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Grubenhoff JA, Bakel LA, Dominguez F, Leonard J, Widmer K, Sanders JS, Spencer SP, Stein JM, Searns JB. Clinical Pathway Adherence and Missed Diagnostic Opportunities Among Children with Musculoskeletal Infections. Jt Comm J Qual Patient Saf 2023; 49:547-556. [PMID: 37495472 DOI: 10.1016/j.jcjq.2023.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 06/14/2023] [Accepted: 06/19/2023] [Indexed: 07/28/2023]
Abstract
INTRODUCTION Clinical care pathways (CPs) integrate best evidence into the local care delivery context to promote efficiency and patient safety. However, the impact of CPs on diagnostic performance remains poorly understood. The objectives of this study were to evaluate adherence to a musculoskeletal infection (MSKI) diagnostic CP and identify recurrent failure points leading to missed diagnostic opportunities (MDOs). METHODS Retrospective chart review was performed from January 2018 to February 2022 for children 6 months to 18 years of age who had an unplanned admission for MSKI after being evaluated and discharged from the pediatric emergency department (PED) for related complaints within the previous 10 days. MDOs were identified using the Revised Safer Dx. Demographic and clinical characteristics of children with and without MDOs were compared using bivariate descriptive statistics. An improvement team reviewed the diagnostic trajectories of MDOs for deviations from the MSKI CP and developed a fishbone diagram to describe contributing factors to CP deviations. RESULTS The study identified 21 children with and 13 children without MSKI-associated MDOs. Children with MDOs were more likely to have an initial C-reactive protein value > 2 mg/dL (90.0% vs. 0%, p = 0.01) and returned to care earlier than children without MDOs (median 2.8 days vs. 6.7 days, p = 0.004). Factors contributing to MDOs included failure to obtain screening laboratory tests, misinterpretation of laboratory values, failure to obtain orthopedic consultation, and failure to obtain definitive imaging. CONCLUSION Several recurrent deviations from an MSKI diagnostic CP were found to be associated with MDOs. Future quality improvement efforts to improve adherence to this MSKI CP may prevent MDOs.
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Bakel LA, Richardson T, De Souza HG, Kaiser SV, Mahant S, Treasure JD, Waynik IY, Winer JC, Bajaj L. Hospital's observed specific standard practice: A novel measure of variation in care for common inpatient pediatric conditions. J Hosp Med 2022; 17:417-426. [PMID: 35535935 DOI: 10.1002/jhm.12811] [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] [Received: 10/29/2021] [Revised: 02/11/2022] [Accepted: 02/19/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Previously few means existed to broadly examine variability across conditions/practices within or between hospitals for common pediatric conditions. OBJECTIVE Our objective was to develop a novel empiric measure of variation in care and test its association with patient-centered outcomes. DESIGNS We conducted a retrospective cohort study of children hospitalized from January 2016 to December 2018 using the Pediatric Hospital Information Systems database. SETTINGS AND PARTICIPANTS We included children ages 0-18 years hospitalized with asthma, bronchiolitis, or gastroenteritis. INTERVENTION We developed a hospital-specific measure of variation in care, the hospital's observed specific standard practice (HOSSP), the most common combination of laboratory studies, imaging, and medications used at each hospital. MAIN OUTCOME AND MEASURES The outcomes were standardized costs, length of stay (LOS), and 7-day all-cause readmissions. RESULTS Among 133,392 hospitalizations from 41 hospitals (asthma = 50,382, bronchiolitis = 54,745, and gastroenteritis = 28,265), there was significant variation in overall HOSSP adherence across hospitals for these conditions (asthma: 3.5%-47.4% [p < .001], bronchiolitis: 2.5%-19.8% [p < .001], gastroenteritis: 1.6%-11.6% [p < .001]). The majority of HOSSP variation was driven by differences in medication prescribing for asthma and bronchiolitis and laboratory ordering for gastroenteritis. For all three conditions, greater HOSSP adherence was associated with significantly lower hospital costs (asthma: p = .04, bronchiolitis: p < .001, acute gastroenteritis: p = .01), without increases in LOS or 7-day all cause readmissions. CONCLUSION We found substantial variation in the components and adherence to HOSSP. Hospitals with greater HOSSP adherence had lower costs for these conditions. This suggests hospitals can use data around laboratory, imaging, and medication prescribing practices to drive standardization of care, reduce unnecessary testing and treatment, determine best practices, and reduce costs.
