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Webber S, Kloster H, Shadman KA, Kelly M, Sklansky D, Coller RJ. Domains of professional fulfillment for pediatric hospital medicine: A concept mapping study. J Hosp Med 2023. [PMID: 37158170 DOI: 10.1002/jhm.13119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 04/12/2023] [Accepted: 04/20/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND We know little about how pediatric hospital medicine (PHM) physicians conceptualize their professional fulfillment (PF). The objective of this study was to determine how PHM physicians conceptualize PF. OBJECTIVE The objective of this study was to determine how PHM physicians conceptualize PF. METHODS We performed a single-site group concept mapping (GCM) study to create a stakeholder-informed model of PHM PF. We followed established GCM steps. For brainstorming, PHM physicians responded to a prompt to generate ideas describing the concept of PHM PF. Next, PHM physicians sorted the ideas based on conceptual relatedness and ranked them on importance. Responses were analyzed to create point cluster maps where each idea represented one point, and point proximity illustrated how often ideas were sorted together. Using an iterative and consensus-driven approach, we selected a cluster map best representing the ideas. Mean rating scores for all the items in each cluster were calculated. RESULTS Sixteen PHM physicians identified 90 unique ideas related to PHM PF. The final cluster map described nine domains for PHM PF: (1) work personal-fit, (2) people-centered climate, (3) divisional cohesion and collaboration, (4) supportive and growth-oriented environment, (5) feeling valued and respected, (6) confidence, contribution, and credibility, (7) meaningful teaching and mentoring, (8) meaningful clinical work, and (9) structures to facilitate effective patient care. The domains with the highest and lowest importance ratings were divisional cohesion and collaboration and meaningful teaching and mentoring. CONCLUSION Domains of PF for PHM physicians extend beyond existing PF models, particularly the importance of teaching and mentoring.
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Affiliation(s)
- Sarah Webber
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Heidi Kloster
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Kristin A Shadman
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Michelle Kelly
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Daniel Sklansky
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Ryan J Coller
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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Howell KD, Kelly MM, DeMuri GP, McBride JA, Katz B, Edmonson MB, Sklansky DJ, Shadman KA, Ehlenbach ML, Butteris SM, Warner G, Zhao Q, Coller RJ. COVID-19 Vaccination Intentions for Children With Medical Complexity. Hosp Pediatr 2022; 12:e295-e302. [PMID: 36039687 PMCID: PMC10039457 DOI: 10.1542/hpeds.2022-006544] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES The chronic conditions and functional limitations experienced by children with medical complexity (CMC) place them at disproportionate risk for COVID-19 transmission and poor outcomes. To promote robust vaccination uptake, specific constructs associated with vaccine hesitancy must be understood. Our objective was to describe demographic, clinical, and vaccine perception variables associated with CMC parents' intention to vaccinate their child against COVID-19. METHODS We conducted a cross-sectional survey (June-August 2021) for primary caregivers of CMC between ages 5 to 17 at an academic medical center in the Midwest. Multivariable logistic regression examined associations between vaccination intent and selected covariates. RESULTS Among 1330 families, 65.8% indicated vaccination intent. In multivariable models, demographics had minimal associations with vaccination intent; however, parents of younger children (<12 years) had significantly lower adjusted odds of vaccination intent (adjusted odds ratio [95% confidence interval]: 0.26 [0.17-0.3]) compared to parents of older children (≥12 years). CMC with higher severity of illness, ie, those with ≥1 hospitalization in the previous year (versus none) or >1 complex chronic condition (vs 1), had higher adjusted odds of vaccination intent (1.82 [1.14-2.92] and 1.77 [1.16-2.71], respectively). Vaccine perceptions associated with vaccine intention included "My doctor told me to get my child a COVID-19 vaccine" (2.82 [1.74-4.55]); and "I'm concerned about my child's side effects from the vaccine" (0.18 [0.12-0.26]). CONCLUSIONS One-third of CMC families expressed vaccine hesitation; however, constructs strongly associated with vaccination intent are potentially modifiable. Pediatrician endorsement of COVID-19 vaccination and careful counseling on side effects might be promising strategies to encourage uptake.
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Affiliation(s)
- Kristina Devi Howell
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Michelle M. Kelly
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Gregory P. DeMuri
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Joseph A. McBride
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | | | - M. Bruce Edmonson
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Daniel J. Sklansky
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Kristin A. Shadman
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Mary L. Ehlenbach
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Sabrina M. Butteris
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Gemma Warner
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Qianqian Zhao
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Ryan J. Coller
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Tiedt K, Webber S, Babal J, Nackers KAM, Allen A, Nacht CL, Coller RJ, Eickhoff J, Sklansky DJ, Kieren M, Shadman KA, Kelly MM. Gender Difference in Teaching Evaluation Scores of Pediatric Faculty. Acad Pediatr 2022; 23:564-568. [PMID: 35914732 DOI: 10.1016/j.acap.2022.07.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 07/07/2022] [Accepted: 07/22/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate associations between faculty gender and milestone-based teaching assessment scores assigned by residents. METHODS We performed a retrospective cohort study of milestone-based clinical teaching assessments of pediatric faculty completed by pediatric residents at a mid-sized residency program from July 2016 to June 2019. Assessments included 3 domains (Clinical Interactions, Teaching Skills, Role Modeling/Professionalism) comprised of a total of 11 sub-competency items. We used multilevel logistic regression accounting for repeat measures and clustering to evaluate associations between faculty gender and assessment scores in the 1) top quartile, 2) bottom quartile, or 3) top-box (highest score). Findings were adjusted for faculty rank and academic track, and resident year and gender. RESULTS Over 3 years, 2889 assessments of 104 faculty were performed by 91 residents. Between assessments of women and men faculty, there were no significant differences in the odds of receiving a score in the top quartile for the 3 domains (Clinical aOR 0.99, P = .86; Teaching aOR 0.99, P = .93; Role Modeling aOR 0.87, P = .089). However, assessments of women were more likely to receive a score in the bottom quartile in both Teaching (aOR 1.23, P = .019) and Role Modeling (aOR 1.26, P = .008). Assessments of women also had lower odds of receiving the highest score in 6 of 11 sub-competencies. CONCLUSION Results suggest that gender bias may play a role in resident assessments of pediatric faculty. Future studies are needed to determine if findings are replicated in other settings and to identify opportunities to reduce the gender gap in pediatric academic medicine.
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Affiliation(s)
- Kristin Tiedt
- Departments of Pediatrics (K Tiedt, S Webber, J Babal, KAM Nackers, A Allen, CL Nacht, RJ Coller, DJ Sklansky, M Kieren, KA Shadman, and MM Kelly), University of Wisconsin School of Medicine and Public Health, Madison, Wis.
