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Coffey M, Marino M, Lyren A, Purcell D, Hoffman JM, Brilli R, Muething S, Hyman D, Saysana M, Sharek PJ. Association Between Hospital-Acquired Harm Outcomes and Membership in a National Patient Safety Collaborative. JAMA Pediatr 2022; 176:924-932. [PMID: 35877132 PMCID: PMC9315995 DOI: 10.1001/jamapediatrics.2022.2493] [Citation(s) in RCA: 13] [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] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Hospital engagement networks supported by the US Centers for Medicare & Medicaid Services Partnership for Patients program have reported significant reductions in hospital-acquired harm, but methodological limitations and lack of peer review have led to persistent questions about the effectiveness of this approach. OBJECTIVE To evaluate associations between membership in Children's Hospitals' Solutions for Patient Safety (SPS), a federally funded hospital engagement network, and hospital-acquired harm using standardized definitions and secular trend adjustment. DESIGN, SETTING, AND PARTICIPANTS This prospective hospital cohort study included 99 children's hospitals. Using interrupted time series analyses with staggered intervention introduction, immediate and postimplementation changes in hospital-acquired harm rates were analyzed, with adjustment for preexisting secular trends. Outcomes were further evaluated by early-adopting (n = 73) and late-adopting (n = 26) cohorts. EXPOSURES Hospitals implemented harm prevention bundles, reported outcomes and bundle compliance using standard definitions to the network monthly, participated in learning events, and implemented a broad safety culture program. Hospitals received regular reports on their comparative performance. MAIN OUTCOMES AND MEASURES Outcomes for 8 hospital-acquired conditions were evaluated over 1 year before and 3 years after intervention. RESULTS In total, 99 hospitals met the inclusion criteria and were included in the analysis. A total of 73 were considered part of the early-adopting cohort (joined between 2012-2013) and 26 were considered part of the late-adopting cohort (joined between 2014-2016). A total of 42 hospitals were freestanding children's hospitals, and 57 were children's hospitals within hospital or health systems. The implementation of SPS was associated with an improvement in hospital-acquired condition rates in 3 of the 8 conditions after accounting for secular trends. Membership in the SPS was associated with an immediate reduction in central catheter-associated bloodstream infections (coefficient = -0.152; 95% CI, -0.213 to -0.019) and falls of moderate or greater severity (coefficient = -0.331; 95% CI, -0.594 to -0.069). The implementation of the SPS was associated with a reduction in the monthly rate of adverse drug events (coefficient = -0.021; 95% CI, -0.034 to -0.008) in the post-SPS period. The study team observed larger decreases for the early-adopting cohort compared with the late-adopting cohort. CONCLUSIONS AND RELEVANCE Through the application of rigorous methods (standard definitions and longitudinal time series analysis with adjustment for secular trends), this study provides a more thorough analysis of the association between the Partnership for Patients hospital engagement network model and reductions in hospital-acquired conditions. These findings strengthen previous claims of an association between this model and improvement. However, inconsistent observations across hospital-acquired conditions when adjusted for secular trends suggests that some caution regarding attributing all effects observed to this model is warranted.
