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Reyes MA, Etinger V, Hronek C, Hall M, Davidson A, Mangione-Smith R, Kaiser SV, Parikh K. Pediatric Respiratory Illnesses: An Update on Achievable Benchmarks of Care. Pediatrics 2023; 152:e2022058389. [PMID: 37403624 DOI: 10.1542/peds.2022-058389] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/24/2023] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Pediatric respiratory illnesses (PRI): asthma, bronchiolitis, pneumonia, croup, and influenza are leading causes of pediatric hospitalizations, and emergency department (ED) visits in the United States. There is a lack of standardized measures to assess the quality of hospital care delivered for these conditions. We aimed to develop a measure set for automated data extraction from administrative data sets and evaluate its performance including updated achievable benchmarks of care (ABC). METHODS A multidisciplinary subject-matter experts team selected quality measures from multiple sources. The measure set was applied to the Public Health Information System database (Children's Hospital Association, Lenexa, KS) to cohorts of ED visits and hospitalizations from 2017 to 2019. ABC for pertinent measures and performance gaps of mean values from the ABC were estimated. ABC were compared with previous reports. RESULTS The measure set: PRI report includes a total of 94 quality measures. The study cohort included 984 337 episodes of care, and 82.3% were discharged from the ED. Measures with low performance included bronchodilators (19.7%) and chest x-rays (14.4%) for bronchiolitis in the ED. These indicators were (34.6%) and (29.5%) in the hospitalized cohort. In pneumonia, there was a 57.3% use of narrow spectrum antibiotics. In general, compared with previous reports, there was improvement toward optimal performance for the ABCs. CONCLUSIONS The PRI report provides performance data including ABC and identifies performance gaps in the quality of care for common respiratory illnesses. Future directions include examining health inequities, and understanding and addressing the effects of the coronavirus disease 2019 pandemic on care quality.
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Affiliation(s)
- Mario A Reyes
- Division of Hospital Medicine, Department of Pediatrics, Nicklaus Children's Hospital, Florida International University, Herbert Wertheim College of Medicine
| | - Veronica Etinger
- Division of Hospital Medicine, Department of Pediatrics, Nicklaus Children's Hospital, Florida International University, Herbert Wertheim College of Medicine
| | | | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | | | | | - Sunitha V Kaiser
- Department of Pediatrics, University of California, San Francisco, California
- Philip R. Lee Institute for Health Policy Studies, San Francisco, California
| | - Kavita Parikh
- Children's National Hospital, Washington, District of Columbia
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2
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Nkoy FL, Wilkins VL, Fassl BA, Johnson JM, Uchida DA, Poll JB, Greene TH, Koopmeiners KJ, Reynolds CC, Valentine KJ, Savitz LA, Maloney CG, Stone BL. Contextual Factors Influencing Implementation of Evidence-Based Care for Children Hospitalized With Asthma. Hosp Pediatr 2019; 9:949-957. [PMID: 31694831 DOI: 10.1542/hpeds.2019-0050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES The translation of research findings into routine care remains slow and challenging. We previously reported successful implementation of an asthma evidence-based care process model (EB-CPM) at 8 (1 tertiary care and 7 community) hospitals, leading to a high health care provider (HCP) adherence with the EB-CPM and improved outcomes. In this study, we explore contextual factors perceived by HCPs to facilitate successful EB-CPM implementation. METHODS Structured and open-ended questions were used to survey HCPs (n = 260) including physicians, nurses, and respiratory therapists, about contextual factors perceived to facilitate EB-CPM implementation. Quantitative analysis was used to identify significant factors (correlation coefficient ≥0.5; P ≤ .05) and qualitative analysis to assess additional facilitators. RESULTS Factors perceived by HCPs to facilitate EB-CPM implementation were related to (1) inner setting (leadership support, adequate resources, communication and/or collaboration, culture, and previous experience with guideline implementation), (2) intervention characteristics (relevant and applicable to the HCP's practice), (3) individuals (HCPs) targeted (agreement with the EB-CPM and knowledge of supporting evidence), and (4) implementation process (participation of HCPs in implementation activities, teamwork, implementation team with a mix of expertise and professional's input, and data feedback). Additional facilitators included (1) having appropriate preparation and (2) providing education and training. CONCLUSIONS Multiple factors were associated with successful EB-CPM implementation and may be used by others as a guide to facilitate implementation and dissemination of evidence-based interventions for pediatric asthma and other chronic diseases in the hospital setting.
