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Feldstein DA, Barata I, McGinn T, Heineman E, Ross J, Kaplan D, Bullaro F, Khan S, Kuehnel N, Berger RP. Disseminating child abuse clinical decision support among commercial electronic health records: Effects on clinical practice. JAMIA Open 2023; 6:ooad022. [PMID: 37063409 PMCID: PMC10101685 DOI: 10.1093/jamiaopen/ooad022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 02/08/2023] [Accepted: 03/28/2023] [Indexed: 04/18/2023] Open
Abstract
Objectives The use of electronic health record (EHR)-embedded child abuse clinical decision support (CA-CDS) may help decrease morbidity from child maltreatment. We previously reported on the development of CA-CDS in Epic and Allscripts. The objective of this study was to implement CA-CDS into Epic and Allscripts and determine its effects on identification, evaluation, and reporting of suspected child maltreatment. Materials and Methods After a preimplementation period, CA-CDS was implemented at University of Wisconsin (Epic) and Northwell Health (Allscripts). Providers were surveyed before the go-live and 4 months later. Outcomes included the proportion of children who triggered the CA-CDS system, had a positive Child Abuse Screen (CAS) and/or were reported to Child Protective Services (CPS). Results At University of Wisconsin (UW), 3.5% of children in the implementation period triggered the system. The CAS was positive in 1.8% of children. The proportion of children reported to CPS increased from 0.6% to 0.9%. There was rapid uptake of the abuse order set.At Northwell Health (NW), 1.9% of children in the implementation period triggered the system. The CAS was positive in 1% of children. The child abuse order set was rarely used. Preimplementation, providers at both sites were similar in desire to have CA-CDS system and perception of CDS in general. After implementation, UW providers had a positive perception of the CA-CDS system, while NW providers had a negative perception. Discussion CA-CDS was able to be implemented in 2 different EHRs with differing effects on clinical care and provider feedback. At UW, the site with higher uptake of the CA-CDS system, the proportion of children who triggered the system and the rate of positive CAS was similar to previous studies and there was an increase in the proportion of cases of suspected abuse identified as measured by reports to CPS. Our data demonstrate how local environment, end-users' opinions, and limitations in the EHR platform can impact the success of implementation. Conclusions When disseminating CA-CDS into different hospital systems and different EHRs, it is critical to recognize how limitations in the functionality of the EHR can impact the success of implementation. The importance of collecting, interpreting, and responding to provider feedback is of critical importance particularly with CDS related to child maltreatment.
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Affiliation(s)
- David A Feldstein
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Isabel Barata
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Thomas McGinn
- CommonSpirit Health, Chicago, Illinois, USA
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Emily Heineman
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Joshua Ross
- Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Dana Kaplan
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Francesca Bullaro
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Sundas Khan
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veteran Affairs (VA) Medical Center, Houston, Texas, USA
| | - Nicholas Kuehnel
- Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Rachel P Berger
- Corresponding Author: Rachel P. Berger, MD, MPH, Division of Child Advocacy, Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA 15224, USA;
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Görgens S, Patel D, Keenan K, Fishbein J, Bullaro F. Assessing the Variability of Antibiotic Management in Patients With Open Hand Fractures Presenting to the Pediatric Emergency Department. Pediatr Emerg Care 2022; 38:502-505. [PMID: 36018726 DOI: 10.1097/pec.0000000000002832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Open hand fractures may be difficult to recognize and treat. There is variability in management and administration of antibiotics for these types of injuries. Unlike open long bone fractures, there is no standardized protocol for antibiotic administration for open hand fractures in children. The objective of this study is to assess the variability of antibiotic management of open hand fractures in children. METHODS We performed a retrospective chart review at a tertiary hospital in New York of patients with hand injuries between ages 0 and 18 years presenting to the emergency department during January 2019 and December 2020. Patient encounters were reviewed for open fractures of the hand. Descriptive statistics were included for demographic and physical characteristics. RESULTS There were 80 encounters with open hand fractures, of which the most common being tuft fractures (77.5%). The mean age was 7.6 years (SD, 4.7 years) with male predominance (58.8%). Crush injuries were the most common mechanism of injury (78.8%). Bedside repair was performed on 62 encounters (77.5%), of which 45 (72.5%) required nail bed repair, 56 (90.3%) required suturing, and 24 (38.7%) required reduction. Antibiotics were given to 62 (77.5%) encounters, most commonly oral cefalexin (45.2%), oral amoxicillin-clavulanic acid (27.4%), and intravenous cefazolin (14.5%). Median time to antibiotics from emergency department registration to administration was 150 minutes (interquartile range, 92-216 minutes). Antibiotic prescriptions were sent for 71 encounters (88.8%). Seventy seven (96.3%) of the encounters were discharged home. CONCLUSIONS Pediatric open hand fractures have a variability of type and timing to antibiotics. Future initiatives should attempt to create standardized guidelines for management of open hand fractures.