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Affiliation(s)
- Maitreya Coffey
- Department of Paediatrics, Temerty Faculty of Medicine, Toronto, Ontario, Canada,The Hospital for Sick Children, Toronto, Ontario, Canada,Children’s Hospitals’ Solutions for Patient Safety, Toronto, Ontario, Canada
| | - Miguel Marino
- Department of Family Medicine, Division of Biostatistics, Oregon Health & Science University, Portland
| | - Anne Lyren
- Children’s Hospitals’ Solutions for Patient Safety, Toronto, Ontario, Canada,Department of Pediatrics and Department of Bioethics, Case Western Reserve University School of Medicine, Cleveland, Ohio,UH Rainbow Babies and Children’s Hospital, Cleveland, Ohio
| | - David Purcell
- Community Research at United Way of Central New Mexico, Albuquerque,James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital, Cincinnati, Ohio
| | - James M. Hoffman
- Office of Quality and Patient Safety, Department of Pharmacy and Pharmaceutical Sciences, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Richard Brilli
- Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio
| | - Stephen Muething
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital, Cincinnati, Ohio
| | - Daniel Hyman
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia,Leonard Davis Institute, University of Pennsylvania, Philadelphia
| | - Michele Saysana
- Riley Hospital for Children, Indiana University Health, Indianapolis,Indiana University School of Medicine, Indianapolis
| | - Paul J. Sharek
- The Center for Quality and Patient Safety, Seattle Children’s Hospital, Seattle, Washington,Division of General Pediatrics and Hospital Medicine, Department of Pediatrics, University of Washington, Seattle
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Paul R, Niedner M, Brilli R, Macias C, Riggs R, Balamuth F, Depinet H, Larsen G, Huskins C, Scott H, Lucasiewicz G, Schaffer M, DeSouza HG, Silver P, Richardson T, Hueschen L, Campbell D, Wathen B, Auletta JJ. Metric Development for the Multicenter Improving Pediatric Sepsis Outcomes (IPSO) Collaborative. Pediatrics 2021; 147:peds.2020-017889. [PMID: 33795482 PMCID: PMC8131032 DOI: 10.1542/peds.2020-017889] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [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: 01/22/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND A 56 US hospital collaborative, Improving Pediatric Sepsis Outcomes, has developed variables, metrics and a data analysis plan to track quality improvement (QI)-based patient outcomes over time. Improving Pediatric Sepsis Outcomes expands on previous pediatric sepsis QI efforts by improving electronic data capture and uniformity across sites. METHODS An expert panel developed metrics and corresponding variables to assess improvements across the care delivery spectrum, including the emergency department, acute care units, hematology and oncology, and the ICU. Outcome, process, and balancing measures were represented. Variables and statistical process control charts were mapped to each metric, elucidating progress over time and informing plan-do-study-act cycles. Electronic health record (EHR) abstraction feasibility was prioritized. Time 0 was defined as time of earliest sepsis recognition (determined electronically), or as a clinically derived time 0 (manually abstracted), identifying earliest physiologic onset of sepsis. RESULTS Twenty-four evidence-based metrics reflected timely and appropriate interventions for a uniformly defined sepsis cohort. Metrics mapped to statistical process control charts with 44 final variables; 40 could be abstracted automatically from multiple EHRs. Variables, including high-risk conditions and bedside huddle time, were challenging to abstract (reported in <80% of encounters). Size or type of hospital, method of data abstraction, and previous QI collaboration participation did not influence hospitals' abilities to contribute data. To date, 90% of data have been submitted, representing 200 007 sepsis episodes. CONCLUSIONS A comprehensive data dictionary was developed for the largest pediatric sepsis QI collaborative, optimizing automation and ensuring sustainable reporting. These approaches can be used in other large-scale sepsis QI projects in which researchers seek to leverage EHR data abstraction.
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Affiliation(s)
- Raina Paul
- Division of Emergency Medicine, Advocate Children's Hospital, Park Ridge, Illinois;
| | - Matthew Niedner
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, School of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Richard Brilli
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio
| | - Charles Macias
- Division of Pediatric Emergency Medicine, Rainbow Babies and Children’s Hospital and Case Western Reserve University, Cleveland, Ohio
| | - Ruth Riggs
- Children’s Hospital Association, Lenexa, Kansas
| | - Frances Balamuth
- Department of Pediatrics, University of Pennsylvania and Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Holly Depinet
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio,Department of Pediatrics, School of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Gitte Larsen
- Pediatric Critical Care, Department of Pediatrics, Primary Children’s Hospital, Salt Lake City, Utah
| | - Charlie Huskins
- Division of Pediatric Infectious Diseases, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - Halden Scott
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado,Section of Pediatric Emergency Medicine, Children’s Hospital Colorado, Aurora, Colorado
| | | | - Melissa Schaffer
- Department of Pediatrics, Upstate Medical University, Syracuse, New York
| | | | - Pete Silver
- Department of Pediatrics, Zucker School of Medicine at Hofstra, Cohen Children’s Medical Center, East Garden City, New York
| | | | - Leslie Hueschen
- Section of Pediatric Emergency Medicine, Department of Pediatrics, University of Missouri-Kansas City and Children’s Mercy Hospital, Kansas City, Missouri
| | | | - Beth Wathen
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado,Section of Pediatric Emergency Medicine, Children’s Hospital Colorado, Aurora, Colorado
| | - Jeffery J. Auletta
- Divisions of Hematology, Oncology, and Blood and Marrow Transplant and Infectious Diseases, Department of Pediatrics, Nationwide Children’s Hospital and College of Medicine, The Ohio State University, Columbus, Ohio
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Larsen GY, Brilli R, Macias CG, Niedner M, Auletta JJ, Balamuth F, Campbell D, Depinet H, Frizzola M, Hueschen L, Lowerre T, Mack E, Paul R, Razzaqi F, Schafer M, Scott HF, Silver P, Wathen B, Lukasiewicz G, Stuart J, Riggs R, Richardson T, Ward L, Huskins WC. Development of a Quality Improvement Learning Collaborative to Improve Pediatric Sepsis Outcomes. Pediatrics 2021; 147:e20201434. [PMID: 33328337 PMCID: PMC7874527 DOI: 10.1542/peds.2020-1434] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [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] [Accepted: 10/20/2020] [Indexed: 12/29/2022] Open
Abstract
Pediatric sepsis is a major public health problem. Published treatment guidelines and several initiatives have increased adherence with guideline recommendations and have improved patient outcomes, but the gains are modest, and persistent gaps remain. The Children's Hospital Association Improving Pediatric Sepsis Outcomes (IPSO) collaborative seeks to improve sepsis outcomes in pediatric emergency departments, ICUs, general care units, and hematology/oncology units. We developed a multicenter quality improvement learning collaborative of US children's hospitals. We reviewed treatment guidelines and literature through 2 in-person meetings and multiple conference calls. We defined and analyzed baseline sepsis-attributable mortality and hospital-onset sepsis and developed a key driver diagram (KDD) on the basis of treatment guidelines, available evidence, and expert opinion. Fifty-six hospital-based teams are participating in IPSO; 100% of teams are engaged in educational and information-sharing activities. A baseline, sepsis-attributable mortality of 3.1% was determined, and the incidence of hospital-onset sepsis was 1.3 cases per 1000 hospital admissions. A KDD was developed with the aim of reducing both the sepsis-attributable mortality and the incidence of hospital-onset sepsis in children by 25% from baseline by December 2020. To accomplish these aims, the KDD primary drivers focus on improving the following: treatment of infection; recognition, diagnosis, and treatment of sepsis; de-escalation of unnecessary care; engagement of patients and families; and methods to optimize performance. IPSO aims to improve sepsis outcomes through collaborative learning and reliable implementation of evidence-based interventions.
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Affiliation(s)
- Gitte Y Larsen
- Pediatric Critical Care, Primary Children's Hospital and Department of Pediatrics, University of Utah, Salt Lake City, Utah;
| | | | - Charles G Macias
- Pediatric Emergency Medicine, Rainbow Babies and Children's Hospital and Case Western Reserve University, Cleveland, Ohio
| | - Matthew Niedner
- Pediatric Critical Care, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Jeffery J Auletta
