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Lopez M, Wilson M, Cobbina E, Kaufman D, Fluitt J, Grainger M, Ruiz R, Abudukadier G, Tiras M, Carlson B, Spaid J, Falsone K, Cocjin I, Moretti A, Vercio C, Tinsley C, Chandnani HK, Samayoa C, Cianci C, Pappas J, Chang NY. Decreasing ICU and Hospital Length of Stay through a Standardized Respiratory Therapist-driven Electronic Clinical Care Pathway for Status Asthmaticus. Pediatr Qual Saf 2023; 8:e697. [PMID: 38058471 PMCID: PMC10697623 DOI: 10.1097/pq9.0000000000000697] [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: 12/20/2022] [Accepted: 09/07/2023] [Indexed: 12/08/2023] Open
Abstract
Introduction Status asthmaticus (SA) is a cause of many pediatric hospitalizations. This study sought to evaluate how a standardized asthma care pathway (ACP) in the electronic medical record impacted the length of stay (LOS). Methods An interdisciplinary team internally validated a standardized respiratory score for patients admitted with SA to a 25-bed pediatric intensive care unit (PICU) at a tertiary children's hospital. The respiratory score determined weaning schedules for albuterol and steroid therapies. In addition, pharmacy and information technology staff developed an electronic ACP within our electronic medical record system using best practice alerts. These best practice alerts informed staff to initiate the pathway, wean/escalate treatment, transition to oral steroids, transfer level of care, and complete discharge education. The PICU, stepdown ICU (SD ICU), and acute care units implemented the clinical pathway. Pre- and postintervention metrics were assessed using process control charts and compared using Welch's t tests with a significance level of 0.05. Results Nine hundred two consecutive patients were analyzed (598 preintervention, 304 postintervention). Order set utilization significantly increased from 68% to 97% (P < 0.001), PICU LOS decreased from 38.4 to 31.1 hours (P = 0.013), and stepdown ICU LOS decreased from 25.7 to 20.9 hours (P = 0.01). Hospital LOS decreased from 59.5 to 50.7 hours (P = 0.003), with cost savings of $1,215,088 for the patient cohort. Conclusions Implementing a standardized respiratory therapist-driven ACP for children with SA led to significantly increased order set utilization and decreased ICU and hospital LOS. Leveraging information technology and standardized pathways may improve care quality, outcomes, and costs for other common diagnoses.
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Affiliation(s)
- Merrick Lopez
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Michele Wilson
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Ekua Cobbina
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Danny Kaufman
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Julie Fluitt
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Michele Grainger
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Robert Ruiz
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Gulixian Abudukadier
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Michael Tiras
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Bronwyn Carlson
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Jeane Spaid
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Kim Falsone
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Invest Cocjin
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Anthony Moretti
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Chad Vercio
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
- Patient Safety and Reliability, Loma Linda University Medical Center, Loma Linda, Calif
- Department of Pediatrics, Riverside University Health System, Moreno Valley, Calif
| | - Cynthia Tinsley
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Harsha K. Chandnani
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Carlos Samayoa
- Patient Safety and Reliability, Loma Linda University Medical Center, Loma Linda, Calif
| | - Carissa Cianci
- Patient Safety and Reliability, Loma Linda University Medical Center, Loma Linda, Calif
| | - James Pappas
- Patient Safety and Reliability, Loma Linda University Medical Center, Loma Linda, Calif
| | - Nancy Y. Chang
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
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Fernando M, Abell B, Tyack Z, Donovan T, McPhail SM, Naicker S. Using Theories, Models, and Frameworks to Inform Implementation Cycles of Computerized Clinical Decision Support Systems in Tertiary Health Care Settings: Scoping Review. J Med Internet Res 2023; 25:e45163. [PMID: 37851492 PMCID: PMC10620641 DOI: 10.2196/45163] [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: 12/18/2022] [Revised: 08/18/2023] [Accepted: 09/14/2023] [Indexed: 10/19/2023] Open
Abstract