| | - Sarah Webber
- Departments of Pediatrics (K Tiedt, S Webber, J Babal, KAM Nackers, A Allen, CL Nacht, RJ Coller, DJ Sklansky, M Kieren, KA Shadman, and MM Kelly), University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Jessica Babal
- Departments of Pediatrics (K Tiedt, S Webber, J Babal, KAM Nackers, A Allen, CL Nacht, RJ Coller, DJ Sklansky, M Kieren, KA Shadman, and MM Kelly), University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Kirstin A M Nackers
- Departments of Pediatrics (K Tiedt, S Webber, J Babal, KAM Nackers, A Allen, CL Nacht, RJ Coller, DJ Sklansky, M Kieren, KA Shadman, and MM Kelly), University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Ann Allen
- Departments of Pediatrics (K Tiedt, S Webber, J Babal, KAM Nackers, A Allen, CL Nacht, RJ Coller, DJ Sklansky, M Kieren, KA Shadman, and MM Kelly), University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Carrie L Nacht
- Departments of Pediatrics (K Tiedt, S Webber, J Babal, KAM Nackers, A Allen, CL Nacht, RJ Coller, DJ Sklansky, M Kieren, KA Shadman, and MM Kelly), University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Ryan J Coller
- Departments of Pediatrics (K Tiedt, S Webber, J Babal, KAM Nackers, A Allen, CL Nacht, RJ Coller, DJ Sklansky, M Kieren, KA Shadman, and MM Kelly), University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Jens Eickhoff
- Departments of Biostatistics (J Eickhoff), University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Daniel J Sklansky
- Departments of Pediatrics (K Tiedt, S Webber, J Babal, KAM Nackers, A Allen, CL Nacht, RJ Coller, DJ Sklansky, M Kieren, KA Shadman, and MM Kelly), University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Madeline Kieren
- Departments of Pediatrics (K Tiedt, S Webber, J Babal, KAM Nackers, A Allen, CL Nacht, RJ Coller, DJ Sklansky, M Kieren, KA Shadman, and MM Kelly), University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Kristin A Shadman
- Departments of Pediatrics (K Tiedt, S Webber, J Babal, KAM Nackers, A Allen, CL Nacht, RJ Coller, DJ Sklansky, M Kieren, KA Shadman, and MM Kelly), University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Michelle M Kelly
- Departments of Pediatrics (K Tiedt, S Webber, J Babal, KAM Nackers, A Allen, CL Nacht, RJ Coller, DJ Sklansky, M Kieren, KA Shadman, and MM Kelly), University of Wisconsin School of Medicine and Public Health, Madison, Wis
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Edmonson MB, Zhao Q, Francis DO, Kelly MM, Sklansky DJ, Shadman KA, Coller RJ. Association of Patient Characteristics With Postoperative Mortality in Children Undergoing Tonsillectomy in 5 US States. JAMA 2022; 327:2317-2325. [PMID: 35727278 PMCID: PMC9214584 DOI: 10.1001/jama.2022.8679] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [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: 01/17/2023]
Abstract
IMPORTANCE The rate of postoperative death in children undergoing tonsillectomy is uncertain. Mortality rates are not separately available for children at increased risk of complications, including young children (aged <3 y) and those with sleep-disordered breathing or complex chronic conditions. OBJECTIVE To estimate postoperative mortality following tonsillectomy in US children, both overall and in relation to recognized risk factors for complications. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study based on longitudinal analysis of linked records in state ambulatory surgery, inpatient, and emergency department discharge data sets distributed by the Healthcare Cost and Utilization Project for 5 states covering 2005 to 2017. Participants included 504 262 persons younger than 21 years for whom discharge records were available to link outpatient or inpatient tonsillectomy with at least 90 days of follow-up. EXPOSURES Tonsillectomy with or without adenoidectomy. MAIN OUTCOME AND MEASURES Postoperative death within 30 days or during a surgical stay lasting more than 30 days. Modified Poisson regression with sample weighting was used to estimate postoperative mortality per 100 000 operations, both overall and in relation to age group, sleep-disordered breathing, and complex chronic conditions. RESULTS The 504 262 children in the cohort underwent a total of 505 182 tonsillectomies (median [IQR] patient age, 7 [4-12] years; 50.6% females), of which 10.1% were performed in young children, 28.9% in those with sleep-disordered breathing, and 2.8% in those with complex chronic conditions. There were 36 linked postoperative deaths, which occurred a median (IQR) of 4.5 (2-20.5) days after surgical admission, and most of which (19/36 [53%]) occurred after surgical discharge. The unadjusted mortality rate was 7.04 (95% CI, 4.97-9.98) deaths per 100 000 operations. In multivariable models, neither age younger than 3 years nor sleep-disordered breathing was significantly associated with mortality, but children with complex chronic conditions had significantly higher mortality (16 deaths/14 299 operations) than children without these conditions (20 deaths/490 883 operations) (117.22 vs 3.87 deaths per 100 000 operations; adjusted rate difference, 113.55 [95% CI, 51.45-175.64] deaths per 100 000 operations; adjusted rate ratio, 29.39 [95% CI, 13.37-64.62]). Children with complex chronic conditions accounted for 2.8% of tonsillectomies but 44% of postoperative deaths. Most deaths associated with complex chronic conditions occurred in children with neurologic/neuromuscular or congenital/genetic disorders. CONCLUSIONS AND RELEVANCE Among children undergoing tonsillectomy, the rate of postoperative death was 7 per 100 000 operations overall and 117 per 100 000 operations among children with complex chronic conditions. These findings may inform decision-making for pediatric tonsillectomy.
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Affiliation(s)
- M. Bruce Edmonson
- Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison
| | - Qianqian Zhao
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison
| | - David O. Francis
- Division of Otolaryngology, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
| | - Michelle M. Kelly
- Division of Hospital Medicine, Department of Pediatrics, University of Wisconsin, Madison
| | - Daniel J. Sklansky
- Division of Hospital Medicine, Department of Pediatrics, University of Wisconsin, Madison
| | - Kristin A. Shadman
- Division of Hospital Medicine, Department of Pediatrics, University of Wisconsin, Madison
| | - Ryan J. Coller
- Division of Hospital Medicine, Department of Pediatrics, University of Wisconsin, Madison
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Shadman KA, Edmonson MB, Coller RJ, Sklansky DJ, Nacht CL, Zhao Q, Kelly MM. US Hospital Stays in Children and Adolescents With Acetaminophen Poisoning. Hosp Pediatr 2022; 12:e60-e67. [PMID: 35048104 DOI: 10.1542/hpeds.2021-005816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Acetaminophen poisoning occurs in all age groups; however, hospital-based outcomes of children with these poisonings were not well characterized. Our objectives were to describe the incidence, characteristics, and outcomes of hospital stays in children with acetaminophen poisoning and evaluate the contribution of intentionality. METHODS We used the 2016 Kids' Inpatient Database and validated International Classification of Diseases, 10th Revision diagnostic codes to identify hospitalizations of children aged 0 to 19 years for acetaminophen poisoning. We used standard survey methods to generate weighted population estimates and describe characteristics and outcomes, both overall and stratified by intentionality. RESULTS There were 9935 (95% confidence interval [CI], 9252-10 619) discharges from acute care hospitals for acetaminophen poisoning in U.S. children aged 0 to 19 years during 2016, corresponding to a population rate of 12.1 (95% CI, 11.3-12.9) hospitalizations per 100 000 children. Most hospitalizations for both intentional and unintentional acetaminophen poisoning occurred in females, with a strongly age-related sex distribution. Median length of stay was 2 days (interquartile range, 1-4 days); however, nearly half of discharges were subsequently transferred to another type of facility (eg, psychiatric hospital). Median hospital charges for acute care were $14 379 (interquartile range, $9162-$23 114), totaling $204.7 million (95% CI, $187.4-$221.9) in aggregate. Of 31 632 hospital discharges associated with self-harm medication poisoning in children aged 0 to 19 years, acetaminophen was the single most commonly implicated agent. CONCLUSIONS Acetaminophen poisoning was the most common cause of U.S. hospital stays associated with medication self-harm poisoning. More effective acetaminophen poisoning prevention strategies are needed, which may reduce the burden of this common adolescent malady.