- Hematology, Oncology, and Blood and Marrow Transplant, and Infectious Diseases, Nationwide Children's Hospital, Columbus, Ohio
| | - Fran Balamuth
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Deborah Campbell
- Infection Prevention and Quality, Kentucky Hospital Association, Louisville, Kentucky
| | - Holly Depinet
- Pediatric Emergency Medicine, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Meg Frizzola
- Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children and Thomas Jefferson University, Wilmington, Delaware
| | - Leslie Hueschen
- Pediatric Emergency Medicine, Children's Mercy Hospital and University of Missouri, Kansas City, Missouri
| | - Tracy Lowerre
- Acute Care Pediatric Unit, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia
| | - Elizabeth Mack
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Raina Paul
- Pediatric Emergency Medicine, Advocate Children's Hospital, Park Ridge, Illinois
| | - Faisal Razzaqi
- Pediatric Hematology and Oncology, Valley Children's Hospital, Madera, California
| | - Melissa Schafer
- Department of Pediatrics, State University of New York Upstate Medical University and Upstate Golisano Children's Hospital, Syracuse, New York
| | - Halden F Scott
- Pediatric Emergency Medicine, Children's Hospital Colorado and Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Pete Silver
- Cohen Children's Medical Center of New York and Department of Pediatrics, Zucker School of Medicine at Hofstra/Northwell, Queens, New York
| | - Beth Wathen
- Pediatric ICU, Children's Hospital Colorado, Aurora, Colorado
| | - Gloria Lukasiewicz
- Children's Hospital Association, Lenexa, Kansas
- Children's Hospital Association, Washington, District of Columbia; and
| | - Jayne Stuart
- Children's Hospital Association, Lenexa, Kansas
- Children's Hospital Association, Washington, District of Columbia; and
| | - Ruth Riggs
- Children's Hospital Association, Lenexa, Kansas
- Children's Hospital Association, Washington, District of Columbia; and
| | - Troy Richardson
- Children's Hospital Association, Lenexa, Kansas
- Children's Hospital Association, Washington, District of Columbia; and
| | - Lowrie Ward
- Children's Hospital Association, Lenexa, Kansas
- Children's Hospital Association, Washington, District of Columbia; and
| | - W Charles Huskins
- Pediatric Infectious Diseases, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
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Merandi J, Vannatta K, Davis JT, McClead RE, Brilli R, Bartman T. Safety II Behavior in a Pediatric Intensive Care Unit. Pediatrics 2018; 141:peds.2018-0018. [PMID: 29739825 DOI: 10.1542/peds.2018-0018] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [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: 03/27/2018] [Indexed: 11/24/2022] Open
Abstract
UNLABELLED : media-1vid110.1542/5763093009001PEDS-VA_2018-0018Video Abstract BACKGROUND AND OBJECTIVE: Safety I error elimination concepts are focused on retrospectively investigating what went wrong and redesigning system processes and individual behaviors to prevent similar future occurrences. The Safety II approach recognizes complex systems and unpredictable circumstances, mandating flexibility and resilience within systems and among individuals to avoid errors. We hypothesized that in our high-complexity and high-risk PICU, Safety II concepts contribute to its remarkably low adverse drug event rate. Our goal was to identify how this microsystem enacts Safety II. METHODS We conducted multidisciplinary focus group sessions with PICU members using nonleading, open-ended questions to elicit free-form conversation regarding how safety occurs in their unit. Qualitatively analyzing transcripts identified system characteristics and behaviors potentially contributing to low adverse drug event rates in PICU. Researchers skilled in qualitative methodologies coded transcripts to identify key domains and common themes. RESULTS Four domains were identified: (1) individual characteristics, (2) relationships and interactions, (3) structural and environmental characteristics, and (4) innovation approaches. The themes identified in the first 3 domains are typically associated with Safety I and adapted for Safety II. Themes in the last domain (innovation approaches) were specific to Safety II, which were layered on Safety I to improve results under unusual situations. CONCLUSIONS Safety II behavior in this unit was based on strong Safety I behaviors adapted to the Safety II environment plus innovation behaviors specific to Safety II situations. We believe these behaviors can be taught and learned. We intend to spread these concepts throughout the organization.