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Affiliation(s)
- Leigh Anne Bakel
- Section of Hospital Medicine, Department of Pediatrics, Clinical Effectiveness Team, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | | | | | - Sunitha V Kaiser
- Department of Pediatrics, University of California at San Francisco, San Francisco, California, USA
| | - Sanjay Mahant
- Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Jennifer D Treasure
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Ilana Y Waynik
- Department of Pediatrics, Connecticut Children's Medical Center, University of Connecticut, Mansfield, Connecticut, USA
| | - Jeffrey C Winer
- Department of Pediatrics, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Lalit Bajaj
- Section of Hospital Medicine, Department of Pediatrics, Clinical Effectiveness Team, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
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Wang GS, Reese J, Bakel LA, Leonard J, Bos T, Bielsky A, Nickels S, Bajaj L. Prescribing Patterns of Oral Opioid Analgesic for Long Bone Fracture at Tertiary Care Children's Hospital Emergency Departments and Urgent Cares. Pediatr Emerg Care 2021; 37:e1524-e1527. [PMID: 32384393 DOI: 10.1097/pec.0000000000002105] [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 Disparities in opioid prescribing in children can lead to underprescribing and poorly controlled pain. On the contrary, unnecessary overprescribing can increase the risk for misuse, abuse, and diversion. The primary objective of this study was to compare the demographics and clinical characteristics of children with an extremity fracture who did and did not receive an opioid prescription from a tertiary care children's hospital. METHODS This was a retrospective cohort study of children younger than 22 years with extremity fracture evaluated at a tertiary care children's hospital emergency department (ED) and surrounding satellite locations (3 EDs and 4 urgent cares), from January 1, 2017, to December 31, 2017. RESULTS There were 3325 patients younger than 22 years who were seen for evaluation of an extremity fracture. The overall median age of patients was 8 years (interquartile range [IQR], 4-11), and 1976 (59.4%) were male. Patients with extremity fractures who received opioid analgesics were older than those who did not receive opioids (median age of 10 years [IQR, 6-13 years] vs 7 years [IQR, 4-11 years], P < 0.001). There was a significant difference found between insurance types, specifically those patients receiving Medicaid and private insurance. Patients who received opioid analgesics had a higher initial pain score (7 [IQR, 4-9] vs 5 [IQR, 2-7], P < 0.001), were more likely to have an physician (MD/DO) provider (P < 0.001), and were more likely to present to the ED (P < 0.001). CONCLUSIONS Younger patients, patients with Medicaid insurance, patients treated by an advanced care provider, and patients who presented to an urgent care were less likely to receive opioid analgesics upon discharge. These findings demonstrate that more standardization and guidance on opioid prescribing are needed in pediatrics, to both adequately treat pain and reduce harms from overprescribing of opioid analgesics.
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Affiliation(s)
| | - Jennifer Reese
- Division of Hospitalist Medicine, University of Colorado Anschutz Medical Campus
| | | | - Jan Leonard
- Division of Emergency Medicine, University of Colorado Anschutz Medical Campus
| | - Tod Bos
- Department of Clinical Effectiveness, Children's Hospital Colorado
| | - Alan Bielsky
- Department of Anesthesia, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Sarah Nickels
- Department of Clinical Effectiveness, Children's Hospital Colorado
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Wang GS, Reese J, Bakel LA, Leonard J, Bielsky A, Reid A, Bos T, Nickels S, Bajaj L. Prescribing Patterns of Oral Opioid Analgesic for Acute Pain at a Tertiary Care Children's Hospital Emergency Departments and Urgent Cares. Pediatr Emerg Care 2021; 37:e841-e845. [PMID: 31688834 DOI: 10.1097/pec.0000000000001909] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVES Despite Centers for Disease Control and Prevention guidelines on adult opioid prescribing, there is a paucity of evidence and no guidelines to inform opioid prescribing in pediatrics. To develop guidelines on pediatric prescribing, it is imperative to evaluate current practice on opioid use. The objectives were to describe prescribing patterns of opioids for acute pain at a children's hospital and to compare clinical characteristics of patients who received less or greater than 3 days. METHODS A retrospective review of oral opioid analgesics prescribed for acute pain at a tertiary care children's hospital emergency department and urgent care from January 1, 2017, to December 31, 2017. Patients younger than 22 years who received an opioid prescription upon discharge were included. Patients with hematology/oncology or chronic pain diagnosis were excluded. RESULTS Opioids were prescribed for a median of 2.2 days (interquartile range, 1.4-3.0 days). Most opioids were prescribed for ≤3 days (1326; 79.3%), and there were 44 (2.6%) prescriptions for >7 days. Twenty-two opioid formulations were prescribed. Single-ingredient oxycodone was the most commonly prescribed (877; 52.5%); there were 724 (43.3%) acetaminophen combination products. Common diagnoses were orthopedic (973; 58.2%), surgery/burn/trauma (195; 11.7%), and ear/nose/throat (143; 8.6%). Patients who received >3 days of opioids were younger (P < 0.001), and there was no differences in sex, ethnicity, insurance, or provider qualifications. CONCLUSIONS Overall, prescribing patterns for the duration of opioid analgesics were ≤3 days, with a median of 2 days. There was a large range of days prescribed, with variations in prescribing characteristics among patients and providers.