BACKGROUND Computerized clinical decision support systems (CDSSs) are essential components of modern health system service delivery, particularly within acute care settings such as hospitals. Theories, models, and frameworks may assist in facilitating the implementation processes associated with CDSS innovation and its use within these care settings. These processes include context assessments to identify key determinants, implementation plans for adoption, promoting ongoing uptake, adherence, and long-term evaluation. However, there has been no prior review synthesizing the literature regarding the theories, models, and frameworks that have informed the implementation and adoption of CDSSs within hospitals. OBJECTIVE This scoping review aims to identify the theory, model, and framework approaches that have been used to facilitate the implementation and adoption of CDSSs in tertiary health care settings, including hospitals. The rationales reported for selecting these approaches, including the limitations and strengths, are described. METHODS A total of 5 electronic databases were searched (CINAHL via EBSCOhost, PubMed, Scopus, PsycINFO, and Embase) to identify studies that implemented or adopted a CDSS in a tertiary health care setting using an implementation theory, model, or framework. No date or language limits were applied. A narrative synthesis was conducted using full-text publications and abstracts. Implementation phases were classified according to the "Active Implementation Framework stages": exploration (feasibility and organizational readiness), installation (organizational preparation), initial implementation (initiating implementation, ie, training), full implementation (sustainment), and nontranslational effectiveness studies. RESULTS A total of 81 records (42 full text and 39 abstracts) were included. Full-text studies and abstracts are reported separately. For full-text studies, models (18/42, 43%), followed by determinants frameworks (14/42,33%), were most frequently used to guide adoption and evaluation strategies. Most studies (36/42, 86%) did not list the limitations associated with applying a specific theory, model, or framework. CONCLUSIONS Models and related quality improvement methods were most frequently used to inform CDSS adoption. Models were not typically combined with each other or with theory to inform full-cycle implementation strategies. The findings highlight a gap in the application of implementation methods including theories, models, and frameworks to facilitate full-cycle implementation strategies for hospital CDSSs.
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Affiliation(s)
- Manasha Fernando
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Bridget Abell
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Zephanie Tyack
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Thomasina Donovan
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Steven M McPhail
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Australia
- Digital Health and Informatics Directorate, Metro South Health, Brisbane, Australia
| | - Sundresan Naicker
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Australia
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Improving Delirium Assessments in Vanderbilt Pediatric and Pediatric Cardiovascular Intensive Care Units. Pediatr Qual Saf 2022; 7:e577. [PMID: 35919397 PMCID: PMC9278948 DOI: 10.1097/pq9.0000000000000577] [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: 11/01/2021] [Accepted: 06/10/2022] [Indexed: 11/26/2022] Open
Abstract
Introduction: Delirium is a disturbance of attention and awareness that represents a change from baseline mental status. Accurate diagnosis of delirium is of paramount importance to improving the management of pediatric delirium in the intensive care unit. Despite ongoing education, inconsistencies in delirium assessments occur. Here, we aimed to determine the extent of the problem and increase compliance with delirium assessments. Methods: We collected preintervention data to assess baseline compliance of delirium assessments in the Pediatric Intensive Care Unit (PICU) and Pediatric Cardiac Intensive Care Unit (PCICU) at Monroe Carell Jr Children’s Hospital at Vanderbilt in November 2020. We executed 2 Plan-Do-Study-Act cycles with different interventions and collected data after each and approximately 1 year after the interventions. The first intervention consisted of virtual lectures on delirium assessments for the nursing staff. The second intervention included an educational handout and a new electronic medical record documentation tool. Results: Five hundred five individual nurse-patient encounters were assessed and collected throughout the project. The mean compliance of delirium documentation before the interventions was 52.5%. Target compliance after interventions was 70%. Mean compliance was 70% after cycle 1, 78% after cycle 2, and 86% in March 2022. Conclusions: Using pre- and postintervention data from chart reviews and nurse interviews regarding delirium screenings, we found that interventions targeting nurse education and EMR flowsheet improved compliance with delirium assessment and documentation in the PICU and PCICU. Future work should focus on assessing the clinical implications of this project in diagnosing and treating delirium.
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