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Affiliation(s)
| | | | | | | | | | - Qianqian Zhao
- Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health
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Nacht CL, Kelly MM, Edmonson MB, Sklansky DJ, Shadman KA, Kind AJH, Zhao Q, Barreda CB, Coller RJ. Association Between Neighborhood Disadvantage and Pediatric Readmissions. Matern Child Health J 2022; 26:31-41. [PMID: 35013884 PMCID: PMC8982848 DOI: 10.1007/s10995-021-03310-4] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2021] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Although individual-level social determinants of health (SDH) are known to influence 30-day readmission risk, contextual-level associations with readmission are poorly understood among children. This study explores associations between neighborhood disadvantage measured by Area Deprivation Index (ADI) and pediatric 30-day readmissions. METHODS This retrospective cohort study included discharges of patients aged < 20 years from Maryland's 2013-2016 all-payer dataset. The ADI, which quantifies 17 indicators of neighborhood socioeconomic disadvantage within census block groups, is used as a proxy for contextual-level SDH. Readmissions were identified with the 30-day Pediatric All-Condition Readmissions measure. Associations between ADI and readmission were identified with generalized estimating equations adjusted for patient demographics and clinical severity (Chronic Condition Indicator [CCI], Pediatric Medical Complexity Algorithm [PMCA], Index Hospital All Patients Refined Diagnosis Related Groups [APR-DRG]), and hospital discharge volume. RESULTS Discharges (n = 138,998) were mostly female (52.7%), publicly insured (55.1%), urban-dwelling (93.0%), with low clinical severity levels (0-1 CCIs [82.3%], minor APR-DRG severity [48.4%]). Overall readmission rate was 4.0%. Compared to the least disadvantaged ADI quartile, readmissions for the most disadvantaged quartile were significantly more likely (aOR 1.19, 95% CI 1.09-1.30). After adjustment, readmissions were associated with public insurance and indicators of medical complexity (higher number of CCIs, complex-chronic disease PMCA, and APR-DRG severity). CONCLUSION In this all-payer, statewide sample, living in the most socioeconomically disadvantaged neighborhoods independently predicted pediatric readmission. While the relative magnitude of neighborhood disadvantage was modest compared to medical complexity, disadvantage is modifiable and thus represents an important consideration for prevention and risk stratification efforts.
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Affiliation(s)
- Carrie L. Nacht
- University of Wisconsin School of Medicine and Public Health, Department of Pediatrics, Madison, Wisconsin
| | - Michelle M. Kelly
- University of Wisconsin School of Medicine and Public Health, Department of Pediatrics, Madison, Wisconsin
| | - M Bruce Edmonson
- University of Wisconsin School of Medicine and Public Health, Department of Pediatrics, Madison, Wisconsin
| | - Daniel J. Sklansky
- University of Wisconsin School of Medicine and Public Health, Department of Pediatrics, Madison, Wisconsin
| | - Kristin A. Shadman
- University of Wisconsin School of Medicine and Public Health, Department of Pediatrics, Madison, Wisconsin
| | - Amy J. H. Kind
- Madison VA Hospital Geriatrics Research Education and Clinical Center (GRECC),University of Wisconsin School of Medicine and Public Health, Department of Medicine
| | - Qianqian Zhao
- University of Wisconsin School of Medicine and Public Health, Department of Biostatistics and Medical Informatics, Madison, Wisconsin
| | - Christina B. Barreda
- University of Wisconsin School of Medicine and Public Health, Department of Pediatrics, Madison, Wisconsin
| | - Ryan J. Coller
- University of Wisconsin School of Medicine and Public Health, Department of Pediatrics, Madison, Wisconsin
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Shadman KA, Srinivasan M. Continuous Versus Bolus Feeds in Bronchiolitis: Is it Time to Stop the Debate? Hosp Pediatr 2022; 12:e44-e47. [PMID: 34927676 DOI: 10.1542/hpeds.2021-006396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Kristin A Shadman
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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Peters ME, Boriosi JP, Sklansky DJ, Hollman GA, Eickhoff JC, Christenson DK, Shadman KA. Reducing Delays in a Pediatric Procedural Unit With Ultrasound-Guided Intravenous Line Insertion. Hosp Pediatr 2021; 11:1222-1228. [PMID: 34607884 DOI: 10.1542/hpeds.2021-005870] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Delay in vascular access is a leading cause of procedure delay in our pediatric procedure and infusion center. Use of ultrasound decreases time to peripheral intravenous catheter (PIV) insertion; however, ultrasound availability in our center was limited to an external venous access team (VAT). The objective of this project was to reduce PIV-related delays by 25%. METHODS Stakeholders convened and theorized that creating a unit-based nurse team specializing in ultrasound-guided peripheral intravenous catheter (USgPIV) insertion would facilitate faster access and a reduction in delayed procedures. An initial plan-do-study-act cycle was performed, training 2 nurses in USgPIV placement. Subsequent cycles were focused on increasing availability of USgPIV-trained nurses. The outcome measure was the rate of procedures delayed by PIV placement, analyzed on a statistical process control U-chart. The process measure was the percentage of USgPIV placements requiring consultations to the VAT, analyzed on a statistical process control P-chart. The balancing measure was the success rate per method of insertion. Comparisons of success rates were conducted by using a χ2 test and Fisher's exact test. RESULTS The mean rate of procedures delayed because of vascular access fell by special cause variation from 10.8% to 6.4%. The mean VAT consultation rate fell from 86.4% to 32.0%. The VAT had higher rates of overall success (100% vs 87%; P = .01) and first-attempt success (93% vs 77%; P = .03) compared with unit nurse USgPIV placement. CONCLUSIONS Unit-based USgPIV placement in a pediatric procedural center was successfully implemented, with a significant decline in procedures delayed by PIV access.
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Kelly MM, Sklansky DJ, Nackers KAM, Coller RJ, Dean SM, Eickhoff JC, Bentley NL, Nacht CL, Shadman KA. Evaluation and Improvement of Intern Progress Note Assessments and Plans. Hosp Pediatr 2021; 11:401-405. [PMID: 33692085 DOI: 10.1542/hpeds.2020-003244] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Progress notes communicate providers' assessments of patients' diagnoses, progress, and treatment plans; however, providers perceive that note quality has degraded since the introduction of electronic health records. In this study, we aimed to (1) develop a tool to evaluate progress note assessments and plans with high interrater reliability and (2) assess whether a bundled intervention was associated with improved intern note quality without delaying note file time. METHODS An 8-member stakeholder team developed a 19-item progress note assessment and plan evaluation (PNAPE) tool and bundled intervention consisting of a new note template and intern training curriculum. Interrater reliability was evaluated by calculating the intraclass correlation coefficient. Blinded assessors then used PNAPE to evaluate assessment and plan quality in pre- and postintervention notes (fall 2017 and 2018). RESULTS PNAPE revealed high internal interrater reliability between assessors (intraclass correlation coefficient = 0.86; 95% confidence interval: 0.66-0.95). Total median PNAPE score increased from 13 (interquartile range [IQR]: 12-15) to 15 (IQR: 14-17; P = .008), and median file time decreased from 4:30 pm (IQR: 2:33 pm-6:20 pm) to 1:13 pm (IQR: 12:05 pm-3:59 pm; P < .001) in pre- and postintervention notes. In the postintervention period, a higher proportion of assessments and plans indicated the primary problem requiring ongoing hospitalization and progress of this problem (P = .0016 and P < .001, respectively). CONCLUSIONS The PNAPE tool revealed high reliability between assessors, and the bundled intervention may be associated with improved intern note assessment and plan quality without delaying file time. Future studies are needed to evaluate whether these improvements can be sustained throughout residency and reproduced in future intern cohorts and other inpatient settings.