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Lockwood JM, Scott HF, Wathen B, Rolison E, Smith C, Bundy J, Swanson A, Nickels S, Bakel LA, Bajaj L. An Acute Care Sepsis Response System Targeting Improved Antibiotic Administration. Hosp Pediatr 2021; 11:944-955. [PMID: 34404744 DOI: 10.1542/hpeds.2021-006011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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
BACKGROUND AND OBJECTIVES Pediatric sepsis quality improvement in emergency departments has been well described and associated with improved survival. Acute care (non-ICU inpatient) units differ in important ways, and optimal approaches to improving sepsis processes and outcomes in this setting are not yet known. Our objective was to increase the proportion of acute care sepsis cases in our health system with initial antibiotic order-to-administration time ≤60 minutes by 20% from a baseline of 43% to 52% by December 2020. METHODS Employing the Model for Improvement with broad stakeholder engagement, we developed and implemented interventions aimed at effective intervention for sepsis cases on acute care units. We analyzed process and outcome metrics over time using statistical process control charts. We used descriptive statistics to explore differences in antibiotic order-to-administration time and inform ongoing improvement. RESULTS We cared for 187 patients with sepsis over the course of our initiative. The proportion within our goal antibiotic order-to-administration time rose from 43% to 64% with evidence of special cause variation after our interventions. Of all patients, 66% experienced ICU transfer and 4% died. CONCLUSIONS We successfully decreased antibiotic order-to-administration time. We also introduced a novel model for sepsis response systems that integrates interventions designed for the complexities of acute care settings. We demonstrated impactful local improvements in the acute care setting where quality improvement reports and success have previously been limited.
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Affiliation(s)
| | - Halden F Scott
- Emergency Medicine, Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
| | | | - Elise Rolison
- Clinical Effectiveness Team, Children's Hospital Colorado, Aurora, Colorado
| | - Carter Smith
- Clinical Effectiveness Team, Children's Hospital Colorado, Aurora, Colorado
| | - Jane Bundy
- Clinical Effectiveness Team, Children's Hospital Colorado, Aurora, Colorado
| | - Angela Swanson
- Clinical Effectiveness Team, Children's Hospital Colorado, Aurora, Colorado
| | - Sarah Nickels
- Clinical Effectiveness Team, Children's Hospital Colorado, Aurora, Colorado
| | - Leigh Anne Bakel
- Sections of Hospital Medicine.,Clinical Effectiveness Team, Children's Hospital Colorado, Aurora, Colorado
| | - Lalit Bajaj
- Emergency Medicine, Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado.,Clinical Effectiveness Team, Children's Hospital Colorado, Aurora, Colorado
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Manning WA, Bakel LA. Adaptation of Adult Pathways to Improve the Care of Adult Patients at Pediatric Hospitals. Hosp Pediatr 2021; 11:e164-e166. [PMID: 34326163 DOI: 10.1542/hpeds.2020-004093] [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)
- W Aaron Manning
- Children's Hospital Colorado, Aurora, Colorado .,UCHealth University of Colorado Hospital, Aurora, Colorado
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Rao S, Kwan BM, Curtis DJ, Swanson A, Bakel LA, Bajaj L, Boguniewicz J, Lockwood JM, Ogawa K, Pemberton K, Fuhlbrigge RC, Brumbaugh D, Givens P, Nozik ES, Sills MR. Implementation of a Rapid Evidence Assessment Infrastructure during the Coronavirus Disease 2019 (COVID-19) Pandemic to Develop Policies, Clinical Pathways, Stimulate Academic Research, and Create Educational Opportunities. J Pediatr 2021; 230:4-8.e2. [PMID: 33091418 PMCID: PMC7572277 DOI: 10.1016/j.jpeds.2020.10.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 10/14/2020] [Indexed: 10/25/2022]
Affiliation(s)
- Suchitra Rao
- Department of Pediatrics (Infectious Diseases), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO; Department of Pediatrics (Epidemiology), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO; Department of Pediatrics (Hospital Medicine), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Bethany M Kwan
- Department of Family Medicine, University of Colorado Denver - Anschutz Medical Campus, Aurora, CO
| | - Donna J Curtis
- Department of Pediatrics (Infectious Diseases), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Angela Swanson
- Clinical Effectiveness, Children's Hospital Colorado, Aurora, CO
| | - Leigh Anne Bakel
- Department of Pediatrics (Hospital Medicine), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Lalit Bajaj
- Clinical Effectiveness, Children's Hospital Colorado, Aurora, CO; Department of Pediatrics (Emergency Medicine), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Juri Boguniewicz
- Department of Pediatrics (Infectious Diseases), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Justin M Lockwood
- Department of Pediatrics (Hospital Medicine), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Kaleigh Ogawa
- Clinical Effectiveness, Children's Hospital Colorado, Aurora, CO
| | | | - Robert C Fuhlbrigge
- Department of Pediatrics (Rheumatology), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - David Brumbaugh
- Department of Pediatrics (Gastroenterology), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Patricia Givens
- Department of Nursing, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Eva S Nozik
- Department of Pediatrics (Critical Care), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Marion R Sills
- Department of Pediatrics (Emergency Medicine), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO.