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Kusulas MP, Drenis A, Cooper A, Fishbein J, Crevi D, Stein Etess M, Bullaro F. "Code Green Active" Curriculum: Implementation of an Educational Initiative to Increase Awareness of Active Shooter Protocols Among Emergency Department Staff. Pediatr Emerg Care 2022; 38:e1485-e1488. [PMID: 35904959 DOI: 10.1097/pec.0000000000002666] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND There has been an increase in violent acts against hospital employees, including active shooter events. Emergency department (ED) staff must be able to respond to these events efficiently to ensure the safest possible outcome. However, few in our ED were aware of our hospital's active shooter protocol. We aimed to increase staff knowledge of and confidence in these guidelines. METHODS We developed and implemented a 7-week spiral curriculum using the Kern model of curriculum development. Each week, a segment of the hospital active shooter protocol was featured. Multimodal instructional methods including posters, instruction at daily team huddles, descriptions in the weekly division newsletter, and email summaries were used.A 10-question assessment was administered to ED staff both before and after the implementation of our curriculum. During both assessments, staff were asked to rate their confidence in both knowledge of and ability to follow hospital active shooter guidelines. RESULTS There were 95 and 102 participants in the preintervention and postintervention periods, respectively.The median proportion of correct answers on the knowledge assessment increased when comparing preintervention with postintervention performances (P < 0.05).Staff confidence in both knowledge of and ability to follow active shooter protocols increased after the implementation of our curriculum (P < 0.05). CONCLUSIONS Our 7-week curriculum resulted in improved knowledge of and confidence in hospital active shooter protocols among ED staff. Given that our sample was an unpaired convenience sample, inferences from our analysis were limited. Tabletop simulations are currently underway to further reinforce and clarify concepts.
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Affiliation(s)
| | - Anastasios Drenis
- From the Division of Emergency Medicine, Cohen Children's Medical Center, New Hyde Park
| | - Alison Cooper
- From the Division of Emergency Medicine, Cohen Children's Medical Center, New Hyde Park
| | | | - Diana Crevi
- From the Division of Emergency Medicine, Cohen Children's Medical Center, New Hyde Park
| | - Melanie Stein Etess
- From the Division of Emergency Medicine, Cohen Children's Medical Center, New Hyde Park
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McGinn T, Feldstein DA, Barata I, Heineman E, Ross J, Kaplan D, Richardson S, Knox B, Palm A, Bullaro F, Kuehnel N, Park L, Khan S, Eithun B, Berger RP. Dissemination of child abuse clinical decision support: Moving beyond a single electronic health record. Int J Med Inform 2020; 147:104349. [PMID: 33360791 PMCID: PMC8351590 DOI: 10.1016/j.ijmedinf.2020.104349] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 10/28/2020] [Accepted: 11/20/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Child maltreatment is a leading cause of pediatric morbidity and mortality. We previously reported on development and implementation of a child abuse clinical decision support system (CA-CDSS) in the Cerner electronic health record (EHR). Our objective was to develop a CA-CDSS in two different EHRs. METHODS Using the CA-CDSS in Cerner as a template, CA-CDSSs were developed for use in four hospitals in the Northwell Health system who use Allscripts and two hospitals in the University of Wisconsin health system who use Epic. Each system had a combination of triggers, alerts and child abuse-specific order sets. Usability evaluation was done prior to launch of the CA-CDSS. RESULTS Over an 18-month period, a CA-CDSS was embedded into Epic and Allscripts at two hospital systems. The CA-CDSSs vary significantly from each other in terms of the type of triggers which were able to be used, the type of alert, the ability of the alert to link directly to child abuse-specific order sets and the order sets themselves. CONCLUSIONS Dissemination of CA-CDSS from one EHR into the EHR in other health care systems is possible but time-consuming and needs to be adapted to the strengths and limitations of the specific EHR. Site-specific usability evaluation, buy-in of multiple stakeholder groups and significant information technology support are needed. These barriers limit scalability and widespread dissemination of CA-CDSS.