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Affiliation(s)
| | - Kathryn Vannatta
- Nationwide Children's Hospital, Columbus, Ohio; and.,Departments of Pediatrics.,Psychology, and
| | - J Terrance Davis
- Nationwide Children's Hospital, Columbus, Ohio; and .,Surgery, College of Medicine, The Ohio State University, Columbus, Ohio
| | - Richard E McClead
- Nationwide Children's Hospital, Columbus, Ohio; and.,Departments of Pediatrics
| | - Richard Brilli
- Nationwide Children's Hospital, Columbus, Ohio; and.,Departments of Pediatrics
| | - Thomas Bartman
- Nationwide Children's Hospital, Columbus, Ohio; and.,Departments of Pediatrics
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5
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Lyren A, Brilli R, Bird M, Lashutka N, Muething S. Ohio Children's Hospitals' Solutions for Patient Safety: A Framework for Pediatric Patient Safety Improvement. J Healthc Qual 2018; 38:213-22. [PMID: 26042749 DOI: 10.1111/jhq.12058] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Building upon their previous collective success and a clinical imperative for rapid improvement, the eight tertiary pediatric referral centers in Ohio sought to dramatically decrease the most serious types of harm that occur to hospitalized children by collectively employing high reliability methods focused on safety culture. METHODS With the support of the hospitals' executives, the Ohio collaborative obtained legal protection and built will by clearly identifying types and frequency of harm events that occur in each participating hospital and across the state. The improvement efforts were divided among task forces designed to incorporate the principles of high reliability organizations into the work of all employees, focusing primarily on the consistent application of error prevention behaviors. RESULTS Between January 2010 and October 2012, the serious safety event rate among the participating hospitals decreased by 55%, equating to 70 fewer children per year who experienced this most severe type of event in the participating hospitals. Between January 2011 and October 2012, all events of serious harm were decreased by 40%, meaning 18 fewer children per month suffered serious harm. CONCLUSION Rapid and significant improvement in pediatric patient safety is possible through collaboration of children's hospitals dedicated to the application of high reliability principles and the noncompetitive sharing of outcomes and best practices.
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6
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Cromeens B, Brilli R, Kurtovic K, Kenney B, Nwomeh B, Besner GE. Implementation of a pediatric surgical quality improvement (QI)-driven M&M conference. J Pediatr Surg 2016; 51:137-42. [PMID: 26581322 DOI: 10.1016/j.jpedsurg.2015.10.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [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: 10/01/2015] [Accepted: 10/09/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND/PURPOSE The M&M conference at Nationwide Children's Hospital (NCH) categorized failures as technical error or patient disease, but failure modes were never captured, action items rarely assigned, and follow-up rarely completed. In 2013 a QI-driven M&M conference was developed, supporting implementation of directed actions to improve quality of care. METHODS A classification was developed to enhance analysis of complications. Each complication was analyzed for identification of failure modes with subcategorization of root cause, a level of preventability assigned, and action items designated. Failure determinations from 11/2013-10/2014 were reviewed to evaluate the distribution of failure modes and action items. RESULTS Two-hundred thirty-seven patients with complications were reviewed. One-hundred thirty patients had complications attributed to patient disease with no individual or system failure identified, whereas 107 patients had identifiable failures. Eighty-five patients had one failure identified, and 22 patients had multiple failures identified. Of the 142 failures identified in 107 patients, 112 (78.9%) were individual failures, and 30 (21.1%) were system failures. One-hundred forty-seven action items were implemented including education initiatives, establishing criteria for interdisciplinary consultation, resolving equipment inadequacies, removing high risk medications from formulary, restructuring physician handoffs, and individual practitioner counseling/training. CONCLUSIONS Development of a QI-driven M&M conference allowed us to categorize complications beyond surgical or patient disease categories, ensuring added focus on system solutions and a reliable accountability structure to ensure implementation of assigned interventions intended to address failures. This may lead to improvement in the processes of patient care.
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Affiliation(s)
- Barrett Cromeens
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Richard Brilli
- Department of Quality Improvement Services, Nationwide Children's Hospital, Columbus, OH, USA
| | - Kelli Kurtovic
- Department of Quality Improvement Services, Nationwide Children's Hospital, Columbus, OH, USA
| | - Brian Kenney
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Benedict Nwomeh
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Gail E Besner
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA.