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Affiliation(s)
- Flory L Nkoy
- Department of Pediatrics University of Utah, Salt Lake City, Utah;
| | | | - Bernhard A Fassl
- Department of Pediatrics University of Utah, Salt Lake City, Utah
| | | | - Derek A Uchida
- Department of Pediatrics University of Utah, Salt Lake City, Utah
| | | | - Tom H Greene
- Department of Pediatrics University of Utah, Salt Lake City, Utah
| | | | | | | | | | | | - Bryan L Stone
- Department of Pediatrics University of Utah, Salt Lake City, Utah
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3
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Hospital admissions in children with acute respiratory disease in Portugal. Pulmonology 2019; 25:122-125. [PMID: 30795975 DOI: 10.1016/j.pulmoe.2018.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 11/29/2018] [Accepted: 12/13/2018] [Indexed: 11/21/2022] Open
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Subramony A, Hall M, Thomas C, Chiang VW, McClead RE, Macias CG, Frank G, Simon HK, Mann K, Morse R. Asthma Care Quality Measures at Children's Hospitals and Asthma-Related Outcomes. J Healthc Qual 2018; 38:243-53. [PMID: 25158598 DOI: 10.1111/jhq.12075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The Joint Commission requires hospitals to report on Children's Asthma Care (CAC) measures, although their relationship to outcomes is not clear. The objective of this study was to (1) characterize metrics hospitals use for asthma, and to (2) determine if the number and type of metrics used is associated with readmission rates. STUDY DESIGN Pediatric hospital quality leaders were asked to identify asthma metrics utilized by their respective organizations via an online survey. "Use" of metrics was defined as periodically measuring data regardless of performance. Linear regression was used to determine if the number or domain of metrics grouped by topic used was associated with 7-, 30-, and 90-day same-cause readmission rates obtained from the Pediatric Health Information System (PHIS). RESULTS Among respondents (n = 27, 62.7%), the mean number of metrics used was 20.5 (SD = 9.1, range = 4-38). There was no association between the number or domain type of metrics used and 7-, 30-, or 90-day readmission rates. CONCLUSIONS Despite using a wide variety of asthma metrics, there was no association between use of any metric or domain of metrics and asthma-related readmission rates. Additional work should identify asthma process measures that are associated with meaningful outcomes.
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Hogan AH, Rastogi D, Rinke ML. A Quality Improvement Intervention to Improve Inpatient Pediatric Asthma Controller Accuracy. Hosp Pediatr 2018; 8:127-134. [PMID: 29440128 DOI: 10.1542/hpeds.2017-0184] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Our objective was to investigate if a rigorous quality improvement (QI) intervention could increase accuracy of pediatric asthma controller medications on discharge from an inpatient hospitalization. METHODS Our interprofessional QI team developed interventions such as improving documentation and creating standardized language to ensure patients were discharged on an appropriate asthma controller medication and improve assessment of asthma symptom control. Each week of 2015-2016, the first 5 patients discharged with status asthmaticus from the pediatric wards were reviewed for documentation of the 6 asthma control questions and accuracy of the discharge controller therapy. Correct discharge medication was defined as being prescribed the age-appropriate medication and dose on the basis of baseline controller therapy, compliance with baseline medication, and responses to asthma control assessment. The weekly proportion of control questions that were accessed and correct controller medications that were prescribed were analyzed by using Nelson rules and interrupted time series. RESULTS A total of 240 preintervention and 252 postintervention charts were reviewed. The primary outcome of the median proportion of patients discharged on appropriate controller therapy improved from 60% in preintervention data to 80% in the postintervention period. The process measure of proportion of asthma control questions that were assessed improved from 43% in the preintervention period to 98% by the final months of the intervention period. Both of these changes were statistically significant as per Nelson's rules and interrupted time series analyses (P = .02 and P < .001, respectively, for postintervention break). CONCLUSIONS An interdisciplinary QI team successfully improved the accuracy of asthma controller therapy on discharge and the inpatient assessment of asthma control questions.
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Affiliation(s)
- Alexander H Hogan
- Department of Pediatrics, Connecticut Children's Medical Center, Hartford, Connecticut; and
| | - Deepa Rastogi
- Children's Hospital at Montefiore, Bronx, New York, New York
| | - Michael L Rinke
- Children's Hospital at Montefiore, Bronx, New York, New York
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6
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Mangione-Smith R, Roth CP, Britto MT, Chen AY, McGalliard J, Boat TF, Adams JL, McGlynn EA. Development and Testing of the Pediatric Respiratory Illness Measurement System (PRIMES) Quality Indicators. Hosp Pediatr 2017; 7:125-133. [PMID: 28223319 DOI: 10.1542/hpeds.2016-0182] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To develop and test quality indicators for assessing care in pediatric hospital settings for common respiratory illnesses. PATIENTS A sample of 2796 children discharged from the emergency department or inpatient setting at 1 of the 3 participating hospitals with a primary diagnosis of asthma, bronchiolitis, croup, or community-acquired pneumonia (CAP) between January 1, 2010, and December 31, 2011. SETTING Three tertiary care children's hospitals in the United States. METHODS We developed evidence-based quality indicators for asthma, bronchiolitis, croup, and CAP. Expert panel-endorsed indicators were included in the Pediatric Respiratory Illness Measurement System (PRIMES). This new set of pediatric quality measures was tested to assess feasibility of implementation and sensitivity to variations in care. Medical records data were extracted by trained abstractors. Quality measure scores (0-100 scale) were calculated by dividing the number of times indicated care was received by the number of eligible cases. Score differences within and between hospitals were determined by using the Student's t-test or analysis of variance. RESULTS CAP and croup condition-level PRIMES scores demonstrated significant between-hospital variations (P < .001). Asthma and bronchiolitis condition-level PRIMES scores demonstrated significant within-hospital variation with emergency department scores (means [SD] 82.2(6.1)-100.0 (14.4)] exceeding inpatient scores (means [SD] 71.1 (2.0)-90.8 (1.3); P < .001). CONCLUSIONS PRIMES is a new set of measures available for assessing the quality of hospital-based care for common pediatric respiratory illnesses.