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Affiliation(s)
- Thomas McGinn
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States; Baylor College of Medicine, Houston, Texas, United States
| | - David A Feldstein
- University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Isabel Barata
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Emily Heineman
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Joshua Ross
- University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Dana Kaplan
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Safiya Richardson
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Barbara Knox
- Children's Hospital at Providence/Alaska Child Abuse Response and Evaluation Services, United States; University of Washington, Seattle, Washington, United States
| | - Amanda Palm
- University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Francesca Bullaro
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Nicholas Kuehnel
- University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Linda Park
- University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Sundas Khan
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Benjamin Eithun
- University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Rachel P Berger
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States.
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Jensen AR, Bullaro F, Falcone RA, Daugherty M, Young LC, McLaughlin C, Park C, Lane C, Prince JM, Scherzer DJ, Maa T, Dunn J, Wining L, Hess J, Santos MC, O'Neill J, Katz E, O'Bosky K, Young T, Christison-Lagay E, Ahmed O, Burd RS, Auerbach M. EAST multicenter trial of simulation-based team training for pediatric trauma: Resuscitation task completion is highly variable during simulated traumatic brain injury resuscitation. Am J Surg 2019; 219:1057-1064. [PMID: 31421895 DOI: 10.1016/j.amjsurg.2019.07.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 07/24/2019] [Accepted: 07/27/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Best practices for benchmarking the efficacy of simulation-based training programs are not well defined. This study sought to assess feasibility of standardized data collection with multicenter implementation of simulation-based training, and to characterize variability in pediatric trauma resuscitation task completion associated with program characteristics. METHODS A prospective multicenter observational cohort of resuscitation teams (N = 30) was used to measure task completion and teamwork during simulated resuscitation of a child with traumatic brain injury. A survey was used to measure center-specific trauma volume and simulation-based training program characteristics among participating centers. RESULTS No task was consistently performed across all centers. Teamwork skills were associated with faster time to computed tomography notification (r = -0.51, p < 0.01). Notification of the operating room by the resuscitation team occurred more frequently in in situ simulation than in laboratory-based simulation (13/22 versus 0/8, p < 0.01). CONCLUSIONS Multicenter implementation of a standardized pediatric trauma resuscitation simulation scenario is feasible. Standardized data collection showed wide variability in simulated resuscitation task completion.
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Affiliation(s)
- Aaron R Jensen
- UCSF Benioff Children's Hospital Oakland, Oakland, CA, USA.
| | - Francesca Bullaro
- Cohen Children's Medical Center of Northwell Health, New Hyde Park, NY, USA.
| | | | - Margot Daugherty
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
| | | | | | - Caron Park
- Southern California Clinical and Translational Science Institute, University of Southern California, Los Angeles, CA, USA.
| | - Christianne Lane
- Southern California Clinical and Translational Science Institute, University of Southern California, Los Angeles, CA, USA.
| | - Jose M Prince
- Cohen Children's Medical Center of Northwell Health, New Hyde Park, NY, USA.
| | | | - Tensing Maa
- Nationwide Children's Hospital, Columbus, OH, USA.
| | - Julie Dunn
- University of Colorado Health-Medical Center of the Rockies, Loveland, CO, USA.
| | - Laura Wining
- University of Colorado Health-Medical Center of the Rockies, Loveland, CO, USA.
| | - Joseph Hess
- Penn State Children's Hospital, Hershey, PA, USA.
| | | | | | - Eric Katz
- Wake Forest Baptist Health, Winston-Salem, NC, USA.
| | - Karen O'Bosky
- Loma Linda University Medical Center and Children's Hospital, Loma Linda, CA, USA.
| | - Timothy Young
- Loma Linda University Medical Center and Children's Hospital, Loma Linda, CA, USA.
| | | | - Omar Ahmed
- Children's National Medical Center, Washington, DC, USA.
| | - Randall S Burd
- Children's National Medical Center, Washington, DC, USA.
