ICU, ordering of serum sodium laboratory tests, and adverse events. Data were analyzed by using statistical process control. RESULTS We analyzed 500 hospital admissions and found a significant increase in exclusive isotonic IVF use (63% to 95%) within 9 months of starting our QI intervention. We found no significant changes in balancing measures (serum sodium laboratory tests [24% to 25%], ICU transfer [0.3% to 1%], adverse events [0.3% to 1%]). CONCLUSIONS Our interdisciplinary QI team led interventions that were associated with significant improvements in isotonic IVF use, in accordance with AAP clinical practice guidelines. With our study, we provide detailed guidance on successful interventions for implementing this evidence-based guideline.
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Affiliation(s)
| | - Geri Landman
- Sutter East Bay Medical Group, Berkeley, California
| | | | - Sunitha V Kaiser
- Departments of Pediatrics and.,Epidemiology and Biostatistics and.,Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California; and
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9
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Schechter S, Jaladanki S, Rodean J, Jennings B, Genies M, Cabana MD, Kaiser SV. Sustainability of paediatric asthma care quality in community hospitals after ending a national quality improvement collaborative. BMJ Qual Saf 2021; 30:876-883. [PMID: 33468549 DOI: 10.1136/bmjqs-2020-012292] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 01/04/2021] [Accepted: 01/10/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Community hospitals, which care for most hospitalised children in the USA, may be vulnerable to declines in paediatric care quality when quality improvement (QI) initiatives end. We aimed to evaluate changes in care quality in community hospitals after the end of the Pathways for Improving Paediatric Asthma Care (PIPA) national QI collaborative. METHODS We conducted a longitudinal cohort study during and after PIPA. PIPA included 45 community hospitals, of which 34 completed the 12-month collaborative and were invited for extended sustainability monitoring (total of 21-24 months from collaborative start). PIPA provided paediatric asthma pathways, educational materials/seminars, QI mentorship, monthly data reports, a mobile application and peer-to-peer learning opportunities. Access to pathways, educational materials and the mobile application remained during sustainability monitoring. Charts were reviewed for children aged 2-17 years old hospitalised with a primary diagnosis of asthma (maximum 20 monthly per hospital). Outcomes included measures of guideline adherence (early bronchodilator administration via metered-dose inhaler (MDI), secondhand smoke screening and referral to smoking cessation resources) and length of stay (LOS). We evaluated outcomes using multilevel regression models adjusted for patient mix, using an interrupted time-series approach. RESULTS We analysed 2159 hospitalisations from 23 hospitals (68% of eligible). Participating hospitals were structurally similar to those that dropped out but had more improvement in guideline adherence during the collaborative (29% vs 15%, p=0.02). The end of the collaborative was associated with a significant initial decrease in early MDI administration (81%-68%) (adjusted OR (aOR) 0.26 (95% CI 0.15 to 0.42)) and decreased rate of referral to smoking cessation resources (2.2% per month increase to 0.3% per month decrease) (aOR 0.86 (95% CI 0.75 to 0.98)) but no significant changes in LOS or secondhand smoke screening. CONCLUSIONS The end of a paediatric asthma QI collaborative was associated with concerning declines in guideline adherence in community hospitals.