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Affiliation(s)
- Rita Mangione-Smith
- Seattle Children Research Institute, Center for Child Health, Behavior and Development, Seattle, Washington; .,Department of Pediatrics, University of Washington, Seattle, Washington
| | | | - Maria T Britto
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Alex Y Chen
- AltaMed Health Services, Los Angeles, California; and
| | - Julie McGalliard
- Seattle Children Research Institute, Center for Child Health, Behavior and Development, Seattle, Washington
| | - Thomas F Boat
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - John L Adams
- Kaiser Permanente Center for Effectiveness and Safety Research, Pasadena, California
| | - Elizabeth A McGlynn
- Kaiser Permanente Center for Effectiveness and Safety Research, Pasadena, California
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Zipkin R, Schrager SM, Nguyen E, Mamey MR, Banuelos I, Wu S. Association between pediatric home management plan of care compliance and asthma readmission. J Asthma 2016; 54:761-767. [PMID: 27929691 DOI: 10.1080/02770903.2016.1263651] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVES In 2007, The Joint Commission implemented three children's asthma care (CAC) measures to help improve the quality of care for patients admitted with asthma. Due to lack of consistent evidence showing a relationship between home management plan of care (HMPC) compliance and readmission rates, CAC-3 was retired in 2016. We aimed to understand the relationship between HMPC compliance and revisits to the hospital, and investigate which components of the HMPC, if any, were driving the effect. METHODS This was a retrospective cohort study at a quaternary care freestanding children's hospital, including patients between 2 and 17 years of age admitted with a primary diagnosis of asthma between January 1, 2006, and July 1, 2013. Bivariate and multiple logistic regression analyses examined effects of HMPC provider compliance on hospital readmission and emergency department utilization for asthma within 180 days of initial discharge, controlling for admission to the intensive care unit, age, gender, ethnicity, insurance type, and whether inhaled corticosteroids were prescribed. RESULTS A total of 1,176 patients were included. Those discharged with an HMPC (n = 756, of which 84% were fully compliant) were found to have significantly lower readmission rates (7 vs. 11.9%; aOR = 0.63; 95% CI, 0.41-0.95) and ED revisit rates (aOR = 0.73; 95% CI, 0.56-0.96) within 180 days of discharge. CONCLUSIONS Providing an HMPC upon discharge was found to be associated with decreased asthma readmission and ED utilization rates. This suggests that although HMPC is no longer a required measure, there may still be utility in continuing this practice.
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Affiliation(s)
- Ronen Zipkin
- a Division of Hospital Medicine , Children's Hospital Los Angeles , Los Angeles , CA , USA
| | - Sheree M Schrager
- a Division of Hospital Medicine , Children's Hospital Los Angeles , Los Angeles , CA , USA
| | - Eugene Nguyen
- a Division of Hospital Medicine , Children's Hospital Los Angeles , Los Angeles , CA , USA
| | - Mary Rose Mamey
- a Division of Hospital Medicine , Children's Hospital Los Angeles , Los Angeles , CA , USA
| | - Ingrid Banuelos
- a Division of Hospital Medicine , Children's Hospital Los Angeles , Los Angeles , CA , USA
| | - Susan Wu
- a Division of Hospital Medicine , Children's Hospital Los Angeles , Los Angeles , CA , USA
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Hasegawa K, Tsugawa Y, Clark S, Eastin CD, Gabriel S, Herrera V, Bittner JC, Camargo CA. Improving Quality of Acute Asthma Care in US Hospitals: Changes Between 1999-2000 and 2012-2013. Chest 2016; 150:112-22. [PMID: 27056585 DOI: 10.1016/j.chest.2016.03.037] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Revised: 03/14/2016] [Accepted: 03/21/2016] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Little is known about the longitudinal change in the quality of acute asthma care for hospitalized children and adults in the United States. We investigated whether the concordance of inpatient asthma care with the national guidelines improved over time, identified hospital characteristics predictive of guideline concordance, and determined whether guideline-concordant care is associated with a shorter hospital length of stay (LOS). METHODS This study was an analysis of data from two multicenter chart review studies of hospitalized patients aged 2 to 54 years with acute asthma during two time periods: 1999-2000 and 2012-2013. Outcomes were guideline concordance at the patient and hospital levels, and association of patient composite concordance with hospital LOS. RESULTS The analytic cohort for the comparison of guideline concordance comprised 1,634 patients: 834 patients from 1999-2000 vs 800 patients from 2012-2013. Over these 15 years, inpatient asthma care became more concordant at the hospital-level, with the mean composite score increasing from 74 to 82 (P < .001). However, during 2012-2013, wide variability in guideline concordance of acute asthma care remained across hospitals, with the greatest variation in provision of individualized written action plan at discharge (SD, 36). Guideline concordance was significantly lower in Midwestern and Southern hospitals compared with Northeastern hospitals. After adjusting for severity, patients who received care perfectly concordant with the guidelines had significantly shorter hospital LOS (-14% [95% CI, -23 to -4]; P = .009). CONCLUSIONS Between 1999 and 2013, the guideline concordance of acute asthma care for hospitalized patients improved. However, interhospital variability remains substantial. Greater concordance with evidence-based guidelines was associated with a shorter hospital LOS.