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Widmer K, Schmidt S, Bakel LA, Cookson M, Leonard J, Tyler A. Use of Procalcitonin in a Febrile Infant Clinical Pathway and Impact on Infants Aged 29 to 60 Days. Hosp Pediatr 2021; 11:223-230. [PMID: 33597148 DOI: 10.1542/hpeds.2020-000380] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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 Recent evidence suggests that measuring the procalcitonin level may improve identification of low-risk febrile infants who may not need intervention. We describe outcomes after the implementation of a febrile infant clinical pathway recommending measurement of the procalcitonin level for risk stratification. METHODS In this single-center retrospective pre-post intervention study of febrile infants aged 29 to 60 days, we used interrupted time series analyses to evaluate outcomes of lumbar puncture (LP), antibiotic administration, hospital admission, and emergency department (ED) length of stay (LOS). A multivariable logistic regression was used to evaluate the odds of LP. RESULTS Data were analyzed between January 2017 and December 2019 and included 740 participants. Procalcitonin use increased post-pathway implementation (PI). The proportion of low-risk infants receiving an LP decreased significantly post-PI (P = .001). In the adjusted interrupted time series analysis, there was no immediate level change (shift) post-PI for LP (0.98 [95% confidence interval (CI): 0.49-1.97]), antibiotics (1.17 [95% CI: 0.56-2.43]), admission (1.07 [95% CI: 0.59-1.96]), or ED LOS (1.08 [95% CI: 0.92-1.28]), and there was no slope change post-PI versus pre-PI for any measure (LP: 1.01 [95% CI: 0.94-1.08]; antibiotics: 1.00 [95% CI: 0.93-1.08]; admission: 1.03 [95% CI: 0.97-1.09]; ED LOS: 1.01 [95% CI: 0.99-1.02]). More patients were considered high risk, and fewer had incomplete laboratory test results post-PI (P < .001). There were no missed serious bacterial infections. A normal procalcitonin level significantly decreased the odds of LP (P < .001). CONCLUSIONS Clinicians quickly adopted procalcitonin testing. Resource use for low-risk infants decreased; however, there was no change to resource use for the overall population because more infants underwent laboratory evaluation and were classified as high risk post-PI.
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Affiliation(s)
- Kaitlin Widmer
- Sections of Hospital Medicine and .,Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
| | - Sarah Schmidt
- Sections of Hospital Medicine and.,Emergency Medicine, Department of Pediatrics, Children's Hospital Colorado, Aurora, Colorado; and
| | - Leigh Anne Bakel
- Sections of Hospital Medicine and.,Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
| | - Michael Cookson
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
| | - Jan Leonard
- Sections of Hospital Medicine and.,Emergency Medicine, Department of Pediatrics, Children's Hospital Colorado, Aurora, Colorado; and
| | - Amy Tyler
- Sections of Hospital Medicine and.,Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
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Tyler A, Krack P, Bakel LA, O'Hara K, Scudamore D, Topoz I, Freeman J, Moss A, Allen R, Swanson A, Bajaj L. Interventions to Reduce Over-Utilized Tests and Treatments in Bronchiolitis. Pediatrics 2018; 141:peds.2017-0485. [PMID: 29752289 DOI: 10.1542/peds.2017-0485] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [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] [Accepted: 12/12/2017] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES The American Academy of Pediatrics published bronchiolitis clinical practice guidelines in 2014 recommending against the routine use of bronchodilators, chest radiographs, or respiratory viral testing in children with a clinical diagnosis of bronchiolitis. Our aim in this project was to align care with the American Academy of Pediatrics clinical practice guidelines by decreasing the overuse of these interventions. METHODS This study included patients who were admitted to a non-ICU setting with a primary or secondary diagnosis of bronchiolitis. The team used a multidisciplinary kickoff event to understand the problem and develop interventions, including sharing provider-specific data and asking providers to sign a pledge to reduce use. We used a novel, real-time data dashboard to collect and analyze data. RESULTS Special cause variation on control charts indicated improvement for all outcomes for inpatients during the intervention season. Pre- and postanalyses in which we compared baseline to intervention values for all admitted patients and patients who were discharged from the emergency department or urgent care revealed a significant reduction in the ordering of chest radiographs (from 22.7% to 13.6%; P ≤ .001), respiratory viral testing (from 12.5% to 9.8%; P = .001), and bronchodilators (from 17.5% to 10.3%; P = .001) without changes in balancing measures (eg, hospital readmission within 7 days [1.7% (preanalysis) and 1.0% (postanalysis); P = .21]) for bronchiolitis. CONCLUSIONS This multidisciplinary improvement initiative resulted in a significant reduction in use for bronchiolitis care at our institution. Our approach, which included a novel, real-time data dashboard and interventions such as individual providers pledging to reduce use, may have the potential to reduce overuse in other settings and diseases.