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Lodwick DL, Cooper JN, Kelleher KJ, Brilli R, Minneci PC, Deans KJ. Variation in Utilization of Computed Tomography Imaging at Tertiary Pediatric Hospitals. Pediatrics 2015; 136:e1212-9. [PMID: 26504136 DOI: 10.1542/peds.2015-1671] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [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] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Recent efforts have focused on reducing computed tomography (CT) imaging in children. Although published reports show variability in CT scanning for specific indications, an assessment of the effects of institutional factors (case-mix or hospital volume) on the rate of CT scanning for any indication is necessary to better understand variability across pediatric hospitals. METHODS Data from 2009 to 2013 on inpatient, observation, and emergency department (ED) encounters were extracted from the Pediatric Health Information System. Chronological trends and institutional variability in CT scan rates were examined by using negative binomial regression models. Case-mix was adjusted by using All Patient Refined Diagnosis Related Groups and severity level. RESULTS Thirty hospitals were included. There were 12 531 184 patient encounters and 701 644 CT scans resulting in a mean of 56 scans per 1000 encounters (range: 26-108). The most common scan types were head (60.1%) and abdomen/pelvis (19.9%). There was an inverse relationship between the CT scan rate and hospital volume (P = .002) and a direct relationship between the CT scan rates for inpatient/observation and ED encounters (P < .001). The rate of CT imaging decreased from 69.2 to 49.6 scans per 1000 encounters during the study period (P < .001). CONCLUSIONS The overall use of CT imaging is decreasing, and significant variability remains in CT use across tertiary pediatric hospitals. Hospital volume and institutional-level practices account for a significant portion of the variability. This finding suggests an opportunity for standardization through multi-institutional quality improvement projects to reduce CT imaging.
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Affiliation(s)
- Daniel L Lodwick
- The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Jennifer N Cooper
- The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Kelly J Kelleher
- The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Richard Brilli
- The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Peter C Minneci
- The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Katherine J Deans
- The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
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Brady PW, Zix J, Brilli R, Wheeler DS, Griffith K, Giaccone MJ, Dressman K, Kotagal U, Muething S, Tegtmeyer K. Developing and evaluating the success of a family activated medical emergency team: a quality improvement report. BMJ Qual Saf 2014; 24:203-11. [PMID: 25516987 DOI: 10.1136/bmjqs-2014-003001] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Family-activated medical emergency teams (MET) have the potential to improve the timely recognition of clinical deterioration and reduce preventable adverse events. Adoption of family-activated METs is hindered by concerns that the calls may substantially increase MET workload. We aimed to develop a reliable process for family activated METs and to evaluate its effect on MET call rate and subsequent transfer to the intensive care unit (ICU). METHODS The setting was our free-standing children's hospital. We partnered with families to develop and test an educational intervention for clinicians and families, an informational poster in each patient room and a redesigned process with hospital operators who handle MET calls. We tracked our primary outcome of count of family-activated MET calls on a statistical process control chart. Additionally, we determined the association between family-activated versus clinician-activated MET and transfer to the ICU. Finally, we compared the reason for MET activation between family calls and a 2:1 matched sample of clinician calls. RESULTS Over our 6-year study period, we had a total of 83 family-activated MET calls. Families made an average of 1.2 calls per month, which represented 2.9% of all MET calls. Children with family-activated METs were transferred to the ICU less commonly than those with clinician MET calls (24% vs 60%, p<0.001). Families, like clinicians, most commonly called MET for concerns of clinical deterioration. Families also identified lack of response from clinicians and a dismissive interaction between team and family as reasons. CONCLUSIONS Family MET activations were uncommon and not a burden on responders. These calls recognised clinical deterioration and communication failures. Family activated METs should be tested and implemented in hospitals that care for children.
