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Edwards Y, Yang N, Auerbach AD, Gonzales R, McCulloch CE, Howell EE, Goldstein J, Thompson S, Kaiser SV. Simultaneously implementing pathways for improving asthma, pneumonia, and bronchiolitis care for hospitalized children: Protocol for a hybrid effectiveness-implementation, cluster-randomized trial. J Hosp Med 2024. [PMID: 39139049 DOI: 10.1002/jhm.13482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Revised: 07/22/2024] [Accepted: 07/25/2024] [Indexed: 08/15/2024]
Abstract
BACKGROUND Asthma, pneumonia, and bronchiolitis are the top causes of childhood hospitalization in the United States, leading to over 350,000 hospitalizations and ≈$2 billion in costs annually. The majority of these hospitalizations occur in general/community hospitals. Poor guideline adoption by clinicians contributes to poor health outcomes for children hospitalized with these illnesses, including longer recovery time/hospital stay, higher rates of intensive care unit transfer, and increased risk of hospital readmission. A prior single-center study at a children's hospital tested a multicondition clinical pathway intervention (simultaneous implementation of multiple pathways for multiple pediatric conditions) and demonstrated improved clinician guideline adherence and patient health outcomes. This intervention has not yet been studied in community hospitals, which face unique implementation barriers. OBJECTIVE To study the implementation and effectiveness of a multicondition pathway intervention for children hospitalized with asthma, pneumonia, or bronchiolitis in community hospitals. METHODS We will conduct a pragmatic, hybrid effectiveness-implementation, cluster-randomized trial in community hospitals around the United States (1:1 randomization to intervention vs. wait-list control). Our primary outcome will be the adoption of 2-3 evidence-based practices for each condition over a sustained period of 2 years. Secondary outcomes include hospital length of stay, ICU transfer, and readmission. DISCUSSION This hybrid trial will lead to a comprehensive understanding of how to pragmatically and sustainably implement a multicondition pathway intervention in community hospitals and an assessment of its effects. Enrollment began in July 2022 and is projected to be completed in September 2024. Primary analysis completion is anticipated in March 2025, with reporting of results following.
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Affiliation(s)
- Yeelen Edwards
- Department of Pediatrics, University of California, San Francisco, California, USA
| | - Nancy Yang
- Department of Pediatrics, University of California, San Francisco, California, USA
| | - Andrew D Auerbach
- Department of Medicine, University of California, San Francisco, California, USA
| | - Ralph Gonzales
- Department of Medicine, University of California, San Francisco, California, USA
| | - Charles E McCulloch
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
| | - Eric E Howell
- Society of Hospital Medicine, Philadelphia, Pennsylvania, USA
| | - Jenna Goldstein
- Society of Hospital Medicine, Philadelphia, Pennsylvania, USA
| | - Sara Thompson
- Society of Hospital Medicine, Philadelphia, Pennsylvania, USA
| | - Sunitha V Kaiser
- Department of Pediatrics, University of California, San Francisco, California, USA
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2
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Rickey L, Auger K, Britto MT, Rodgers I, Field S, Odom A, Lehr M, Cronin A, Walsh KE. Measurement of Ambulatory Medication Errors in Children: A Scoping Review. Pediatrics 2023; 152:e2023061281. [PMID: 37986581 DOI: 10.1542/peds.2023-061281] [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] [Accepted: 09/20/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Children use most medications in the ambulatory setting where errors are infrequently intercepted. There is currently no established measure set for ambulatory pediatric medication errors. We have sought to identify the range of existing measures of ambulatory pediatric medication errors, describe the data sources for error measurement, and describe their reliability. METHODS We performed a scoping review of the literature published since 1986 using PubMed, CINAHL, PsycINFO, Web of Science, Embase, and Cochrane and of grey literature. Studies were included if they measured ambulatory, including home, medication errors in children 0 to 26 years. Measures were grouped by phase of the medication use pathway and thematically by measure type. RESULTS We included 138 published studies and 4 studies from the grey literature and identified 21 measures of medication errors along the medication use pathway. Most measures addressed errors in medication prescribing (n = 6), and administration at home (n = 4), often using prescription-level data and observation, respectively. Measures assessing errors at multiple phases of the medication use pathway (n = 3) frequently used error reporting databases and prospective measurement through direct in-home observation. We identified few measures of dispensing and monitoring errors. Only 31 studies used measurement methods that included an assessment of reliability. CONCLUSIONS Although most available, reliable measures are too resource and time-intensive to assess errors at the health system or population level, we were able to identify some measures that may be adopted for continuous measurement and quality improvement.