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Affiliation(s)
- Kohei Hasegawa
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
| | | | - Sunday Clark
- Department of Emergency Medicine, Weill Cornell Medical College, New York, NY
| | - Carly D Eastin
- University of Arkansas for Medical Sciences, Little Rock, AR
| | | | | | - Jane C Bittner
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Nkoy F, Fassl B, Stone B, Uchida DA, Johnson J, Reynolds C, Valentine K, Koopmeiners K, Kim EH, Savitz L, Maloney CG. Improving Pediatric Asthma Care and Outcomes Across Multiple Hospitals. Pediatrics 2015; 136:e1602-10. [PMID: 26527553 PMCID: PMC9923521 DOI: 10.1542/peds.2015-0285] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/11/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Gaps exist in inpatient asthma care. Our aims were to assess the impact of an evidence-based care process model (EB-CPM) 5 years after implementation at Primary Children's Hospital (PCH), a tertiary care facility, and after its dissemination to 7 community hospitals. METHODS Participants included asthmatics 2 to 17 years admitted at 8 hospitals between 2003 and 2013. The EB-CPM was implemented at PCH between January 2008 and March 2009, then disseminated to 7 community hospitals between January and June 2011. We measured compliance using a composite score (CS) for 8 quality measures. Outcomes were compared between preimplementation and postimplementation periods. Confounding was addressed through multivariable regression analyses. RESULTS At PCH, the CS increased and remained at >90% for 5 years after implementation. We observed sustained reductions in asthma readmissions (P = .026) and length of stay (P < .001), a trend toward reduced costs (P = .094), and no change in hospital resource use, ICU transfers, or deaths. The CS also increased at the 7 community hospitals, reaching 80% to 90% and persisting >2 years after dissemination, with a slight but not significant readmission reduction (P = .119), a significant reduction in length of stay (P < .001) and cost (P = .053), a slight increase in hospital resource use (P = .032), and no change in ICU transfers or deaths. CONCLUSIONS Our intervention resulted in sustained, long-term improvement in asthma care and outcomes at the tertiary care hospital and successful dissemination to community hospitals.
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Affiliation(s)
- Flory Nkoy
- Department of Pediatrics, University of Utah, Salt Lake City, Utah; and
| | - Bernhard Fassl
- Department of Pediatrics, University of Utah, Salt Lake City, Utah; and
| | - Bryan Stone
- Department of Pediatrics, University of Utah, Salt Lake City, Utah; and
| | - Derek A. Uchida
- Department of Pediatrics, University of Utah, Salt Lake City, Utah; and
| | | | | | | | | | - Eun Hea Kim
- Department of Pediatrics, University of Utah, Salt Lake City, Utah; and
| | - Lucy Savitz
- Intermountain Healthcare, Salt Lake City, Utah
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10
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Auger KA, Kahn RS, Davis MM, Simmons JM. Pediatric asthma readmission: asthma knowledge is not enough? J Pediatr 2015; 166:101-8. [PMID: 25241184 DOI: 10.1016/j.jpeds.2014.07.046] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Revised: 05/14/2014] [Accepted: 07/24/2014] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To characterize factors associated with readmission for acute asthma exacerbation, particularly around caregiver asthma knowledge, beliefs, and reported adherence to prescribed medication regimens. STUDY DESIGN We enrolled 601 children (aged 1-16 years) who had been hospitalized for asthma. Caregivers completed a face-to-face survey regarding their asthma knowledge, beliefs, and medication adherence. Caregivers also reported demographic data, child's asthma severity, exposure to triggers, access to primary care, and financial strains. We prospectively identified asthma readmission events via billing data over a 1-year minimum follow-up period. We examined time to readmission with Cox proportional hazards. RESULTS The study cohort's median age was 5 years, 53% were African American, and 57% were covered by Medicaid. At 1 year, 22% had been readmitted for asthma. In the multivariate analysis, a caregiver's demonstration of increased asthma knowledge was associated with increased readmission risk. In addition, children whose caregivers reported less-than-perfect adherence to daily medication regimens had increased readmission risk. Likewise, having previously been admitted for asthma, decreased medical home access, and black race were associated with increased readmission risk. CONCLUSION In a multifactorial assessment of risk factors for asthma readmission, greater asthma knowledge and decreased medication adherence were associated with readmission. Inpatient efforts to prevent readmission might best target medication adherence rather than continuing to primarily provide asthma education.