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Affiliation(s)
- Amy Tyler
- Children's Hospital Colorado, Aurora, Colorado; .,Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado; and
| | - Paige Krack
- Children's Hospital Colorado, Aurora, Colorado
| | - Leigh Anne Bakel
- Children's Hospital Colorado, Aurora, Colorado.,Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado; and
| | - Kimberly O'Hara
- Children's Hospital Colorado, Aurora, Colorado.,Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado; and
| | - Douglas Scudamore
- Children's Hospital Colorado, Aurora, Colorado.,Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado; and
| | - Irina Topoz
- Children's Hospital Colorado, Aurora, Colorado.,Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado; and
| | - Julia Freeman
- Children's Hospital Colorado, Aurora, Colorado.,Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado; and
| | - Angela Moss
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, Aurora, Colorado
| | - Renee Allen
- Children's Hospital Colorado, Aurora, Colorado
| | | | - Lalit Bajaj
- Children's Hospital Colorado, Aurora, Colorado.,Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado; and
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Bakel LA, Hamid J, Ewusie J, Liu K, Mussa J, Straus S, Parkin P, Cohen E. International Variation in Asthma and Bronchiolitis Guidelines. Pediatrics 2017; 140:peds.2017-0092. [PMID: 29070533 DOI: 10.1542/peds.2017-0092] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [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: 08/16/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Guideline recommendations for the same clinical condition may vary. The purpose of this study was to determine the degree of agreement among comparable asthma and bronchiolitis treatment recommendations from guidelines. METHODS National and international guidelines were searched by using guideline databases (eg, National Guidelines Clearinghouse: December 16-17, 2014, and January 9, 2015). Guideline recommendations were categorized as (1) recommend, (2) optionally recommend, (3) abstain from recommending, (4) recommend against a treatment, and (5) not addressed by the guideline. The degree of agreement between recommendations was evaluated by using an unweighted and weighted κ score. Pairwise comparisons of the guidelines were evaluated similarly. RESULTS There were 7 guidelines for asthma and 4 guidelines for bronchiolitis. For asthma, there were 166 recommendation topics, with 69 recommendation topics given in ≥2 guidelines. For bronchiolitis, there were 46 recommendation topics, with 21 recommendation topics provided in ≥2 guidelines. The overall κ for asthma was 0.03, both unweighted (95% confidence interval [CI]: -0.01 to 0.07) and weighted (95% CI: -0.01 to 0.10); for bronchiolitis, it was 0.32 unweighted (95% CI: 0.16 to 0.52) and 0.15 weighted (95% CI: -0.01 to 0.5). CONCLUSIONS Less agreement was found in national and international guidelines for asthma than for bronchiolitis. Additional studies are needed to determine if differences are based on patient preferences and values and economic considerations or if other recommendation-level, guideline-level, and condition-level factors are driving these differences.