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Affiliation(s)
- Lisa Rickey
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Katherine Auger
- Division of Hospital Medicine
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Maria T Britto
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Isabelle Rodgers
- Section of Pediatric Infectious Diseases, Boston Medical Center, Boston, Massachusetts
| | - Shayna Field
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Alayna Odom
- Division of Hospital Medicine
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Madison Lehr
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | | | - Kathleen E Walsh
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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Outram SM, Rooholamini SN, Desai M, Edwards Y, Ja C, Morton K, Vaughan JH, Shaw JS, Gonzales R, Kaiser SV. Barriers and Facilitators of High-Efficiency Clinical Pathway Implementation in Community Hospitals. Hosp Pediatr 2023; 13:931-939. [PMID: 37697946 PMCID: PMC10520265 DOI: 10.1542/hpeds.2023-007173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
BACKGROUND An intervention that involved simultaneously implementing clinical pathways for multiple conditions was tested at a tertiary children's hospital and it improved care quality. We are conducting a randomized trial to evaluate this multicondition pathway intervention in community hospitals. Our objectives in this qualitative study were to prospectively (1) identify implementation barriers and (2) map barriers to facilitators using an established implementation science framework. METHODS We recruited participants via site leaders from hospitals enrolled in the trial. We designed an interview guide using the Consolidated Framework for Implementation Research and conducted individual interviews. Analysis was done using constant comparative methods. Anticipated barriers were mapped to facilitators using the Capability, Opportunity, Motivation, Behavior Framework. RESULTS Participants from 12 hospitals across the United States were interviewed (n = 21). Major themes regarding the multicondition pathway intervention included clinician perceptions, potential benefits, anticipated barriers/challenges, potential facilitators, and necessary resources. We mapped barriers to additional facilitators using the Capability, Opportunity, Motivation, Behavior framework. To address limited time/bandwidth of clinicians, we will provide Maintenance of Certification credits. To address new staff and trainee turnover, we will provide easily accessible educational videos/resources. To address difficulties in changing practice across other hospital units, we will encourage emergency department engagement. To address parental concerns with deimplementation, we will provide guidance on parent counseling. CONCLUSIONS We identified several potential barriers and facilitators for implementation of a multicondition clinical pathway intervention in community hospitals. We also illustrate a prospective process for identifying implementation facilitators.