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Affiliation(s)
- Katherine A Auger
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; James M Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
| | - Robert S Kahn
- James M Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Division of General Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Matthew M Davis
- Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI; Department of Internal Medicine, University of Michigan, Ann Arbor, MI; Robert Wood Johnson Foundation Clinical Scholars Program, University of Michigan, Ann Arbor, MI; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI; Gerald R Ford School of Public Policy, University of Michigan, Ann Arbor, MI
| | - Jeffrey M Simmons
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; James M Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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Parikh K, Hall M, Mittal V, Montalbano A, Mussman GM, Morse RB, Hain P, Wilson KM, Shah SS. Establishing benchmarks for the hospitalized care of children with asthma, bronchiolitis, and pneumonia. Pediatrics 2014; 134:555-62. [PMID: 25136044 DOI: 10.1542/peds.2014-1052] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Asthma, pneumonia, and bronchiolitis are the leading causes of admission for pediatric patients; however, the lack of accepted benchmarks is a barrier to quality improvement efforts. Using data from children hospitalized with asthma, bronchiolitis, or pneumonia, the goals of this study were to: (1) measure the 2012 performance of freestanding children's hospitals using clinical quality indicators; and (2) construct achievable benchmarks of care (ABCs) for the clinical quality indicators. METHODS This study was a cross-sectional trial using the Pediatric Health Information System database. Patient inclusions varied according to diagnosis: asthma (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes 493.0-493.92) from 2 to 18 years of age; bronchiolitis (ICD-9-CM codes 466.11 and 466.19) from 2 months to 2 years of age; and pneumonia (ICD-9-CM codes 480-486, 487.0) from 2 months to 18 years of age. ABC methods use the best-performing hospitals that comprise at least 10% of the total population to compute the benchmark. RESULTS Encounters from 42 hospitals included: asthma, 22186; bronchiolitis, 14882; and pneumonia, 12983. Asthma ABCs include: chest radiograph utilization, 24.5%; antibiotic administration, 6.6%; and ipratropium bromide use >2 days, 0%. Bronchiolitis ABCs include: chest radiograph utilization, 32.4%; viral testing, 0.6%; antibiotic administration, 18.5%; bronchodilator use >2 days, 11.4%; and steroid use, 6.4%. Pneumonia ABCs include: complete blood cell count utilization, 28.8%; viral testing, 1.5%; initial narrow-spectrum antibiotic use, 60.7%; erythrocyte sedimentation rate, 3.5%; and C-reactive protein, 0.1%. CONCLUSIONS We report achievable benchmarks for inpatient care for asthma, bronchiolitis, and pneumonia. The establishment of national benchmarks will drive improvement at individual hospitals.
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Affiliation(s)
- Kavita Parikh
- Children's National Medical Center and George Washington School of Medicine, Washington, District of Columbia;
| | - Matt Hall
- Children's Hospital Association, Overland Park, Kansas
| | - Vineeta Mittal
- Children's Medical Center and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Amanda Montalbano
- Children's Mercy Hospitals and Clinics and University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | | | - Rustin B Morse
- Children's Medical Center and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Paul Hain
- Children's Medical Center and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Karen M Wilson
- Children's Hospital Colorado and the University of Colorado School of Medicine, Aurora, Colorado
| | - Samir S Shah
- Divisions of Hospital Medicine and Infectious Diseases, Cincinnati Children's Hospital Medical Center, and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; and
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12
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Stang AS, Straus SE, Crotts J, Johnson DW, Guttmann A. Quality indicators for high acuity pediatric conditions. Pediatrics 2013; 132:752-62. [PMID: 24062374 DOI: 10.1542/peds.2013-0854] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Identifying gaps in care and improving outcomes for severely ill children requires the development of evidence-based performance measures. We used a systematic process involving multiple stakeholders to identify and develop evidence-based quality indicators for high acuity pediatric conditions relevant to any emergency department (ED) setting where children are seen. METHODS A prioritized list of clinical conditions was selected by an advisory panel. A systematic review of the literature was conducted to identify existing indicators, as well as guidelines and evidence that could be used to inform the creation of new indicators. A multiphase, Rand-modified Delphi method consisting of anonymous questionnaires and a face-to-face meeting of an expert panel was used for indicator selection. Measure specifications and evidence grading were created for each indicator, and the feasibility and reliability of measurement was assessed in a tertiary care pediatric ED. RESULTS The conditions selected for indicator development were diabetic ketoacidosis, status asthmaticus, anaphylaxis, status epilepticus, severe head injury, and sepsis. The majority of the 62 selected indicators reflect ED processes (84%) with few indicators reflecting structures (11%) or outcomes (5%). Thirty-seven percent (n = 23) of the selected indicators are based on moderate or high quality evidence. Data were available and interrater reliability acceptable for the majority of indicators. CONCLUSIONS A systematic process involving multiple stakeholders was used to develop evidence-based quality indicators for high acuity pediatric conditions. Future work will test the reliability and feasibility of data collection on these indicators across the spectrum of ED settings that provide care for children.
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Affiliation(s)
- Antonia S Stang
- MDCM, MBA, MSc, Alberta Children's Hospital, 2888 Shaganappi Trail, Calgary AB, T3B 6A8.