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Affiliation(s)
| | | | | | | | | | - Jens C Eickhoff
- Biostatistics and Medical Informatics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin; and
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Nackers KAM, Shadman KA, Kelly MM, Waterman HG, Bentley NL, Gorski DP, Chorney C, Eickhoff JC, Nacht CL, Sklansky DJ. Resident Workshop to Improve Inpatient Documentation Using the Progress Note Assessment and Plan Evaluation (PNAPE) Tool. MedEdPORTAL 2020; 16:11040. [PMID: 33274296 PMCID: PMC7703481 DOI: 10.15766/mep_2374-8265.11040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 07/23/2020] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Physicians enter residency with varied knowledge regarding the purpose of progress notes and proficiency writing them. The objective of this study was to test whether resident knowledge, beliefs, and confidence writing inpatient progress notes improved after a 2.5-hour workshop intervention. METHODS An educational workshop and note assessment tool was constructed by resident and faculty stakeholders based on a review of literature and institutional best practices. The Progress Note Assessment and Plan Evaluation (PNAPE) tool was designed to assess adherence to best practices in the assessment and plan section of progress notes. Thirty-four residents from a midsized pediatric residency program attended the workshop, which consisted of didactics and small-group work evaluating sample notes using the PNAPE tool. Participants completed a four-question online pre- and postworkshop survey to evaluate their knowledge of progress note components and attitudes regarding note importance. Pre-post analysis was performed with Chi-square testing for true/false questions, and Mann-Whitney testing for Likert scale questions and summative scores. RESULTS A majority of pediatric residents completed the preintervention (n = 26, 76% response rate) and postintervention (n = 23, 68% response rate) surveys. Accurate response rate improved in 15 of 20 of the true/false items, with a statistically significant improvement in five items. Resident perceptions of note importance and confidence in note writing also increased. DISCUSSION A workshop intervention may effectively educate pediatric residents about progress note best practices. Further studies should assess the impact of the intervention on sustained knowledge and beliefs about progress notes and subsequent note quality.
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Affiliation(s)
- Kirstin A. M. Nackers
- Assistant Professor, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health
| | - Kristin A. Shadman
- Associate Professor, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health
| | - Michelle M. Kelly
- Associate Professor, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health
| | - Helen G. Waterman
- Resident Physician, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health
| | - Nicole L. Bentley
- Pediatrician, UnityPoint Clinic at Allen Hospital, Waterloo, Iowa, UnityPoint Health
| | - Daniel P. Gorski
- Resident Physician, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health
| | - Collette Chorney
- Resident Physician, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health
| | - Jens C. Eickhoff
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison
| | - Carrie L. Nacht
- Research Specialist, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health
| | - Daniel J. Sklansky
- Associate Professor, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health
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11
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Coller RJ, Kelly MM, Sklansky DJ, Shadman KA, Ehlenbach ML, Barreda CB, Chung PJ, Zhao Q, Edmonson MB. Ambulatory quality, special health care needs, and emergency department or hospital use for US children. Health Serv Res 2020; 55:671-680. [PMID: 32594526 PMCID: PMC7518884 DOI: 10.1111/1475-6773.13308] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE This study examined family-reported ambulatory care quality and its association with emergency department and hospital utilization, and how these relationships differed across levels of medical complexity. DATA SOURCES The 2006-2013 Medical Expenditure Panel Survey (MEPS). STUDY DESIGN Secondary analysis of MEPS data. Variables fitting the National Quality Measures Clearinghouse clinical quality measures domain framework were selected. Exploratory factor analysis grouped ambulatory quality into 12 access, experience, or process measures. Weighted negative binomial regression stratified by health status identified associations between ambulatory quality and ED visits or hospitalizations. DATA COLLECTION 41,497 children ≤18 years were included. The 5-item special health care needs (SHCN) screener categorized health status as complex, less complex, or no SHCN. PRINCIPAL FINDINGS Weighted SHCN proportions were 1.6 Percent complex, 18.2 Percent less complex, and 80.0 Percent no SHCN. Mean ED visits were 130 and 335 visits/1000 children/year for no/ complex SHCN, respectively. Mean hospitalizations were 20 and 175 hospitalizations/1000 children/year for no/complex SHCN, respectively. ED visits were associated with 8 of 12 quality measures for no/less complex SHCN. For example, usually/always receiving needed care right away was associated with 22 Percent lower ED visit rate (95% CI 0.64-0.96). Hospitalizations were associated with 4 of 12 quality measures for less complex SHCN. In complex SHCN, associations between ambulatory quality and ED/hospital use were weak and inconsistent. CONCLUSIONS Ambulatory quality may best predict ED and hospital use for children with no or less complex SHCN. Whether and how ambulatory care predicts emergency and hospital care in complex SHCN remains an important question.
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Affiliation(s)
- Ryan J. Coller
- Department of PediatricsUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
| | - Michelle M. Kelly
- Department of PediatricsUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
| | - Daniel J. Sklansky
- Department of PediatricsUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
| | - Kristin A. Shadman
- Department of PediatricsUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
| | - Mary L Ehlenbach
- Department of PediatricsUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
| | - Christina B. Barreda
- Department of PediatricsUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
| | - Paul J. Chung
- Departments of Pediatrics and Health Policy & Management, Health Systems ScienceKaiser Permanente School of MedicinePasadenaCaliforniaUSA
| | - Qianqian Zhao
- Department of PediatricsUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
| | - Marshall Bruce Edmonson
- Department of PediatricsUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
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12
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Coller RJ, Ahrens S, Ehlenbach ML, Shadman KA, Mathur M, Caldera K, Chung PJ, LaRocque A, Peto H, Binger K, Smith W, Sheehy A. Priorities and Outcomes for Youth-Adult Transitions in Hospital Care: Perspectives of Inpatient Clinical Leaders at US Children's Hospitals. Hosp Pediatr 2020; 10:774-782. [PMID: 32759291 DOI: 10.1542/hpeds.2020-0016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Adults with chronic conditions originating in childhood experience ongoing hospitalizations; however, efforts to guide youth-adult transitions rarely address transitioning to adult-oriented inpatient care. Our objectives were to identify perceptions of clinical leaders on important and feasible inpatient transition activities and outcomes, including when, how, and for whom inpatient transition processes are needed. METHODS Clinical leaders at US children's hospitals were surveyed between January and July 2016. Questionnaires were used to assess 21 inpatient transition activities and 13 outcomes. Perceptions about feasible and important outcome measures and appropriate patients and settings for activities were summarized. Each transition activity was categorized into one of the Six Core Elements (policy, tracking, readiness, planning, transfer, or completion). Associations between perceived transition activity importance or feasibility, hospital characteristics, and transition activity performance were evaluated. RESULTS In total, 96 of 195 (49.2%) children's hospital leaders responded. The most important and feasible activities were identifying patients needing or overdue for transition, discussing transition timing with youth and/or families, and informing youth and/or families that future stays would be at an adult facility. Feasibility, but not importance, ratings were associated with current performance of transition activities. Inpatient transition activities were perceived to be important for children with medical and/or social complexity or high hospital use. Emergency department visits and patient experience during transition were top outcome measurement priorities. CONCLUSIONS Children's hospital clinical leaders rated inpatient youth-adult transition activities and outcome measures as important and feasible; however, feasibility may ultimately drive implementation. This work should be used to inform initial research and quality improvement priorities, although additional stakeholder perspectives are needed.