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Affiliation(s)
- Simon M. Outram
- Department of Pediatrics, University of California, San Francisco, California
| | | | - Mansi Desai
- Department of Pediatrics, University of California, San Francisco, California
| | - Yeelen Edwards
- Department of Pediatrics, University of California, San Francisco, California
| | | | - Kayce Morton
- Department of Pediatrics, CoxHealth, Springfield, Missouri
- Department of Pediatrics, University of Missouri, Columbia, Missouri
| | - Jordan H. Vaughan
- Department of Pediatrics, University of California, San Francisco, California
| | - Judith S. Shaw
- Department of Pediatrics, University of Vermont, Burlington, Vermont
| | - Ralph Gonzales
- Department of Pediatrics, University of California, San Francisco, California
| | - Sunitha V. Kaiser
- Department of Pediatrics, University of California, San Francisco, California
- Philip R. Lee Institute for Health Policy Studies, San Francisco, California
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Dudas RA, Krugman SD. How Should Pediatric Residents Prepare for a Career in Pediatric Hospital Medicine? Hosp Pediatr 2022; 12:e47-e49. [PMID: 34913061 DOI: 10.1542/hpeds.2021-006383] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Robert A Dudas
- Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Scott D Krugman
- Herman & Walter Samuelson Children's Hospital at Sinai, Baltimore, Maryland
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Qunibi DW, A Dudas R, Auerbach M, Abulebda K, McDaniel CE. Building Inpatient Pediatric Readiness for the Clinically Deteriorating Child. Hosp Pediatr 2021; 12:e89-e92. [PMID: 34993532 DOI: 10.1542/hpeds.2021-006230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Danna W Qunibi
- Division of Pediatric Critical Care Medicine Nationwide Children's Hospital Columbus Ohio.,Department of Pediatrics The Ohio State University Columbus Ohio
| | - Robert A Dudas
- Department of Pediatrics Johns Hopkins All Children's Hospital St Petersburg, Florida
| | - Marc Auerbach
- Departments of Pediatrics and Emergency Medicine Yale University New Haven, Connecticut
| | - Kamal Abulebda
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Riley Hospital for Children at Indiana University Health and Indiana University School of Medicine Indianapolis Indiana
| | - Corrie E McDaniel
- Seattle Children's Hospital Seattle, Washington; and.,Department of Pediatrics University of Washington School of Medicine Seattle, Washington
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Leyenaar JK, Harrison W, Truelove JJ, House S, Freed GL, Leslie LK. Responsibilities and Interests of Pediatricians Practicing Hospital Medicine in the United States. J Hosp Med 2021; 16:709-715. [PMID: 34797999 PMCID: PMC8626056 DOI: 10.12788/jhm.3720] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 10/07/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVES In 2016, the American Board of Medical Specialties (ABMS) approved pediatric hospital medicine (PHM) as the newest pediatric subspecialty. To characterize development of the field, this article aims to: (1) describe the responsibilities and practice settings of US pediatricians self-identifying as hospitalists; and (2) determine how exclusive PHM practice, compared with PHM practice in combination with general or subspecialty care, was associated with professional development interests. METHODS Pediatricians enrolling in the 2017-2018 American Board of Pediatrics (ABP) Maintenance of Certification program were offered a voluntary survey about their responsibilities, interests, and practice settings. Logistic regression was employed to characterize associations between exclusive PHM practice and: (1) interest in quality improvement (QI) leadership; (2) intention to take the PHM certifying exam; (3) satisfaction with allocation of professional time; and (4) intention to maintain more than one ABP certification. RESULTS The survey response rate was 70.0%; 1662 (13.1%) self-reported PHM practice. Four-hundred ninety-one (29.5%) practiced PHM exclusively, 518 (31.1%) practiced PHM and general pediatrics, and 653 (39.3%) practiced PHM and one or more subspecialties. Respondents reporting exclusive PHM practice were significantly more likely to report interest in QI leadership or consultation (adjusted odds ratio [OR], 1.39; 95% CI, 1.09-1.79), PHM exam certification (adjusted OR, 7.10; 95% CI, 5.45-9.25), and maintenance of more than one ABP certification (adjusted OR, 2.64; 95% CI, 1.89-3.68). CONCLUSIONS Hospitalists reported diverse clinical and nonclinical responsibilities. Those practicing PHM exclusively expressed high levels of interest in board certification and QI leadership. Ongoing monitoring of PHM responsibilities and practice settings will be important to support the professional development of the PHM workforce.