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13
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Chang J, Freed GL, Prosser LA, Patel I, Erickson SR, Bagozzi RP, Balkrishnan R. Associations between physician financial incentives and the prescribing of anti-asthmatic medications in children in US outpatient settings. J Child Health Care 2013; 17:125-37. [PMID: 23424001 DOI: 10.1177/1367493512456110] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study examined how sociological factors including financial incentives influenced whether asthmatic children received a controller medication, a reliever medication or both. The 2007 National Ambulatory Medical Care Survey was used for this analysis. A logistic regression was applied to capture the physician's decision-making and to analyze anti-asthmatic medication choice. Children with asthma seeing a pediatrician were approximately 69% more likely than children seeing a family doctor to receive a controller medication than reliever medication (p<0.01). Children with asthma enrolled in a capitated plan were 23% more likely to receive controller medications than reliever medications (p<0.01). Children with asthma of Hispanic ethnicity were 28% less likely to receive controller medication compared to non-Hispanic white (p<0.05) children. Compared with physicians with lower financial incentives, physicians who received medium (39%, p<0.05) or higher (42%, p<0.01) financial incentives from payers were more likely to prescribe controller medication than reliever medication for asthmatic children. An important finding of this study is that physicians who had medium or higher financial incentives from payers were about 40% more likely to prescribe a controller medication in asthmatic children. Findings suggest that physician incentives and capitated plans are associated with an increase in physicians prescribing controller medications or preventive care in children with asthma.
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Paciorkowski N, Pruitt C, Lashly D, Hrach C, Harrison E, Srinivasan M, Turmelle M, Carlson D. Development of performance tracking for a pediatric hospitalist division. Hosp Pediatr 2013; 3:118-128. [PMID: 24340412 DOI: 10.1542/hpeds.2012-0064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVES Our goal was to develop a comprehensive performance tracking process for a large pediatric hospitalist division. We aimed to use established dimensions and theory of health care quality to identify measures relevant to common inpatient diagnoses, reflective of current standards of clinical care, and applicable to individual physician performance. We also sought to implement a reproducible data collection strategy that minimizes manual data collection and measurement bias. METHODS Washington University Division of Pediatric Hospital Medicine provides clinical care in 17 units within 3 different hospitals. Hospitalist services were grouped into 5 areas, and a task group was created of divisional leaders representing clinical services. The group was educated on the health care quality theory and tasked to search clinical practice standards and quality resources. The groups proposed a broad spectrum of performance questions that were screened for electronic data availability and modified into measurable formulas. RESULTS Eighty-seven performance questions were identified and analyzed for their alignment with known clinical guidelines and value in measuring performance. Questions were distributed across quality domains, with most addressing safety. They reflected structure, outcome, and, most commonly, process. Forty-seven questions were disease specific, and 79 questions reflected individual physician performance; 52 questions had electronically available data. CONCLUSIONS We describe a systematic approach to the development of performance indicators for a pediatric hospitalist division that can be used to measure performance on a division and physician level. We outline steps to develop a broad-spectrum quality tracking process to standardize clinical care and build invaluable resources for quality improvement research.
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Affiliation(s)
- Natalia Paciorkowski
- Washington University, St Louis School of Medicine, Department of Pediatrics, Division of Hospitalist Medicine, St Louis, Missouri 63110, USA
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Fassl BA, Nkoy FL, Stone BL, Srivastava R, Simon TD, Uchida DA, Koopmeiners K, Greene T, Cook LJ, Maloney CG. The Joint Commission Children's Asthma Care quality measures and asthma readmissions. Pediatrics 2012; 130:482-91. [PMID: 22908110 PMCID: PMC4074621 DOI: 10.1542/peds.2011-3318] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/27/2012] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The Joint Commission introduced 3 Children's Asthma Care (CAC 1-3) measures to improve the quality of pediatric inpatient asthma care. Validity of the commission's measures has not yet been demonstrated. The objectives of this quality improvement study were to examine changes in provider compliance with CAC 1-3 and associated asthma hospitalization outcomes after full implementation of an asthma care process model (CPM). METHODS The study included children aged 2 to 17 years who were admitted to a tertiary care children's hospital for acute asthma between January 1, 2005, and December 31, 2010. The study was divided into 3 periods: preimplementation (January 1, 2005-December 31, 2007), implementation (January 1, 2008-March 31, 2009), and postimplementation (April 1, 2009-December 31, 2010) periods. Changes in provider compliance with CAC 1-3 and associated changes in hospitalization outcomes (length of stay, costs, PICU transfer, deaths, and asthma readmissions within 6 months) were measured. Logistic regression was used to control for age, gender, race, insurance type, and time. RESULTS A total of 1865 children were included. Compliance with quality measures before and after the CPM implementation was as follows: 99% versus 100%, CAC-1; 100% versus 100%, CAC-2; and 0% versus 87%, CAC-3 (P < .01). Increased compliance with CAC-3 was associated with a sustained decrease in readmissions from an average of 17% to 12% (P = .01) postimplementation. No change in other outcomes was observed. CONCLUSIONS Implementation of the asthma CPM was associated with improved compliance with CAC-3 and with a delayed, yet significant and sustained decrease in hospital asthma readmission rates, validating CAC-3 as a quality measure. Due to high baseline compliance, CAC-1 and CAC-2 are of questionable value as quality measures.
