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Sullivan GA, Schäfer WLA, Raval MV, Johnson JK. Implementation science for quality improvement in pediatric surgery. Semin Pediatr Surg 2023; 32:151282. [PMID: 37075658 DOI: 10.1016/j.sempedsurg.2023.151282] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
Abstract
Despite the widespread integration of quality improvement principles into pediatric surgical practice, the actual adoption of evidence-based practices continues to be a challenge. The field of pediatric surgery, in particular, has been slow to adopt clinical pathways and protocols that lead to decreased practice variation and improved clinical outcomes. This manuscript provides an introduction to how implementation science principles into quality improvement efforts may optimize uptake of evidence-based practices, ensure success of these endeavors, and help assess the effectiveness of the interventions. Examples of implementation science application to pediatric surgical quality improvement endeavors are explored.
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Affiliation(s)
- Gwyneth A Sullivan
- Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Northwestern University Feinberg School of Medicine, 633 N. Saint Clair St, 20(th) floor, Chicago, IL 60611
| | - Willemijn L A Schäfer
- Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Northwestern University Feinberg School of Medicine, 633 N. Saint Clair St, 20(th) floor, Chicago, IL 60611
| | - Mehul V Raval
- Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Northwestern University Feinberg School of Medicine, 633 N. Saint Clair St, 20(th) floor, Chicago, IL 60611
| | - Julie K Johnson
- Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Northwestern University Feinberg School of Medicine, 633 N. Saint Clair St, 20(th) floor, Chicago, IL 60611.
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Mahdi E, Toscano N, Pierson L, Ndikumana E, Ayers B, Chacon A, Brayer A, Chess M, Davis C, Dorman R, Livingston M, Arca M, Wakeman D. Sustaining the gains: Reducing unnecessary computed tomography scans in pediatric trauma patients. J Pediatr Surg 2023; 58:111-117. [PMID: 36272813 DOI: 10.1016/j.jpedsurg.2022.09.027] [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: 09/12/2022] [Accepted: 09/16/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND/PURPOSE "Pan-scanning" pediatric blunt trauma patients leads to exposure to harmful radiation and increased healthcare costs without improving outcomes. We aimed to reduce computed tomography (CT) scans that are not indicated (NI) by imaging guidelines for injured children. METHODS In July 2017, our Pediatric Trauma Center prospectively implemented validated imaging guidelines to direct CT imaging for trauma activations and consultations for children younger than 16 years old with blunt traumatic injuries. Patients with suspected physical abuse, CT imaging prior to arrival, penetrating mechanism, and instability precluding CT imaging were excluded. We compared CT scanning rates for pre-implementation (01/2016-06/2017) and post-implementation (07/2017-08/2021) time periods. Guideline compliance was evaluated by chart review and sustained through iterative process improvement cycles. RESULTS During the pre-implementation era, 61 patients underwent 171 CT scans of which 87 (51%) scans were not indicated by guidelines. Post-implementation, 363 patients had 531 scans and only 134 (25%) CTs were not indicated. Total CTs performed declined after initiation of guidelines (2.80 vs 1.46 scans/patient, p<0.0001). Total NI CTs declined (1.41 vs 0.37 NI scans/patient, p<0.0001) reflected in significant reductions in all anatomic regions: head, cervical spine, chest, and abdomen/pelvis. Charges related to NI scans decreased from $1,490.31/patient to $408.21/patient, saving $218,000 in charges. Based on prior utilization, 146 children were spared excessive radiation with no clinically significant missed injuries since guideline implementation. CONCLUSIONS Quality improvement and implementation science methodologies to enhance compliance with imaging guidelines for children with blunt injuries can significantly reduce unnecessary CT scanning without compromising care. This practice reduces harmful radiation exposure in a sensitive patient population and may save healthcare systems money and resources.
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Affiliation(s)
- Elaa Mahdi
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Nicole Toscano
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Lauren Pierson
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Eric Ndikumana
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Brian Ayers
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Alexander Chacon
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Anne Brayer
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Mitchell Chess
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Colleen Davis
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Robert Dorman
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Michael Livingston
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Marjorie Arca
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Derek Wakeman
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, United States.