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Affiliation(s)
- JoAnna K Leyenaar
- Department of Pediatrics and The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth-Hitchcock Medical Center and Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- Corresponding Author: JoAnna K Leyenaar, MD, PhD, MPH; ; Telephone: 603-653-0855
| | - Wade Harrison
- Department of Pediatrics and Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Jessica J Truelove
- Pediatrics Residency Program, Dartmouth-Hitchcock Medical Center and Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Samantha House
- Department of Pediatrics and The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth-Hitchcock Medical Center and Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Gary L Freed
- Susan B. Meister Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, Michigan
| | - Laurel K Leslie
- The American Board of Pediatrics, Chapel Hill, North Carolina
- Tufts University School of Medicine, Boston, Massachusetts
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McCulloh RJ, McDaniel LM, Kerns E, Biondi EA. Prevalence of Invasive Bacterial Infections in Well-Appearing, Febrile Infants. Hosp Pediatr 2021; 11:e184-e188. [PMID: 34465602 DOI: 10.1542/hpeds.2020-002147] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Data on invasive bacterial infection (IBI), defined as bacteremia and/or bacterial meningitis, in febrile infants aged <60 days old primarily derive from smaller, dated studies conducted at large, university-affiliated medical centers. Our objective with the current study was to determine current prevalence and epidemiology of IBI from a contemporary, national cohort of well-appearing, febrile infants at university-affiliated and community-based hospitals. PATIENTS AND METHODS Retrospective review of well-appearing, febrile infants aged 7 to 60 days was performed across 31 community-based and 44 university-affiliated centers from September 2015 to December 2017. Blood and cerebrospinal fluid bacterial culture results were reviewed and categorized by using a priori criteria for pathogenic organisms. Prevalence estimates and subgroup comparisons were made by using descriptive statistics. RESULTS A total of 10 618 febrile infants met inclusion criteria; cerebrospinal fluid and blood cultures were tested from 6747 and 10 581 infants, respectively. Overall, meningitis prevalence was 0.4% (95% confidence interval [CI]: 0.2-0.5); bacteremia prevalence was 2.4% (95% CI: 2.1-2.7). Neonates aged 7 to 30 days had significantly higher prevalence of bacteremia, as compared with infants in the second month of life. IBI prevalence did not differ between community-based and university-affiliated hospitals (2.7% [95% CI: 2.3-3.1] vs 2.1% [95% CI: 1.7-2.6]). Escherichia coli and Streptococcus agalactiae were the most commonly identified organisms. CONCLUSIONS This contemporary study of well-appearing, febrile infants supports previous epidemiological estimates of IBI prevalence and suggests that the prevalence of IBI may be similar among community-based and university-affiliated hospitals. These results can be used to aid future clinical guidelines and prediction tool development.
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Affiliation(s)
- Russell J McCulloh
- Children's Hospital and Medical Center, Omaha, Nebraska .,Department of Pediatrics, University of Nebraska Medical Center, Omaha, Nebraska
| | | | - Ellen Kerns
- Children's Hospital and Medical Center, Omaha, Nebraska.,Department of Pediatrics, University of Nebraska Medical Center, Omaha, Nebraska
| | - Eric A Biondi
- Johns Hopkins Children's Center, Baltimore, Maryland
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Marin JR, Hollander MAG, Ray KN, Donohue JM, Cole ES. Low-Value Diagnostic Imaging in Children with Medicaid. J Pediatr 2021; 235:253-263.e14. [PMID: 33556364 PMCID: PMC8316256 DOI: 10.1016/j.jpeds.2021.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 01/29/2021] [Accepted: 02/01/2021] [Indexed: 01/20/2023]
Abstract
OBJECTIVES To estimate rates and settings of low-value imaging among pediatric Medicaid beneficiaries and estimate the associated expenditures. STUDY DESIGN Retrospective longitudinal cohort study from 2014 to 2016 of children <18 years enrolled in Pennsylvania Medicaid. Outcomes were rates of low-value imaging for 5 conditions identified by diagnosis codes, healthcare settings of imaging performance, and cost based on paid amounts. RESULTS Of the 645 767 encounters for the 5 conditions, there were 37 525 (5.8%) low-value imaging services. Per 1000 encounters, there were 246.0 radiographs for bronchiolitis, 174.0 head computed tomography (CT) studies for minor head trauma, 155.0 and 33.3 neuroimaging studies for headache and simple febrile seizure, respectively, and 19.5 abdominal CT scans (without prior ultrasound examination) for abdominal pain. Rates of low-value imaging were highest in non-Hispanic White children and those in rural areas. In adjusted analysis, non-Hispanic White children were more likely to receive a CT scan for abdominal pain, and Black children were more likely to have imaging for bronchiolitis and minor head trauma. For individual conditions, up to 87.9% of low-value imaging (CT scan for minor head trauma) was in the emergency department (ED), with most imaging across all conditions occurring in nonpediatric EDs, up to 42.2% was in the outpatient setting (neuroimaging for headache), and up to 20.7% was during inpatient encounters (neuroimaging for febrile seizure). Outpatient and ED low-value imaging resulted in more than $7 million in Medicaid expenditures. CONCLUSIONS Among the studied conditions, more than 1 in 20 encounters included low-value imaging, mostly in nonpediatric EDs and for bronchiolitis, head trauma, and headache. Interventions are needed to decrease the future performance of these low-value services.