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Affiliation(s)
| | - Flory L. Nkoy
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Bryan L. Stone
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | | | - Tamara D. Simon
- Department of Pediatrics, University of Washington, Seattle, Washington; and
| | - Derek A. Uchida
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | | | - Tom Greene
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Lawrence J. Cook
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
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Ohadike YU, Malveaux FJ, Lesch JK. Challenges and lessons learned from the translation of evidence-based childhood asthma interventions: a commentary on the MCAN initiative. Health Promot Pract 2012; 12:91S-9S. [PMID: 22068365 DOI: 10.1177/1524839911414565] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The Merck Childhood Asthma Network (MCAN) used evidence-based interventions (EBIs) for children with asthma to design community-based programs in a wide variety of settings--with varying resource constraints and priorities--that were often determined by the program context. Although challenges were faced, lessons learned strongly suggest that adapting and implementing EBIs is feasible in a variety of settings using a multisite approach. Lessons learned during the MCAN initiative presented unique opportunities to refine best practices that proved to be important to translation of EBIs in community-based settings. The adopted best practices were based on experiential learning during different phases of the project cycle, including monitoring and evaluation, translational research, and implementing policies in local program environments. Throughout this discussion it is important to note the importance of program context in determining the effectiveness of the interventions, opportunities to scale them, their affordability, and the ability to sustain them. Lessons learned from this effort will be important not only to advance science-based approaches to manage childhood asthma but also to assist in closing the gap between intervention development (discovery) and program dissemination and implementation (delivery).
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Van Cleave J, Dougherty D, Perrin JM. Strategies for addressing barriers to publishing pediatric quality improvement research. Pediatrics 2011; 128:e678-86. [PMID: 21844057 PMCID: PMC9923785 DOI: 10.1542/peds.2010-0809] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Advancing the science of quality improvement (QI) requires dissemination of the results of QI. However, the results of few QI interventions reach publication. OBJECTIVE To identify barriers to publishing results of pediatric QI research and provide practical strategies that QI researchers can use to enhance publishability of their work. METHODS We reviewed and summarized a workshop conducted at the Pediatric Academic Societies 2007 meeting in Toronto, Ontario, Canada, on conducting and publishing QI research. We also interviewed 7 experts (QI researchers, administrators, journal editors, and health services researchers who have reviewed QI manuscripts) about common reasons that QI research fails to reach publication. We also reviewed recently published pediatric QI articles to find specific examples of tactics to enhance publishability, as identified in interviews and the workshop. RESULTS We found barriers at all stages of the QI process, from identifying an appropriate quality issue to address to drafting the manuscript. Strategies for overcoming these barriers included collaborating with research methodologists, creating incentives to publish, choosing a study design to include a control group, increasing sample size through research networks, and choosing appropriate process and clinical quality measures. Several well-conducted, successfully published QI studies in pediatrics offer guidance to other researchers in implementing these strategies in their own work. CONCLUSION Specific, feasible approaches can be used to improve opportunities for publication in pediatric, QI, and general medical journals.
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Affiliation(s)
- Jeanne Van Cleave
- Center for Child and Adolescent Health Policy, Mass General Hospital for Children, Boston, Massachusetts 02114, USA.
| | | | - James M. Perrin
- Center for Child and Adolescent Health Policy, Mass General Hospital for Children, Boston, Massachusetts; and
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Urrusuno RF, de la Pisa BP, Balosa MM. Impact of postal prescriber feedback on prescribing practice of Andalucian primary care paediatricians. JOURNAL OF PHARMACEUTICAL HEALTH SERVICES RESEARCH 2011. [DOI: 10.1111/j.1759-8893.2011.00047.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Hartman ME, Linde-Zwirble WT, Angus DC, Watson RS. Trends in admissions for pediatric status asthmaticus in New Jersey over a 15-year period. Pediatrics 2010; 126:e904-11. [PMID: 20876177 DOI: 10.1542/peds.2009-3239] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Status asthmaticus accounts for a large portion of the morbidity and mortality associated with asthma, but we know little about its epidemiology. We describe here the hospitalization characteristics of children with status asthmaticus, how they changed over time, and how they differed between hospitals with and without PICUs. PATIENTS AND METHODS We used administrative data from New Jersey that included all hospitalizations in the state from 1992, 1995, and 1999-2006. We identified children with status asthmaticus by using International Classification of Diseases, Ninth Revision, diagnosis codes that indicate status asthmaticus and the use of mechanical ventilation by using procedure codes. We designated hospitals with a PICU as "PICU hospitals" and those without as "adult hospitals." RESULTS We identified 28 309 admissions of children with status asthmaticus (22.8% of all asthma hospitalizations). From 1992 to 2006, the rate of hospital admissions decreased by half (from 1.98 in 1000 to 0.93 in 1000 children), and there was a 70% decrease in the number of children admitted to adult hospitals. The rate of ICU care in PICU hospitals more than tripled. However, the rate of mechanical ventilation remained low, and the number of deaths was small and unchanged (n=14 total). Hospital costs climbed from $6.6 million to $9.5 million. CONCLUSIONS Although fewer children are being admitted with status asthmaticus, the proportion of patients managed in PICUs is climbing. There has been no substantial change in rates of mechanical ventilation or death. Additional research is needed to better understand how patients and physicians decide on the appropriate site for hospital care and how that choice affects outcome.