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Yang K, Zhao M, Sun J, Nie X. Accuracy of PECARN decision rule in minor blunt head trauma in pediatric emergency department: A meta-analysis. Int J Clin Pract 2021; 75:e14586. [PMID: 34191372 DOI: 10.1111/ijcp.14586] [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] [Received: 05/11/2021] [Accepted: 06/21/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Paediatric Emergency Care Applied Research Network (PECARN) is a useful Clinical Decision Support Tool (CDST) to identify traumatic brain injuries and reduce the use of head computed tomography (CT) scans among paediatric patients. The present Meta-analysis aims to evaluate the diagnostic accuracy of the PECARN rule from 2009 to 2020 in children with a very low risk of blunt head trauma. METHODS A detailed search was conducted from the databases of Medline (via PubMed), Cinahl (via Ebsco), Scopus, Web of Sciences, from 2009 till the end of December 2020 using the keywords like decreased use of CT scan, blunt head trauma (BHT) combined with accuracy, PECARN OR CDST. Studies showing the diagnostic accuracy of the PECARN rule in children younger than 18 years of age with minor BHT were included. RESULTS Thirteen studies were included in the present analysis. Pooled sensitivity of 0.08, (95% confidence interval of 0.074-0.087), pooled specificity of 0.20 (95% CI of 0.196-0.213) and diagnostic odds ratio of 0.004 (95% CI of 0.000-0.1666) was in <2 years of age. The overall sensitivity of 0.07, specificity of 0.66, and the diagnostic odds ratio of 0.54 (95% CI of 0.10-2.78) were seen in ≥2 years of age. Overall sensitivity of 0.13 (95% CI 0.12-0.14), specificity of 0.81 (95% CI 0.80-0.82) and diagnostic odds ratio of 0.79 (95% CI of 0.08-7.71) was in 0-18 years of age. CONCLUSION The present analysis indicates the PECARN decision tool as an accurate CDST in low-risk minor BHT cases in children below two years of age and can become a valuable tool in reducing Head CT scan overuse in paediatric emergency departments.
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Affiliation(s)
- Ke Yang
- Department of CT and MRI, The First People's Hospital of Tianmen City, Tianmen, China
| | - Meng Zhao
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jing Sun
- Department of Radiology, Jinan Central Hospital Affiliated to Shandong University, Jinan, China
| | - Xiuli Nie
- Department of Radiology, Jinan Central Hospital Affiliated to Shandong University, Jinan, China
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The Use of Chest Computed Tomographic Angiography in Blunt Trauma Pediatric Population. Pediatr Emerg Care 2020; 36:e682-e685. [PMID: 29406478 DOI: 10.1097/pec.0000000000001422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Blunt chest trauma in children is common. Although rare, associated major thoracic vascular injuries (TVIs) are lethal potential sequelae of these mechanisms. The preferred study for definitive diagnosis of TVI in stable patients is computed tomographic angiography imaging of the chest. This imaging modality is, however, associated with high doses of ionizing radiation that represent significant carcinogenic risk for pediatric patients. The aim of the present investigation was to define the incidence of TVI among blunt pediatric trauma patients in an effort to better elucidate the usefulness of computed tomographic angiography use in this population. METHODS A retrospective cohort study was conducted including all blunt pediatric (age < 14 y) trauma victims registered in Israeli National Trauma Registry maintained by Gertner Institute for Epidemiology and Health Policy Research between the years 1997 and 2015. Data collected included age, sex, mechanism of injury, Glasgow Coma Scale, Injury Severity Score, and incidence of chest named vessel injuries. Statistical analysis was performed using SAS statistical software version 9.2 (SAS Institute Inc, Cary, NC). RESULTS Among 433,325 blunt trauma victims, 119,821patients were younger than 14 years. Twelve (0.0001%, 12/119821) of these children were diagnosed with TVI. The most common mechanism in this group was pedestrian hit by a car. Mortality was 41.7% (5/12). CONCLUSIONS Thoracic vascular injury is exceptionally rare among pediatric blunt trauma victims but does contribute to the high morbidity and mortality seen with blunt chest trauma. Computed tomographic angiography, with its associated radiation exposure risk, should not be used as a standard tool after trauma in injured children. Clinical protocols are needed in this population to minimize radiation risk while allowing prompt identification of life-threatening injuries.
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Khalifa M, Gallego B. Grading and assessment of clinical predictive tools for paediatric head injury: a new evidence-based approach. BMC Emerg Med 2019; 19:35. [PMID: 31200643 PMCID: PMC6570950 DOI: 10.1186/s12873-019-0249-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 06/03/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Many clinical predictive tools have been developed to diagnose traumatic brain injury among children and guide the use of computed tomography in the emergency department. It is not always feasible to compare tools due to the diversity of their development methodologies, clinical variables, target populations, and predictive performances. The objectives of this study are to grade and assess paediatric head injury predictive tools, using a new evidence-based approach, and to provide emergency clinicians with standardised objective information on predictive tools to support their search for and selection of effective tools. METHODS Paediatric head injury predictive tools were identified through a focused review of literature. Based on the critical appraisal of published evidence about predictive performance, usability, potential effect, and post-implementation impact, tools were evaluated using a new framework for grading and assessment of predictive tools (GRASP). A comprehensive analysis was conducted to explain why certain tools were more successful. RESULTS Fourteen tools were identified and evaluated. The highest-grade tool is PECARN; the only tool evaluated in post-implementation impact studies. PECARN and CHALICE were evaluated for their potential effect on healthcare, while the remaining 12 tools were only evaluated for predictive performance. Three tools; CATCH, NEXUS II, and Palchak, were externally validated. Three tools; Haydel, Atabaki, and Buchanich, were only internally validated. The remaining six tools; Da Dalt, Greenes, Klemetti, Quayle, Dietrich, and Güzel did not show sufficient internal validity for use in clinical practice. CONCLUSIONS The GRASP framework provides clinicians with a high-level, evidence-based, comprehensive, yet simple and feasible approach to grade, compare, and select effective predictive tools. Comparing the three main tools which were assigned the highest grades; PECARN, CHALICE and CATCH, to the remaining 11, we find that the quality of tools' development studies, the experience and credibility of their authors, and the support by well-funded research programs were correlated with the tools' evidence-based assigned grades, and were more influential, than the sole high predictive performance, on the wide acceptance and successful implementation of the tools. Tools' simplicity and feasibility, in terms of resources needed, technical requirements, and training, are also crucial factors for their success.