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El-Shafy IA, Delgado J, Akerman M, Bullaro F, Christopherson NAM, Prince JM. Closed-Loop Communication Improves Task Completion in Pediatric Trauma Resuscitation. J Surg Educ 2018; 75:58-64. [PMID: 28780315 DOI: 10.1016/j.jsurg.2017.06.025] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 05/05/2017] [Accepted: 06/19/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND Pediatric trauma care requires effective and clear communication in a time-sensitive manner amongst a variety of disciplines. Programs such as Crew Resource Management in aviation have been developed to systematically prevent errors. Similarly, teamSTEPPS has been promoted in healthcare with a strong focus on communication. We aim to evaluate the ability of closed-loop communication to improve time-to-task completion in pediatric trauma activations. METHODS All pediatric trauma activations from January to September, 2016 at an American College of Surgeons verified level I pediatric trauma center were video recorded and included in the study. Two independent reviewers identified and classified all verbal orders issued by the trauma team leader for order audibility, directed responsibility, check-back, and time-to-task-completion. The impact of pre-notification and level of activation on time-to-task-completion was also evaluated. All analyses were performed using SAS® version 9.4(SAS Institute Inc., Cary, NC). RESULTS In total, 89 trauma activation videos were reviewed, with 387 verbal orders identified. Of those, 126(32.6%) were directed, 372(96.1%) audible, and 101(26.1%) closed-loop. On average each order required 3.85 minutes to be completed. There was a significant reduction in time-to-task-completion when closed-loop communication was utilized (p < 0.0001). Orders with closed-loop communication were completed 3.6 times sooner as compared to orders with an open-loop [HR = 3.6 (95% CI: 2.5, 5.3)]. There was not a significant difference in time-to-task-completion with respect to pre-notification by emergency service providers (p < 0.6100). [HR = 1.1 (95% CI: 0.9, 1.3)]. There was also not a significant difference in time-to-task-completion with respect to level of trauma team activation (p < 0.2229). [HR = 1.3 (95% CI: 0.8, 2.1)]. CONCLUSION While closed-loop communication prevents medical errors, our study highlights the potential to increase the speed and efficiency with which tasks are completed in the setting of pediatric trauma resuscitation. Trauma drills and systems of communication that emphasize the use of closed-loop communication should be incorporated into the training of trauma team leaders. LEVEL OF EVIDENCE This is a prospective observational study with intervention level II evidence.
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Affiliation(s)
- Ibrahim Abd El-Shafy
- Department of Surgery, Hofstra Northwell School of Medicine, Cohen Children׳s Medical Center, New Hyde Park, New York; Feinstein Institute for Medical Research, Manhasset, New York; Department of Surgery, Maimonadies Medical Center, Brooklyn, New York
| | - Jennifer Delgado
- Department of Surgery, Hofstra Northwell School of Medicine, Cohen Children׳s Medical Center, New Hyde Park, New York
| | | | - Francesca Bullaro
- Department of Surgery, Hofstra Northwell School of Medicine, Cohen Children׳s Medical Center, New Hyde Park, New York
| | - Nathan A M Christopherson
- Department of Surgery, Hofstra Northwell School of Medicine, Cohen Children׳s Medical Center, New Hyde Park, New York; Department of Surgery, Maimonadies Medical Center, Brooklyn, New York
| | - Jose M Prince
- Department of Surgery, Hofstra Northwell School of Medicine, Cohen Children׳s Medical Center, New Hyde Park, New York; Feinstein Institute for Medical Research, Manhasset, New York; Trauma Institute, Northwell Health System, New York.
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