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Affiliation(s)
- Leigh Anne Bakel
- Section of Pediatric Hospital Medicine and the Clinical Effectiveness Team, Department of Pediatrics, Children's Hospital Colorado, Aurora, Colorado;
| | - Jemila Hamid
- Li Ka Shing Knowledge Institute, St. Michael's Hospital and University of Toronto, Toronto, Ontario, Canada
| | | | - Kai Liu
- Mathematics and Statistics, and
| | - Joseph Mussa
- Biochemistry, McMaster University, Hamilton, Ontario, Canada
| | - Sharon Straus
- Li Ka Shing Knowledge Institute, St. Michael's Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Patricia Parkin
- Division of Pediatric Medicine and the Pediatric Outcomes Research Team, Department of Pediatrics, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada; and
| | - Eyal Cohen
- Division of Pediatric Medicine and the Pediatric Outcomes Research Team, Department of Pediatrics, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada; and
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Kaiser SV, Huynh T, Bacharier LB, Rosenthal JL, Bakel LA, Parkin PC, Cabana MD. Preventing Exacerbations in Preschoolers With Recurrent Wheeze: A Meta-analysis. Pediatrics 2016; 137:peds.2015-4496. [PMID: 27230765 DOI: 10.1542/peds.2015-4496] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [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: 03/16/2016] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Half of children experience wheezing by age 6 years, and optimal strategies for preventing severe exacerbations are not well defined. OBJECTIVE Synthesize the evidence of the effects of daily inhaled corticosteroids (ICS), intermittent ICS, and montelukast in preventing severe exacerbations among preschool children with recurrent wheeze. DATA SOURCES Medline (1946, 2/25/15), Embase (1947, 2/25/15), CENTRAL. STUDY SELECTION Studies were included based on design (randomized controlled trials), population (children ≤6 years with asthma or recurrent wheeze), intervention and comparison (daily ICS vs placebo, intermittent ICS vs placebo, daily ICS vs intermittent ICS, ICS vs montelukast), and outcome (exacerbations necessitating systemic steroids). DATA EXTRACTION Completed by 2 independent reviewers. RESULTS Twenty-two studies (N = 4550) were included. Fifteen studies (N = 3278) compared daily ICS with placebo and showed reduced exacerbations with daily medium-dose ICS (risk ratio [RR] 0.70; 95% confidence interval [CI], 0.61-0.79; NNT = 9). Subgroup analysis of children with persistent asthma showed reduced exacerbations with daily ICS compared with placebo (8 studies, N = 2505; RR 0.56; 95% CI, 0.46-0.70; NNT = 11) and daily ICS compared with montelukast (1 study, N = 202; RR 0.59; 95% CI, 0.38-0.92). Subgroup analysis of children with intermittent asthma or viral-triggered wheezing showed reduced exacerbations with preemptive high-dose intermittent ICS compared with placebo (5 studies, N = 422; RR 0.65; 95% CI, 0.51-0.81; NNT = 6). LIMITATIONS More studies are needed that directly compare these strategies. CONCLUSIONS There is strong evidence to support daily ICS for preventing exacerbations in preschool children with recurrent wheeze, specifically in children with persistent asthma. For preschool children with intermittent asthma or viral-triggered wheezing, there is strong evidence to support intermittent ICS for preventing exacerbations.
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Affiliation(s)
| | - Tram Huynh
- School of Public Health, University of California, Berkeley, California
| | - Leonard B Bacharier
- Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri
| | | | - Leigh Anne Bakel
- Department of Pediatrics, University of Colorado, Denver, Colorado; and
| | - Patricia C Parkin
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Michael D Cabana
- Department of Pediatrics, Phillip Lee Institute for Health Policy Studies, and Department of Epidemiology and Biostatistics, University of California, San Francisco, California
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Bakel LA, Hamid J, Straus S, Parkin P, Cohen E. 128: Examining Agreement Between Treatment Recommendations from Different National Clinical Practice Guidelines for Bronchiolitis. Paediatr Child Health 2015. [DOI: 10.1093/pch/20.5.e80a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Dean SM, Eickhoff JC, Bakel LA. The effectiveness of a bundled intervention to improve resident progress notes in an electronic health record. J Hosp Med 2015; 10:104-7. [PMID: 25425386 PMCID: PMC4498456 DOI: 10.1002/jhm.2283] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [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] [Received: 06/13/2014] [Revised: 10/10/2014] [Accepted: 10/28/2014] [Indexed: 11/09/2022]
Abstract
Providers nationally have observed a decline in the quality of documentation after implementing electronic health records (EHRs). In this pilot study, we examined the effectiveness of an intervention bundle designed to improve resident progress notes written in an EHR and to establish the reliability of an audit tool used to evaluate notes. The bundle consisted of establishing note-writing guidelines, developing an aligned note template, and educating interns about the guidelines and using the template. Twenty-five progress notes written by pediatric interns before and after this intervention were examined using an audit tool. Reliability of the tool was evaluated using the intraclass correlation coefficient (ICC). The total score of the audit tool was summarized in terms of means and standard deviation. Individual item responses were summarized using percentages and compared between the pre- and postintervention assessment using the Fisher exact test. The ICC for the audit tool was 0.96 (95% confidence interval: 0.91-0.98). A significant improvement in the total note score and in questions related to note clutter was seen. No significant improvement was seen for questions related to copy-paste. The study suggests that an intervention bundle can lead to some improvements in note writing.