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Affiliation(s)
| | | | | | | | | | - Kristin Caldera
- Orthopedics and Rehabilitation, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
| | - Paul J Chung
- Department of Pediatrics, David Geffen School of Medicine and.,RAND Health Care, RAND Corporation, Santa Monica, California.,Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California.,Children's Discovery and Innovation Institute, Mattel Children's Hospital, Los Angeles, California; and
| | | | | | | | - Windy Smith
- American Family Children's Hospital, Madison, Wisconsin
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13
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Webber S, Babal JC, Shadman KA, Coller RJ, Moreno MA. Exploring Academic Pediatrician Perspectives of Factors Impacting Physician Well-Being. Acad Pediatr 2020; 20:833-839. [PMID: 32097783 DOI: 10.1016/j.acap.2020.02.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 02/10/2020] [Accepted: 02/16/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Promotion of physician well-being has emerged as a national priority, yet meaningful interventions depend on further understanding the factors that promote and detract from physician well-being. The aim of this study was to better understand the perspectives of academic pediatricians regarding the factors influencing their well-being. METHODS We conducted a qualitative study using grounded theory methodology. In June 2018, we performed facilitated focus groups with academic pediatric faculty at our institution. Focus groups were audio recorded, transcribed, and analyzed using the constant comparative method to identify key themes. RESULTS Fifty-four pediatricians participated in the focus groups. Key themes included 1) pediatricians feel inundated by collective professional and personal pressures, 2) pediatricians feel they have lost control over how time at work is spent, and 3) obscured professional-personal boundaries can cause erosion of personal life. CONCLUSIONS Pediatricians identified 3 key barriers to well-being: collective pressures, including increasing and competing academic and clinical responsibilities; low value tasks that consume their time; and erosion of personal life. This study adds to the growing literature describing physician well-being as strongly influenced by workplace factors, and offers examples of modifiable factors for further investigation.
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Affiliation(s)
- Sarah Webber
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wis.
| | - Jessica C Babal
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Kristin A Shadman
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Ryan J Coller
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Megan A Moreno
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wis
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14
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Sklansky DJ, Butteris S, Shadman KA, Kelly MM, Edmonson MB, Nackers K, Allen A, Barreda CB, Ehlenbach ML, Webber SA, Tiedt K, Smith W, Hoffman RJ, Zhao Q, Thurber AS, Coller RJ. Earlier Hospital Discharge With Prospectively Designated Discharge Time in the Electronic Health Record. Pediatrics 2019; 144:peds.2019-0929. [PMID: 31604828 DOI: 10.1542/peds.2019-0929] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/23/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Hospital discharge requires multidisciplinary coordination. Insufficient coordination impacts patient flow, resource use, and postdischarge outcomes. Our objectives were to (1) implement a prospective, multidisciplinary discharge timing designation in the electronic health record (EHR) and (2) evaluate its association with discharge timing. METHODS This quality-improvement study evaluated the implementation of confirmed discharge time (CDT), an EHR designation representing specific discharge timing developed jointly by a patient's family and the health care team. CDT was intended to support task management and coordination of multidisciplinary discharge processes and could be entered and viewed by all team members. Four plan-do-study-act improvement phases were studied: (1) baseline, (2) provider education, (3) provider feedback, and (4) EHR modification. Statistical process control charts tracked CDT use and the proportion of discharges before noon. Length of stay was used as a balancing measure. RESULTS During the study period from April 2013 through March 2017, 20 133 pediatric discharges occurred, with similar demographics observed throughout all phases. Mean CDT use increased from 0% to 62%, with special cause variations being detected after the provider education and EHR modification phases. Over the course of the study, the proportion of discharges before noon increased by 6.2 percentage points, from 19.9% to 26.1%, whereas length of stay decreased from 47 (interquartile range: 25-95) to 43 (interquartile range: 24-88) hours (both P < .001). CONCLUSIONS The implementation of a prospective, multidisciplinary EHR discharge time designation was associated with more before-noon discharges. Next steps include replicating results in other settings and determining populations that are most responsive to discharge coordination efforts.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Windy Smith
- American Family Children's Hospital, Madison, Wisconsin
| | - Robert J Hoffman
- Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin; and
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15
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Kaiser SV, Shadman KA, Biondi EA, McCulloh RJ. Feasible Strategies for Sustaining Guideline Adherence: Cross-sectional Analysis of a National Collaborative. Hosp Pediatr 2019; 9:903-908. [PMID: 31604794 DOI: 10.1542/hpeds.2019-0152] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Health care providers' adherence to guidelines declines over time, and feasible strategies for sustaining adherence have not yet been identified. We assessed the long-term feasibility of various strategies for sustaining guideline adherence and described factors influencing their use. We conducted a cross-sectional survey (N = 104) of physician leaders who participated in a national collaborative to improve care of infants with suspected sepsis. Data were collected on long-term use of strategies to promote guideline adherence (use, perceived effectiveness, and barriers to use). Sixty (58%) participants from diverse hospital settings responded. There were significant declines in use of quality improvement and educational strategies, largely driven by lack of time or staff resources and competing priorities. Electronic strategies (eg, order sets) and hospital policies or guidelines were feasible to continue long-term after the collaborative ended and were perceived as effective. Clinicians and healthcare leaders should consider prioritizing these strategies in their efforts to improve care and outcomes for children in hospital settings.
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Affiliation(s)
- Sunitha V Kaiser
- Department of Pediatrics, University of California, San Francisco, San Francisco, California;
| | - Kristin A Shadman
- Department of Pediatrics, University of Wisconsin-Madison, Madison, Wisconsin
| | - Eric A Biondi
- Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, Maryland; and
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16
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Shadman KA, Kelly MM, Edmonson MB, Sklansky DJ, Nackers K, Allen A, Barreda CB, Thurber AS, Coller RJ. Feeding during High-Flow Nasal Cannula for Bronchiolitis: Associations with Time to Discharge. J Hosp Med 2019; 14:E43-E48. [PMID: 31532750 DOI: 10.12788/jhm.3306] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 08/12/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND High-flow nasal cannula (HFNC) is increasingly used to treat children hospitalized with bronchiolitis; however, the best practices for feeding during HFNC and the impact of feeding on time to discharge and adverse events are unknown. The study objective was to assess whether feeding exposure during HFNC was associated with time to discharge or feeding-related adverse events. METHODS This retrospective cohort study included inpatients aged 1-24 months receiving HFNC for bronchiolitis at an academic children's hospital from January 1, 2015 to March 1, 2017. Feeding exposures during HFNC were categorized as fed or not fed. Among fed children, we further evaluated mixed (oral and tube) or exclusive oral feeding. The primary outcome was time to discharge after HFNC cessation. Secondary outcomes were aspiration, intubation after HFNC, and seven-day readmission. RESULTS Of 123 children treated with HFNC, 45 (37 %) were never fed. A total of 78 children (63%) were fed; 50 (41%) were exclusively orally fed and 28 (23 %) had mixed feeding. Median (interquartile range) time to discharge after HFNC was 29.5 hours (23.5-47.9) and 39.8 hours (26.4-61.5) hours in the fed and not fed groups, respectively. In adjusted models, time to discharge was shorter with any feeding (hazard ratio [HR] 2.17; 95% CI: 1.34-3.50) and with exclusive oral feeding (HR 2.13; 95% CI: 1.31-3.45) compared with no feeding. Time to discharge from HFNC initiation was shorter for exclusive oral feeding versus not feeding (propensity weighted HR 1.97 [95% CI: 1.13-3.43]). Adverse events (one intubation, one aspiration pneumonia, one readmission) occurred in both groups. LIMITATIONS Assessment of feeding exposure did not account for quantity and duration. DISCUSSION Children fed while receiving HFNC for bronchiolitis may have shorter time to discharge than those not fed. Feeding-related adverse events were rare regardless of the feeding method. Controlled prospective studies addressing residual confounding are needed to justify a change in the current practice.