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Affiliation(s)
- Sarah Schechter
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Sravya Jaladanki
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | | | | | - Marquita Genies
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Michael D Cabana
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York, USA.,Children's Hospital at Montefiore (CHAM), Bronx, New York, USA
| | - Sunitha Vemula Kaiser
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA.,Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
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10
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Andrews AL, Williams DC, Hogan AH. Clinical Progress Note: Care of Children Hospitalized for Acute Asthma Exacerbation. J Hosp Med 2020; 15:416-418. [PMID: 32118556 DOI: 10.12788/jhm.3382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
| | - Daniel C Williams
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Alexander H Hogan
- Department of Pediatrics, University of Connecticut School of Medicine, Farmington, Connecticut
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11
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Gupta N, Cattamanchi A, Cabana MD, Jennings B, Parikh K, Kaiser SV. Implementing pediatric inpatient asthma pathways. J Asthma 2020; 58:893-902. [PMID: 32160068 DOI: 10.1080/02770903.2020.1741612] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Pathways are succinct, operational versions of evidence-based guidelines. Studies have demonstrated pathways improve quality of care for children hospitalized with asthma, but we have limited information on other key factors to guide hospital leaders and clinicians in pathway implementation efforts. Our objective was to evaluate the adoption, implementation, and reach of inpatient pediatric asthma pathways. METHODS This was a mixed-methods study of hospitals participating in a national collaborative to implement pathways. Data sources included electronic surveys of implementation leaders and staff, field observations, and chart review of children ages 2-17 years admitted with a primary diagnosis of asthma. Outcomes included adoption by hospitals, pathway implementation factors, and reach of pathways to children hospitalized with asthma. Quantitative data were analyzed using descriptive statistics and multivariable regression. Qualitative data were analyzed using thematic content analysis. RESULTS Eighty-five hospitals enrolled; 68 (80%) adopted/completed the collaborative. These 68 hospitals implemented pathways with overall high fidelity, implementing a median of 5 of 5 core pathway components (Interquartile Range [IQR] 4-5) in a median of 5 months (IQR 3-9). Implementation teams reported a median time cost of 78 h (IQR: 40-120) for implementation. Implementation leaders reported the values of pathway implementation included improvements in care, enhanced interdisciplinary collaboration, and access to educational resources. Leaders reported barriers in modifying electronic health records (EHRs), and only 63% of children had electronic pathway orders placed. CONCLUSIONS Hospitals implemented pathways with high fidelity. Barriers in modifying EHRs may have limited the reach of pathways to children hospitalized with asthma.
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Affiliation(s)
- Nisha Gupta
- Department of Pediatrics, University of California, San Francisco, CA, USA
| | | | - Michael D Cabana
- Department of Pediatrics, University of California, San Francisco, CA, USA.,Pediatrics, Philip R. Lee Institute for Health Policy Studies University of California, San Francisco, CA, USA
| | - Brittany Jennings
- Division of Quality, The American Academy of Pediatrics, Itasca, IL, USA
| | - Kavita Parikh
- Department of Pediatrics, Children's National Medical Center, Washington, DC, USA
| | - Sunitha V Kaiser
- Department of Pediatrics, University of California, San Francisco, CA, USA
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McDaniel CE, Jeske M, Sampayo EM, Liu P, Walls TA, Kaiser SV. Implementing Pediatric Asthma Pathways in Community Hospitals: A National Qualitative Study. J Hosp Med 2020; 15:35-41. [PMID: 31532746 DOI: 10.12788/jhm.3296] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Pathways can improve the quality of care and outcomes for children with asthma; however, we know little about how to successfully implement pathways across diverse hospital settings. Prior studies of pathways have focused on determining clinical effectiveness and the majority were conducted in children's hospitals. These approaches have left crucial gaps in our understanding of how to successfully implement pathways in community hospitals, where most of the children with asthma are treated nationally. OBJECTIVE The aim of this study was to identify the key determinants of successful pediatric asthma pathway implementation in community hospitals. METHODS We conducted a qualitative study of healthcare providers that served as project leaders in a national collaborative to improve pediatric asthma care. Data were collected by recording semi-structured discussions between project leaders and external facilitators (EF) from December 2017 to April 2018. Using inductive thematic analysis, we identified the themes that describe the key determinants of pathway implementation. RESULTS Project leaders (n = 32) from 18 hospitals participated in this study. The key determinants of pathway implementation in community hospitals included (1) building an implementation infrastructure (eg, forming a team of local champions, modifying clinical workflows, delivering education/skills training), (2) engaging and motivating providers (eg, obtaining project buy-in, facilitating multidisciplinary collaboration, handling conflict), (3) addressing organizational and resource limitations (eg, support for electronic medical record integration), and (4) devising implementation solutions with EFs (eg, potential workflow modifications). CONCLUSIONS Our identification of the key determinants of pathway implementation may help guide pediatric quality improvement efforts in community hospitals. EFs may play an important role in successfully implementing pathways in community settings.
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Affiliation(s)
- Corrie E McDaniel
- Department of Pediatrics, University of Washington, Seattle, Washington
| | - Melanie Jeske
- Department of Social and Behavioral Sciences, University of California, San Francisco, California
| | - Esther M Sampayo
- Section of Emergency Medicine, Baylor College of Medicine, Houston, Texas
| | - Peony Liu
- Kaiser Permanente Southern California Medical Group, San Diego, California
| | - Theresa A Walls
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sunitha V Kaiser
- Department of Pediatrics, University of California, San Francisco, San Francisco, California
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