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Affiliation(s)
- Shannon M. Dean
- University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Jens C. Eickhoff
- University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Leigh Anne Bakel
- The University of Colorado School of Medicine, Aurora, CO, United States
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Tyler A, Boyer A, Martin S, Neiman J, Bakel LA, Brittan M. Development of a discharge readiness report within the electronic health record-A discharge planning tool. J Hosp Med 2014; 9:533-9. [PMID: 24825848 DOI: 10.1002/jhm.2212] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [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] [Received: 12/03/2013] [Revised: 04/07/2014] [Accepted: 04/23/2014] [Indexed: 11/11/2022]
Abstract
BACKGROUND With increasingly complex pediatric inpatients, efficient and effective hospital discharge requires optimal interdisciplinary care coordination and communication. We describe the development of a discharge readiness report (DRR) for the electronic health record (EHR), an integrated summary of discharge-related information organized into a highly visible and easily accessible report. METHODS We used interviews and process mapping to understand the roles of all disciplines involved in discharge planning and identified key drivers affecting our aim of designing a discharge tool in the EHR. Based on identified key drivers, we designed the DRR and made changes to the report using rapid improvement cycles. The final report includes information necessary for discharge planning organized into 4 domains: potential barriers to discharge, transitional care, home care, and discharge criteria. RESULTS The DRR was activated in June 2012. As planned, the final product incorporated previously existing discharge-related information from within the EHR, organized into 1 report. Shortly after its introduction, the DRR was included in daily care coordination rounds (CCRs) for medical and medical subspecialty patients. End users found the report to be completely populated and accurate. We measured time to completion of CCRs and found no difference between duration of CCRs pre- and postuse of the DRR. CONCLUSIONS Given widespread adoption, EHRs should be optimized to improve healthcare delivery. A discharge planning tool in the EHR may improve the efficiency and effectiveness of care transitions by allowing for proactive discharge planning and improved interdisciplinary communication.
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Affiliation(s)
- Amy Tyler
- Section of Hospital Medicine, Children's Hospital Colorado, and Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
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Abstract
BACKGROUND The problem list is a meaningful use incentivized criterion, and >80% of patients should have 1 problem entered as structured data. OBJECTIVE The aim of the present study was to use a series of interventions to increase the use of the problem list for inpatients to >80% as measured by at least 1 hospital problem at discharge. METHODS This study was a quasi-experimental time series quality improvement trial. The primary outcome was 80% of medical and psychiatric inpatients with a problem added to the problem list before discharge. Control charts of percentage (p charts) of medical and psychiatric patients with an inpatient problem list at discharge were constructed with three-σ control limits. Control limits were revised after evidence of improvement. The charts were annotated with interventions, including increasing awareness, focused education, and timely feedback in the form of performance graphs e-mailed to providers. RESULTS For medical inpatients, use rose from 31% to 97% at its peak in April 2011 and continues to maintain above the goal of 80%. In psychiatry, problem list use rose from 2% initially to an average of 72% after the interventions. CONCLUSIONS Significant gains were made with inpatient problem list usage by the medical and psychiatric teams. Our goal ascribed by meaningful use for >80% of inpatients to have a problem at discharge was met after initiation of our series of interventions.
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Affiliation(s)
- Leigh Anne Bakel
- Department of Pediatrics-Hospital for Sick Children, Toronto, Ontario
| | - Karen Wilson
- Department of Pediatrics-Section of Hospital Medicine
| | - Amy Tyler
- Department of Pediatrics-Section of Hospital Medicine
| | - Eric Tham
- Department of Pediatrics-Sections of Emergency Medicine Department of Pediatrics-Section of Clinical Informatics, and
| | | | - Joan Bothner
- Department of Pediatrics-Sections of Emergency Medicine
| | - David W Kaplan
- Department of Pediatrics-Section of Adolescent Medicine, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado
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Seltz LB, Bakel LA, Tiehen J, Gao D, Cadnapaphornchai MA, Lum G, Ford D. Efficacy and safety of clopidogrel in children with diarrhea associated hemolytic uremic syndrome. Thromb Res 2012; 130:e26-30. [PMID: 22683020 DOI: 10.1016/j.thromres.2012.05.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Revised: 05/09/2012] [Accepted: 05/16/2012] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Hemolytic uremic syndrome is a thrombotic microangiopathy. Clopidogrel, a recently developed platelet aggregation inhibitor, has not been previously reported as a treatment for this illness. Our study's objective was to explore the efficacy and safety of clopidogrel in children with diarrhea associated hemolytic uremic syndrome. MATERIALS AND METHODS We performed a retrospective chart review of all children (≤ 18 years) hospitalized with diarrhea associated hemolytic uremic syndrome. Outcomes in clopidogrel treated children were described. In subgroup analysis, outcomes were compared to those untreated with platelet aggregation inhibitors. RESULTS Of 72 children with diarrhea associated hemolytic uremic syndrome, 88% were treated with platelet aggregation inhibitors (clopidogrel 56%, sulfinpyrazone 19%, dipyridamole 13%). The median age of clopidogrel treated children was 5 years; 40% were male. Initial median hemoglobin, platelet count, and serum creatinine were 10.1g/dL, 53 × 10(3)/μL, and 2.3mg/dL respectively. Clopidogrel (median dose 1mg/kg/d) was given for a median of 4 days (range 1-15). Other therapies included erythropoietin (98%), red blood cell transfusions (80%), diuretics (58%), anti-hypertensive agents (45%), and dialysis (33%). The median hospital length of stay was 9 days (range 3-26). Three children had bleeding complications (epistaxis/hematemesis). The risk of chronic kidney disease was 5% and death 2.5%. In subgroup analysis, median duration of dialysis was 11 days in thirteen clopidogrel treated children compared to 21 days in five untreated patients (P=0.04). CONCLUSIONS Children with diarrhea associated hemolytic uremic syndrome treated with clopidogrel have outcomes comparable to untreated patients. Bleeding complications may occur.