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Affiliation(s)
- Kristin A Shadman
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Michelle M Kelly
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - M Bruce Edmonson
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Daniel J Sklansky
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Kirstin Nackers
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Ann Allen
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Christina B Barreda
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Anne S Thurber
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Ryan J Coller
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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17
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Shadman KA, Coller RJ, Smith W, Kelly MM, Cody P, Taft W, Bodine L, Sklansky DJ. Managing Eating Disorders on a General Pediatrics Unit: A Centralized Video Monitoring Pilot. J Hosp Med 2019; 14:357-360. [PMID: 30986188 PMCID: PMC6625438 DOI: 10.12788/jhm.3176] [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: 11/20/2022]
Abstract
Adolescents with severe eating disorders require hospitalization for medical stabilization. Supervision best practices for these patients are not established. This study sought to evaluate the cost and feasibility of centralized video monitoring (CVM) supervision on a general pediatric unit of an academic quaternary care center. This was a retrospective cohort study of nursing assistant (NA) versus CVM supervision for girls 12-18 years old admitted for medical stabilization of an eating disorder between September 2013 and March 2017. There were 37 consecutive admissions (NA = 23 and CVM = 14). NA median supervision cost was more expensive than CVM ($4,104/admission vs $1,166/admission, P < .001). Length of stay and days to weight gain were not statistically different. There were no occurances of family refusal of CVM, conversion from CVM to NA, technological failure, or unplanned discontinuation. Video monitoring was feasible and associated with lower supervision costs than one-to-one NA supervision. Larger samples in multiple centers are needed to confirm the safety, acceptability, and efficacy of CVM.
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Affiliation(s)
- Kristin A Shadman
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
- Corresponding Author: Kristin A Shadman, MD; E-mail: ; Telephone: 608-265-8561
| | - Ryan J Coller
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Windy Smith
- American Family Children’s Hospital, University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | - Michelle M Kelly
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Paula Cody
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - William Taft
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Laura Bodine
- American Family Children’s Hospital, University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | - Daniel J Sklansky
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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18
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Kelly MM, Coller RJ, Kohler JE, Zhao Q, Sklansky DJ, Shadman KA, Thurber A, Barreda CB, Edmonson MB. Trends in Hospital Treatment of Empyema in Children in the United States. J Pediatr 2018; 202:245-251.e1. [PMID: 30170858 DOI: 10.1016/j.jpeds.2018.07.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 05/26/2018] [Accepted: 07/02/2018] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To evaluate trends in procedures used to treat children hospitalized in the US with empyema during a period that included the release of guidelines endorsing chest tube placement as an acceptable first-line alternative to video-assisted thoracoscopic surgery. STUDY DESIGN We used National Inpatient Samples to describe empyema-related discharges of children ages 0-17 years during 2008-2014. We evaluated trends using inverse variance weighted linear regression and characterized treatment failure using multivariable logistic regression to identify factors associated with having more than 1 procedure. RESULTS Empyema-related discharges declined from 3 in 100 000 children to 2 in 100 000 during 2008-2014 (P = .04, linear trend). There was no significant change in the proportion of discharges having 1 procedure (66.1% to 64.1%) or in the proportion having 2 or more procedures (22.1% to 21.6%). The proportion coded for video-assisted thoracoscopic surgery as the only procedure declined (41.4% to 36.2%; P = .03), and the proportions coded for 1 chest tube (14.6% to 20.9%; P = .04) and 2 chest tube procedures (0.9% to 3.5%; P < .01) both increased. The median length of stay for empyema-related discharges remained unchanged (9.3 days to 9.8 days; P = .053). Having more than 1 procedure was associated with continuous mechanical ventilation (adjusted OR, 2.7; 95% CI, 1.8-4.1) but not with age, sex, payer, chronic conditions, transfer admission, hospital size, or census region. CONCLUSIONS The use of video-assisted thoracoscopic surgery to treat children in the US hospitalized with empyema seems to be decreasing without associated increases in length of stay or need for additional drainage procedures.
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Affiliation(s)
- Michelle M Kelly
- Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI.
| | - Ryan J Coller
- Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Jonathan E Kohler
- Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Qianqian Zhao
- Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Daniel J Sklansky
- Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Kristin A Shadman
- Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Anne Thurber
- Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Christina B Barreda
- Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - M Bruce Edmonson
- Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI
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19
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Walley SC, Mussman GM, Lossius M, Shadman KA, Destino L, Garber M, Ralston SL. Implementing Parental Tobacco Dependence Treatment Within Bronchiolitis QI Collaboratives. Pediatrics 2018; 141:peds.2017-3072. [PMID: 29769242 DOI: 10.1542/peds.2017-3072] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/20/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES We sought to implement systematic tobacco dependence interventions for parents and/or caregivers as secondary aims within 2 multisite quality improvement (QI) collaboratives for bronchiolitis. We hypothesized that iterative improvements in tobacco dependence intervention strategies would result in improvement in outcomes between collaboratives. METHODS This study involved 2 separate yearlong, multisite QI collaboratives that were focused on care provided to inpatients with a primary diagnosis of bronchiolitis. In each collaborative, we provided tools and training in tobacco dependence treatment and expert coaching on interventions for parents as a secondary aim. Data were collected by chart review and results analyzed by using analysis of means and statistical process control analysis. Outcomes between collaboratives were compared by using relative risks. RESULTS Between both collaboratives, 56 hospitals participated and 6258 inpatient charts were reviewed. In the first collaborative, 22% of identified parents who smoke received tobacco dependence interventions at baseline. This rate increased to 51% during the postintervention period, with special cause revealed by analysis of means. In the second collaborative, 31% of parents who smoke received baseline interventions. This rate increased to 53% by the conclusion of the collaborative, with special cause revealed by statistical process control analysis. The relative risk for providing any cessation intervention in 1 collaborative versus the other was 0.9 (confidence interval 0.8-1.1). CONCLUSIONS Tobacco dependence treatment of parents and/or caregivers can be integrated into bronchiolitis QI by using relatively low-resource strategies. Using a more intensive QI intervention did not alter the rates of screening or intervention for caregivers who smoke.
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Affiliation(s)
- Susan C Walley
- Department of Pediatrics, University of Alabama at Birmingham and Children's of Alabama, Birmingham, Alabama;
| | - Grant M Mussman
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Michele Lossius
- University of Florida Health Shands Children's Hospital, University of Florida, Gainesville, Florida
| | - Kristin A Shadman
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
| | - Lauren Destino
- Lucile Packard Children's Hospital, School of Medicine, Stanford University, Palo Alto, California
| | - Matthew Garber
- Wolfson Children's Hospital, University of Florida, Jacksonville, Florida; and
| | - Shawn L Ralston
- Department of Pediatrics, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
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20
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Mussman GM, Lossius M, Wasif F, Bennett J, Shadman KA, Walley SC, Destino L, Nichols E, Ralston SL. Multisite Emergency Department Inpatient Collaborative to Reduce Unnecessary Bronchiolitis Care. Pediatrics 2018; 141:peds.2017-0830. [PMID: 29321255 DOI: 10.1542/peds.2017-0830] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/13/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES There is high variation in the care of acute viral bronchiolitis. We sought to promote collaboration between emergency department (ED) and inpatient (IP) units with the goal of reducing unnecessary testing and treatment. METHODS Multisite collaborative with improvement teams co-led by ED and IP physicians and a 1-year period of active participation. The intervention consisted of a multicomponent change package, regular webinars, and optional coaching. Data were collected by chart review for December 2014 through March 2015 (baseline) and December 2015 to March 2016 (improvement period). Patients <24 months of age with a primary diagnosis of bronchiolitis and without ICU admission, prematurity, or chronic lung or heart disease were eligible for inclusion. Control charts were used to detect improvement. Achievable benchmarks of care were calculated for each measure. RESULTS Thirty-five hospitals with 5078 ED patients and 4389 IPs participated. Use of bronchodilators demonstrated special cause for the ED (mean centerline shift: 37.1%-24.5%, benchmark 5.8%) and IP (28.4%-17.7%, benchmark 9.1%). Project mean ED viral testing decreased from 42.6% to 25.4% after revealing special cause with a 3.9% benchmark, whereas chest radiography (30.9%), antibiotic use (6.2%), and steroid use (7.6%) in the ED units did not change. IP steroid use decreased from 7.2% to 4.0% after special cause with 0.0% as the benchmark. Within-site ED and IP performance was modestly correlated. CONCLUSIONS Collaboration between ED and IP units was associated with a decreased use of unnecessary tests and therapies in bronchiolitis; top performers used few unnecessary tests or treatments.