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Affiliation(s)
- Mary E Hartman
- Department of Pediatrics, Duke University, Box 3046, Durham, NC 27710, USA.
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Harlan GA, Nkoy FL, Srivastava R, Lattin G, Wolfe D, Mundorff MB, Colling D, Valdez A, Lange S, Atkinson SD, Cook LJ, Maloney CG. Improving transitions of care at hospital discharge--implications for pediatric hospitalists and primary care providers. J Healthc Qual 2010; 32:51-60. [PMID: 20854359 DOI: 10.1111/j.1945-1474.2010.00105.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Delays, omissions, and inaccuracy of discharge information are common at hospital discharge and put patients at risk for adverse outcomes. We assembled an interdisciplinary team of stakeholders to evaluate our current discharge process between hospitalists and primary care providers (PCPs). We used a fishbone diagram to identify potential causes of suboptimal discharge communication to PCPs. Opportunities for improvement (leverage points) to achieve optimal transfer of discharge information were identified using tally sheets and Pareto charts. Quality improvement strategies consisted of training and implementation of a new discharge process including: (1) enhanced PCP identification at discharge, (2) use of an electronic discharge order and instruction system, and (3) autofaxing discharge information to PCPs. The new discharge process's impact was evaluated on 2,530 hospitalist patient discharges over a 34-week period by measuring: (1) successful transfer of discharge information (proportion of discharge information sheets successfully faxed to PCPs), (2) timeliness (proportion of sheets faxed within 2 days of discharge), and (3) content (presence of key clinical elements in discharge sheets). Postintervention, success, and timeliness of discharge information transfer between pediatric hospitalists and PCPs significantly improved while content remained high.
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Affiliation(s)
- Gregory A Harlan
- Medical Affairs, IPC-The Hospitalist Company, North Hollywood, CA, USA
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Díaz Vázquez C, Carvajal Urueña I, Cano Garcinuño A, Mora Gandarillas I, Mola Caballero de Rodas P, Garcia Merino A, Dominguez Aurrecoechea B. [Feasibility of FeNO measurement in asthmatic children in the primary care setting. CANON Study]. An Pediatr (Barc) 2009; 71:209-14. [PMID: 19608468 DOI: 10.1016/j.anpedi.2009.05.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2009] [Revised: 05/05/2009] [Accepted: 05/19/2009] [Indexed: 11/19/2022] Open
Abstract
AIM Asses the feasibility of exhaled nitric oxide (FeNO) measurement in asthmatic children using a hand-held device in the primary care setting. METHODS Multicentre study performed in the paediatric clinics in seven Spanish primary health care centres. Each centre consecutively included 6-14 year-old children with doctor-diagnosed asthma. Children were asked to obtain two valid measurements of FeNO with the hand-held device NIOX MINO (Aerocrine AB, Solna, Sweden). Feasibility analysis included: (a) percentage of children able to perform the manoeuvre, (b) time required to obtain a successful determination, (c) number of attempts needed, and (d) acceptability of the technical procedure by clinical personnel involved in their guidance. RESULTS The Study enrolled 151 children. A total of 149 (98.7%) were able to perform the FeNO manoeuvre. The majority (55%) of children had previous experience of using the hand-held device. The Overall median (and Interquartile Range, IQR) of attempts needed to reach a first valid measurement was 2 (1-3) and median (IQR) of time taken was 4 min (3-5). Nurses considered the overall procedure was very easy or easy in 87.8% (teaching) and 86.5% (performing) of children. Children with previous experience performed the manoeuvre in less attempts, less time and more easily than children without experience. CONCLUSIONS Measurement of FeNO using NIOX MINO device is technically feasible and acceptable for children and staff in the clinical context of asthma management in primary health care. Previous experience had a positive, learning effect, in teaching and performing the FeNO manoeuvre.
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Ernst MM, Wooldridge JL, Conway E, Dressman K, Weiland J, Tucker K, Seid M. Using quality improvement science to implement a multidisciplinary behavioral intervention targeting pediatric inpatient airway clearance. J Pediatr Psychol 2009; 35:14-24. [PMID: 19366791 DOI: 10.1093/jpepsy/jsp013] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE The objective of this study was to use quality improvement science methodology to develop a multidisciplinary intervention improving occurrence of best-practice airway clearance therapy (ACT) in inpatient adolescents with cystic fibrosis during routine clinical care. METHODS The model for improvement was used to develop and implement interventions. Primary outcomes were quality of ACT (% ACT meeting criteria for best practice) and quantity of ACT (% of hospital days patients received ACT four times/day). Annotated control charts were used to document the impact of the interventions. RESULTS Quality of ACT significantly improved from 21% best practice ACT at baseline to 73%. Quantity of ACT significantly improved from 41% days with ACT four times/day at baseline to 64%. CONCLUSIONS A multidisciplinary, evidence-based intervention was effective for improving occurrence of best-practice ACT. Pediatric psychology can make valuable contributions to improving the quality of care provided in the medical setting.
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Affiliation(s)
- Michelle M Ernst
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.
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Affiliation(s)
- Meyer Kattan
- Department of Pediatrics, Morgan Stanley Children's Hospital of New York, Columbia University, New York, NY 10032, USA.
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