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Affiliation(s)
- L Barry Seltz
- Department of Pediatrics, Section of Hospital Medicine, Children's Hospital Colorado and the University of Colorado School of Medicine. 13123 E 16th Ave, Aurora, CO 80045, USA.
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Kim WY, Fritzsch B, Serls A, Bakel LA, Huang EJ, Reichardt LF, Barth DS, Lee JE. NeuroD-null mice are deaf due to a severe loss of the inner ear sensory neurons during development. Development 2001; 128:417-26. [PMID: 11152640 PMCID: PMC2710102 DOI: 10.1242/dev.128.3.417] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.7] [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: 10/21/2022]
Abstract
A key factor in the genetically programmed development of the nervous system is the death of massive numbers of neurons. Therefore, genetic mechanisms governing cell survival are of fundamental importance to developmental neuroscience. We report that inner ear sensory neurons are dependent on a basic helix-loop-helix transcription factor called NeuroD for survival during differentiation. Mice lacking NeuroD protein exhibit no auditory evoked potentials, reflecting a profound deafness. DiI fiber staining, immunostaining and cell death assays reveal that the deafness is due to the failure of inner ear sensory neuron survival during development. The affected inner ear sensory neurons fail to express neurotrophin receptors, TrkB and TrkC, suggesting that the ability of NeuroD to support neuronal survival may be directly mediated through regulation of responsiveness to the neurotrophins.
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MESH Headings
- Animals
- Basic Helix-Loop-Helix Transcription Factors
- Cell Death
- Cell Movement
- Cell Survival
- Cochlea/growth & development
- Cochlea/innervation
- Cochlea/pathology
- Cochlea/ultrastructure
- Deafness/genetics
- Deafness/physiopathology
- Evoked Potentials, Auditory/genetics
- Evoked Potentials, Auditory/physiology
- Gene Deletion
- Gene Expression Regulation, Developmental
- Genes, Reporter
- Hair Cells, Auditory, Inner/growth & development
- Hair Cells, Auditory, Inner/metabolism
- Hair Cells, Auditory, Inner/pathology
- Hair Cells, Auditory, Inner/ultrastructure
- Helix-Loop-Helix Motifs
- Histocytochemistry
- In Situ Hybridization
- In Situ Nick-End Labeling
- Mice
- Mice, Knockout
- Microscopy, Electron
- Nerve Tissue Proteins/chemistry
- Nerve Tissue Proteins/genetics
- Nerve Tissue Proteins/physiology
- Neural Pathways/growth & development
- Neural Pathways/pathology
- Receptor, trkB/genetics
- Receptor, trkB/metabolism
- Receptor, trkC/genetics
- Receptor, trkC/metabolism
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Affiliation(s)
- Woo-Young Kim
- Department of Molecular Cellular and Developmental Biology, University of Colorado, Boulder, CO 80309, USA
| | - Bernd Fritzsch
- Department of Biochemical Science, Creighton University, Omaha, NE 68178, USA
| | - Amanda Serls
- Department of Molecular Cellular and Developmental Biology, University of Colorado, Boulder, CO 80309, USA
| | - Leigh Anne Bakel
- Department of Psychology, University of Colorado, Boulder, CO 80309, USA
| | - Eric J. Huang
- Pathology Service 113B, VA Medical Center, 4150, San Francisco, CA 94121, USA
| | - Louis F. Reichardt
- Program in Neuroscience, Department of Physiology and Howard Hughes Medical Institute, University of California, San Francisco, CA 94143, USA
| | - Daniel S. Barth
- Department of Psychology, University of Colorado, Boulder, CO 80309, USA
| | - Jacqueline E. Lee
- Department of Molecular Cellular and Developmental Biology, University of Colorado, Boulder, CO 80309, USA
- Author for correspondence (e-mail: )
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