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Affiliation(s)
- Mohamed Khalifa
- Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, 75 Talavera Road, North Ryde, Sydney, NSW, 2113, Australia.
| | - Blanca Gallego
- Centre for Big Data Research in Health, Faculty of Medicine, University of New South Wales, Lowy Cancer Research Centre, Level 4, Cnr High &, Botany St, Kensington, Sydney, NSW, 2052, Australia
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Missed Opportunities to Decrease Radiation Exposure in Children with Renal Trauma. J Urol 2018; 199:552-557. [DOI: 10.1016/j.juro.2017.09.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2017] [Indexed: 11/22/2022]
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McNamara C, Mironova I, Lehman E, Olympia RP. Predictors of Intrathoracic Injury after Blunt Torso Trauma in Children Presenting to an Emergency Department as Trauma Activations. J Emerg Med 2016; 52:793-800. [PMID: 27998635 DOI: 10.1016/j.jemermed.2016.11.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 11/10/2016] [Accepted: 11/19/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Thoracic injuries are a major cause of death associated with blunt trauma in children. Screening for injury with chest x-ray study, compared with chest computed tomography (CT) scan, has been controversial, weighing the benefits of specificity with the detriment of radiation exposure. OBJECTIVE To identify predictors of thoracic injury in children presenting as trauma activations to a Level I trauma center after blunt torso trauma, and to compare these predictors with those previously reported in the literature. METHODS We performed a retrospective chart review of pediatric patients (<18 years of age) who presented to the Emergency Department of a Level I trauma center between June 2010 and June 2013 as a trauma activation after sustaining a blunt torso trauma and who received diagnostic imaging of the chest as part of their initial evaluation. RESULTS Data analysis was performed on 166 patients. There were 33 patients (20%) with 45 abnormalities detected on diagnostic imaging of the chest, with the most common abnormalities being lung contusion (36%), pneumothorax (22%), and rib fracture (13%). Statistically significant predictors of abnormal diagnostic imaging of the chest included Glasgow Coma Scale score (GCS) < 15 (27% with abnormality vs. 13% without abnormality), hypoxia (22% vs. 5%), syncope/loss of consciousness (55% vs. 35%), cervical spine tenderness (12% vs. 3%), thoraco-lumbar-sacral spine tenderness (41% vs. 17%), and abdominal/pelvic tenderness (12% vs. 3%). CONCLUSIONS Based on our data, predictors of thoracic injury in children after blunt torso trauma include GCS < 15, hypoxia, syncope/dizziness, cervical spine tenderness, thoraco-lumbar-sacral spine tenderness, and abdominal/pelvic tenderness.
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Affiliation(s)
| | | | - Erik Lehman
- Department of Public Health Sciences, Penn State University College of Medicine, Hershey, PA
| | - Robert P Olympia
- Department of Emergency Medicine, Penn State Hershey Medical Center, Hershey, PA
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Hemmes B, Jeukens CRLPN, Kemerink GJ, Brink PRG, Poeze M. Effect of spinal immobilisation devices on radiation exposure in conventional radiography and computed tomography. Emerg Radiol 2016; 23:147-53. [PMID: 26754428 PMCID: PMC4805719 DOI: 10.1007/s10140-015-1371-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Accepted: 12/09/2015] [Indexed: 02/04/2023]
Abstract
Trauma patients at risk for, or suspected of, spinal injury are frequently transported to hospital using full spinal immobilisation. At the emergency department, immobilisation is often maintained until radiological work-up is completed. In this study, we examined how these devices influence radiation exposure and noise, as a proxy for objective image quality. Conventional radiographs (CR) and computer tomography (CT) scans were made using a phantom immobilised on two types of spineboard and a vacuum mattress and using two types of headblocks. Images were compared for radiation transmission and quantitative image noise. In CR, up to 23 % and, in CT, up to 11 % of radiation were blocked by the devices. Without compensation for the decreased transmission, noise increased by up to 16 % in CT, depending on the device used. Removing the headblocks led to a statistically significant improvement in transmission with automatic exposure control (AEC) enabled. Physicians should make an informed decision whether the increased radiation exposure outweighs the risk of missing a clinically significant injury by not making a CR or CT scan. Manufacturers of immobilisation devices should take radiological properties of their devices into account in the development and production process.
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Affiliation(s)
- Baukje Hemmes
- Network Acute Care Limburg, Maastricht University Medical Center, Maastricht, The Netherlands.
| | - Cécile R L P N Jeukens
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Gerrit J Kemerink
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Peter R G Brink
- Network Acute Care Limburg, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Martijn Poeze
- Network Acute Care Limburg, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
- NUTRIM, School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
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