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Affiliation(s)
- Jennifer R Marin
- Departments of Pediatrics, Emergency Medicine, and Radiology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA.
| | - Mara A G Hollander
- Center for Mental Health and Addiction Policy Research, Department of Health Policy, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Kristin N Ray
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Julie M Donohue
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
| | - Evan S Cole
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
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Cane R, Kerns E, Maskin L, Natt B, Sieczkowski L, Biondi E, McCulloh RJ. Comparing Patterns of Care for Febrile Infants at Community and University-Affiliated Hospitals. Hosp Pediatr 2021; 11:231-238. [PMID: 33602793 DOI: 10.1542/hpeds.2020-000778] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVES Most children in the United States receive treatment in community hospitals, but descriptions of clinical practice patterns in pediatric care in this setting are lacking. Our objectives were to compare clinical practice patterns primarily between community and university-affiliated hospitals and secondarily by number of pediatric beds before and during participation in a national practice standardization project. METHODS We performed a retrospective secondary analysis on data from 126 hospitals that participated in the American Academy of Pediatrics' Value in Inpatient Pediatrics Reducing Excessive Variability in the Infant Sepsis Evaluation project, a national quality improvement project conducted to improve care for well-appearing febrile infants aged 7 to 60 days. Four use measures were compared by hospital type and by number of non-ICU pediatric beds. RESULTS There were no differences between community and university-affiliated hospitals in the odds of hospital admission, average length of stay, or odds of cerebrospinal fluid culture. The odds of chest radiograph at community hospitals were higher only during the baseline period. There were no differences by number of pediatric beds in odds of admission or average length of stay. For hospitals with ≤30 pediatric beds, the odds of chest radiograph were higher and the odds of cerebrospinal fluid culture were lower compared with hospitals >50 beds during both study periods. CONCLUSIONS In many key aspects, care for febrile infants does not differ between community and university-affiliated hospitals. Clinical practice may differ more by number of pediatric beds.
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Affiliation(s)
- Rachel Cane
- Department of Pediatrics, Johns Hopkins Children's Center, Baltimore, Maryland;
| | - Ellen Kerns
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, Nebraska.,Children's Hospital and Medical Center, Omaha, Nebraska; and
| | - Lauren Maskin
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, Nebraska.,Children's Hospital and Medical Center, Omaha, Nebraska; and
| | - Beth Natt
- Connecticut Children's Medical Center, Hartford, Connecticut
| | - Lisa Sieczkowski
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, Nebraska.,Children's Hospital and Medical Center, Omaha, Nebraska; and
| | - Eric Biondi
- Department of Pediatrics, Johns Hopkins Children's Center, Baltimore, Maryland
| | - Russell J McCulloh
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, Nebraska.,Children's Hospital and Medical Center, Omaha, Nebraska; and
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