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Affiliation(s)
- Grant M Mussman
- Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio;
| | - Michele Lossius
- Shands Children's Hospital, University of Florida Health, Gainesville, Florida
| | - Faiza Wasif
- American Academy of Pediatrics, Elk Grove Village, Illinois
| | - Jeffrey Bennett
- Department of General Pediatrics, University of Tennessee College of Medicine-Chattanooga, Chattanooga, Tennessee
| | - Kristin A Shadman
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
| | - Susan C Walley
- Children's of Alabama and Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Lauren Destino
- Lucile Packard Children's Hospital School of Medicine and Department of Pediatrics, Stanford University, Stanford, California
| | - Elizabeth Nichols
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire; and
| | - Shawn L Ralston
- Children's Hospital at Dartmouth-Hitchcock, Lebanon, New Hampshire
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21
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Coller RJ, Ahrens S, Ehlenbach ML, Shadman KA, Chung PJ, Lotstein D, LaRocque A, Sheehy A. Transitioning from General Pediatric to Adult-Oriented Inpatient Care: National Survey of US Children's Hospitals. J Hosp Med 2018; 13:13-20. [PMID: 29309437 PMCID: PMC6492557 DOI: 10.12788/jhm.2923] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Hospital charges and lengths of stay may be greater when adults with chronic conditions are admitted to children's hospitals. Despite multiple efforts to improve pediatric-adult healthcare transitions, little guidance exists for transitioning inpatient care. OBJECTIVE This study sought to characterize pediatricadult inpatient care transitions across general pediatric services at US children's hospitals. DESIGN, SETTING AND PARTICIPANTS National survey of inpatient general pediatric service leaders at US children's hospitals from January 2016 to July 2016. MEASUREMENTS Questionnaires assessed institutional characteristics, presence of inpatient transition initiatives (having specific process and/or leader), and 22 inpatient transition activities. Scales of highly correlated activities were created using exploratory factor analysis. Logistic regression identified associations between institutional characteristics, transition activities, and presence of an inpatient transition initiative. RESULTS Ninety-six of 195 children's hospitals responded (49.2% response rate). Transition initiatives were present at 38% of children's hospitals, more often when there were dual-trained internal medicine-pediatrics providers or outpatient transition processes. Specific activities were infrequent and varied widely from 2.1% (systems to track youth in transition) to 40.5% (addressing potential insurance problems). Institutions with initiatives more often consistently performed the majority of activities, including using checklists and creating patient-centered transition care plans. Of remaining activities, half involved transition planning, the essential step between readiness and transfer. CONCLUSIONS Relatively few inpatient general pediatric services at US children's hospitals have leaders or dedicated processes to shepherd transitions to adultoriented inpatient care. Across institutions, there is a wide variability in performance of activities to facilitate this transition. Feasible process and outcome measures are needed.
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Affiliation(s)
- Ryan J Coller
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA.
| | - Sarah Ahrens
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Mary L Ehlenbach
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Kristin A Shadman
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Paul J Chung
- Department of Pediatrics, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, USA
- RAND Health, RAND Corporation, Santa Monica California, USA
- Department of Health Policy & Management, University of California, Los Angeles, Fielding School of Public Health, Los Angeles, California, USA
- Children's Discovery & Innovation Institute, Mattel Children's Hospital, Los Angeles, California, USA
| | - Debra Lotstein
- Departments of Pediatrics and Anesthesiology Critical Care Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Andrew LaRocque
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Ann Sheehy
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
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Shadman KA, Ralston SL, Garber MD, Eickhoff J, Mussman GM, Walley SC, Rice-Conboy E, Coller RJ. Sustainability in the AAP Bronchiolitis Quality Improvement Project. J Hosp Med 2017; 12:905-910. [PMID: 29091978 DOI: 10.12788/jhm.2830] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [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: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVES Adherence to American Academy of Pediatrics (AAP) bronchiolitis clinical practice guideline recommendations improved significantly through the AAP's multiinstitutional collaborative, the Bronchiolitis Quality Improvement Project (BQIP). We assessed sustainability of improvements at participating institutions for 1 year following completion of the collaborative. METHODS Twenty-one multidisciplinary hospital-based teams provided monthly data for key inpatient bronchiolitis measures during baseline and intervention bronchiolitis seasons. Nine sites provided data in the season following completion of the collaborative. Encounters included children younger than 24 months who were hospitalized for bronchiolitis without comorbid chronic illness, prematurity, or intensive care. Changes between baseline-, intervention-, and sustainability-season data were assessed using generalized linear mixed-effects models with site-specific random effects. Differences between hospital characteristics, baseline performance, and initial improvement between sites that did and did not participate in the sustainability season were compared. RESULTS A total of 2275 discharges were reviewed, comprising 995 baseline, 877 intervention, and 403 sustainability- season encounters. Improvements in all key bronchiolitis quality measures achieved during the intervention season were maintained during the sustainability season, and orders for intermittent pulse oximetry increased from 40.6% (95% confidence interval [CI], 22.8-61.1) to 79.2% (95% CI, 58.0- 91.3). Sites that did and did not participate in the sustainability season had similar characteristics. DISCUSSION BQIP participating sites maintained improvements in key bronchiolitis quality measures for 1 year following the project's completion. This approach, which provided an evidence-based best-practice toolkit while building the quality-improvement capacity of local interdisciplinary teams, may support performance gains that persist beyond the active phase of the collaborative.
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Affiliation(s)
- Kristin A Shadman
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.
| | - Shawn L Ralston
- Children's Hospital at Dartmouth, Lebanon, New Hampshire, USA
| | - Matthew D Garber
- University of Florida College of Medicine, Gainesville, Florida, USA
| | - Jens Eickhoff
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Grant M Mussman
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Susan C Walley
- American Academy of Pediatrics, Elk Grove, Illinois, USA
| | | | - Ryan J Coller
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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23
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Mussman GM, Sahay RD, Destino L, Lossius M, Shadman KA, Walley SC. Respiratory Scores as a Tool to Reduce Bronchodilator Use in Children Hospitalized With Acute Viral Bronchiolitis. Hosp Pediatr 2017; 7:279-286. [PMID: 28442541 DOI: 10.1542/hpeds.2016-0090] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Adoption of clinical respiratory scoring as a quality improvement (QI) tool in bronchiolitis has been temporally associated with decreased bronchodilator usage. We sought to determine whether documented use of a clinical respiratory score at the patient level was associated with a decrease in either the physician prescription of any dose of bronchodilator or the number of doses, if prescribed, in a multisite QI collaborative. METHODS We performed a secondary analysis of data from a QI collaborative involving 22 hospitals. The project enrolled patients aged 1 month to 2 years with a primary diagnosis of acute viral bronchiolitis and excluded those with prematurity, other significant comorbid diseases, and those needing intensive care. We assessed for an association between documentation of any respiratory score use during an episode of care, as well as the method in which scores were used, and physician prescribing of any bronchodilator and number of doses. Covariates considered were phase of the collaborative, hospital length of stay, steroid use, and presence of household smokers. RESULTS A total of 1876 subjects were included. There was no association between documentation of a respiratory score and the likelihood of physician prescribing of any bronchodilator. Score use was associated with fewer doses of bronchodilators if one was prescribed (P = .05), but this association disappeared with multivariable analysis (P = .73). CONCLUSIONS We found no clear association between clinical respiratory score use and physician prescribing of bronchodilators in a multicenter QI collaborative.
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Affiliation(s)
- Grant M Mussman
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio;
| | - Rashmi D Sahay
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Lauren Destino
- Stanford University School of Medicine, Lucile Packard Children's Hospital, Palo Alto, California
| | - Michele Lossius
- University of Florida Health, Shands Children's Hospital, Gainesville, Florida
| | - Kristin A Shadman
- University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin; and
| | - Susan C Walley
- University of Alabama at Birmingham, Children's of Alabama, Birmingham, Alabama
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Abstract
BACKGROUND AND OBJECTIVES Adherence to the American Academy of Pediatrics safe sleep practice (SSP) recommendations among hospitalized infants is unknown, but is assumed to be low. This quality improvement study aimed to increase adherence to SSPs for infants admitted to a children's hospital general care unit between October 2013 and December 2014. METHODS After development of a hospital policy and redesign of room setup processes, a multidisciplinary team developed intervention strategies based on root cause analysis and implemented changes using iterative Plan-Do-Study-Act cycles. Nurse knowledge was assessed before and after education. SSPs were measured continuously with room audits during sleeping episodes. Statistical process control and run charts identified improvements and sustainability in hospital SSPs. Caregiver home practices after discharge were assessed via structured questionnaires before and after intervention. RESULTS Nursing knowledge of SSPs increased significantly for each item (P ≤ .001) except avoidance of bed sharing. Audits were completed for 316 sleep episodes. Simultaneous adherence to all SSP recommendations improved significantly from 0% to 26.9% after intervention. Significant improvements were noted in individual practices, including maintaining a flat, empty crib, with an appropriately bundled infant. The largest gains were noted in the proportion of empty cribs (from 3.4% to 60.3% after intervention, P < .001). Improvements in caregiver home practices after discharge were not statistically significant. CONCLUSIONS Sustained improvements in hospital SSPs were achieved through this quality improvement initiative, with opportunity for continued improvement. Nurse knowledge increased during the intervention. It is uncertain whether these findings translate to changes in caregiver home practices after discharge.
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Affiliation(s)
- Kristin A Shadman
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; and
| | - Ellen R Wald
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; and
| | - Windy Smith
- American Family Children's Hospital, Madison, Wisconsin
| | - Ryan J Coller
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; and
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Ralston SL, Garber MD, Rice-Conboy E, Mussman GM, Shadman KA, Walley SC, Nichols E. A Multicenter Collaborative to Reduce Unnecessary Care in Inpatient Bronchiolitis. Pediatrics 2016; 137:peds.2015-0851. [PMID: 26628731 DOI: 10.1542/peds.2015-0851] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/19/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Evidence-based Guidelines for acute viral bronchiolitis recommend primarily supportive care, but unnecessary care remains well documented. Published quality improvement work has been accomplished in children's hospitals, but little broad dissemination has been reported outside of those settings. We sought to use a voluntary collaborative strategy to disseminate best practices to reduce overuse of unnecessary care in children hospitalized for bronchiolitis in community settings. METHODS This project was a quality improvement collaborative consisting of monthly interactive webinars with online data collection and feedback. Data were collected by chart review for 2 bronchiolitis seasons, defined as January, February, and March of 2013 and 2014. Patients aged <24 months hospitalized for bronchiolitis and without chronic illness, prematurity, or intensive care use were included. Results were analyzed using run charting, analysis of means, and nonparametric statistics. RESULTS There were 21 participating hospitals contributing a total of 1869 chart reviews to the project, 995 preintervention and 874 postintervention. Mean use of any bronchodilator declined by 29% (P = .03) and doses per patient decreased 45% (P < .01). Mean use of any steroids declined by 68% (P < .01), and doses per patient decreased 35% (P = .04). Chest radiography use declined by 44% (P = .05). Length of stay decreased 5 hours (P < .01), and readmissions remained unchanged. CONCLUSIONS A voluntary collaborative was effective in reducing unnecessary care among a cohort of primarily community hospitals. Such a strategy may be generalizable to the settings where the majority of children are hospitalized in the United States.
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Affiliation(s)
| | - Matthew D Garber
- University of South Carolina School of Medicine, Columbia, South Carolina
| | | | - Grant M Mussman
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | | | - Elizabeth Nichols
- The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire
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Abstract
INTRODUCTION Respiratory syncytial virus (RSV) is an important pathogen in children and adults; however, current treatment options are primarily supportive. Palivizumab, the only approved specific monoclonal antibody for RSV is used prophylactically to reduce morbidity in a select population of high-risk children. AREAS COVERED The development and current use of palivizumab; the potential role of palivizumab as preventive therapy in patients with cystic fibrosis, asthma and compromised immune systems; and explores the limited research in which palivizumab has been used for treatment of RSV. The modified recommendations for the use of palivizumab espoused by the American Academy of Pediatrics and research on the cost-effectiveness of this product are presented. In addition, the authors discuss the development of enhanced monoclonal antibodies including motavizumab, which was recently denied FDA approval for preventative therapy. The authors explore the historical and current efforts to develop a vaccine targeting RSV. The current status of antiviral drug development is also reviewed. The literature search included RSV-Ig, palivizumab, and emerging drugs and vaccines for the treatment of RSV as keywords and titles from 1997 to 2011. EXPERT OPINION Although there are potential drugs and vaccines in development to prevent or reduce the effects of RSV infection, palivizumab remains the only licensed product to reduce the severity of disease in high-risk pediatric patients.
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Affiliation(s)
- Kristin A Shadman
- University of Wisconsin School of Medicine and Public Health, Department of Pediatrics, 600 Highland Avenue, Box 4108, Madison, WI 53792, USA.
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Stucky ER, Maniscalco J, Ottolini MC, Agrawal R, Alverson B, Ballantine A, Beauchamp-Walters J, Billman GF, Buchanan AO, Carlson DW, Chiang VW, Clemmens MR, Clute JL, Phillips SC, Dansky T, Daru J, Daud YN, DeWolfe C, Geskey JM, Hain PD, Herzog K, Hood M, Johnson KB, Johnson R, Kelly B, Kimmons HC, Li STT, Lye PS, Maniscalco J, Marcello DE, Melzer SM, Mikula MI, Mirkinson LJ, Miller CD, O'Hara C, Ottolini MC, Pate BM, Patrick D, Percelay JM, Pressel D, Rehm KP, Rhee KE, Riederer MF, Ruhlen M, Seidel HM, Sekaran A, Shadman KA, Singla V, Smith K, Sperring JL, Stryjewski G, Stucky ER, Thompson ED, Turmelle M, Tynan MG, Williams RJ, Wolf H, Wu S, Zaoutis LB, Zempsky WT. The Pediatric Hospital Medicine Core Competencies Supplement: a Framework for Curriculum Development by the Society of Hospital Medicine with acknowledgement to pediatric hospitalists from the American Academy of Pediatrics and the Academic Pediatric Association. J Hosp Med 2010; 5 Suppl 2:i-xv, 1-114. [PMID: 20440783 DOI: 10.1002/jhm.776] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Erin R Stucky
- University of California San Diego School of Medicine, Department of Pediatrics, USA.
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