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Affiliation(s)
- Patrick W Brady
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA Department of Pediatrics, James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Julie Zix
- Department of Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Richard Brilli
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Derek S Wheeler
- Department of Pediatrics, James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Kristie Griffith
- University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Mary Jo Giaccone
- Department of Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Kathy Dressman
- Department of Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Uma Kotagal
- Department of Pediatrics, James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Stephen Muething
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA Department of Pediatrics, James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Ken Tegtmeyer
- Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Gasperino J, Brilli R, Kvetan V. Teaching intensive care unit administration during critical care medicine training programs. J Crit Care 2008; 23:251-2. [PMID: 18538219 DOI: 10.1016/j.jcrc.2008.01.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2007] [Revised: 12/27/2007] [Accepted: 01/28/2008] [Indexed: 10/22/2022]
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10
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Hutchinson N, Sorter M, Connelly B, Myers S, Brilli R. Reduction in Ventilator-Associated Pneumonia Following Application of a Pediatric Ventilatory Care Bundle. Am J Infect Control 2006. [DOI: 10.1016/j.ajic.2006.05.101] [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: 11/25/2022]
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Abstract
Bacterial tracheitis is characterized by acute upper-airway obstruction and purulent secretions within the trachea. Historically, affected children were young, stridorous, and toxic-appearing and required tracheal intubation, and morbidity and mortality were significant. Staphylococcus aureus was the most common organism involved. During the 14 months of this retrospective study, 46 children were admitted to the pediatric intensive care unit because of this diagnosis, and their medical records were reviewed. Compared with those in previous reports, children in this study were older (mean +/- standard error of the mean [SEM], 69.3 +/- 6.8 months) and less toxic. Only 26 (57%) of 46 patients required tracheal intubation. Intubated patients were significantly younger than nonintubated patients (mean +/- SEM, 46.9 +/- 6.5 vs. 98.9 +/- 9.9 months). Moraxella catarrhalis was identified in 12 (27%) of 45 bacterial respiratory cultures, while influenza A virus was recovered from 18 (72%) of 25 viral respiratory cultures. There were no major complications. This series represents the largest reported cohort of patients with this condition and suggests an epidemiological change toward a less morbid condition.
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Affiliation(s)
- T Bernstein
- Division of Critical Care Medicine, Children's Hospital Medical Center, Cincinnati, Ohio 45229, USA
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Abstract
OBJECTIVES To test the hypothesis that children diagnosed with septic shock have increased plasma thrombomodulin values as a manifestation of microcirculatory dysfunction and endothelial injury; to determine whether plasma thrombomodulin concentrations are associated with the extent of multiple organ system failure and mortality. DESIGN Prospective, cohort study. SETTING Pediatric intensive care unit. PATIENTS Twenty-two children with septic shock and ten, healthy, control children. INTERVENTIONS Blood samples were obtained for plasma thrombomodulin determinations every 6 hrs for 72 hrs in septic shock patients and once in healthy control patients. MEASUREMENTS AND MAIN RESULTS Thirty-two children (22 septic shock, and 10 healthy controls) were enrolled in the study. Thrombomodulin concentrations were determined by an enzyme-linked immunosorbent assay. Septic shock nonsurvivors had significantly greater mean thrombomodulin concentrations (10.6 +/- 2.2 ng/mL) than septic shock survivors (5.5 +/- 0.6 ng/mL) (p < .05) and healthy control patients (3.4 +/- 0.2 ng/mL) (p < .01). Mean thrombomodulin values increased as the number of organ system failures increased. CONCLUSIONS Pediatric survivors and nonsurvivors of septic shock have circulating thrombomodulin concentrations 1.5 and 3 times greater than healthy control patients. These findings likely represent sepsis-induced endothelial injury. Patients with multiple organ system failure have circulating thrombomodulin concentrations which are associated with the extent of organ dysfunction. We speculate that measurement of plasma thrombomodulin concentrations in septic shock may be a useful indicator of the severity of endothelial damage and the development of multiple organ system failure.
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Affiliation(s)
- B Krafte-Jacobs
- Division of Critical Care Medicine, Children's Hospital Medical Center, Cincinnati, OH 45229, USA
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Krafte-Jacobs B, Brilli R, Szabó C, Denenberg A, Moore L, Salzman AL. Circulating methemoglobin and nitrite/nitrate concentrations as indicators of nitric oxide overproduction in critically ill children with septic shock. Crit Care Med 1997; 25:1588-93. [PMID: 9295837 DOI: 10.1097/00003246-199709000-00030] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.7] [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: 02/05/2023]
Abstract
OBJECTIVES To examine the relationship between circulating methemoglobin and nitrite/nitrate concentrations and to compare these markers of nitric oxide overproduction with clinical variables in children diagnosed with septic shock. DESIGN Prospective, controlled, clinical study. SETTING Pediatric intensive care unit and outpatient clinic in a children's hospital. PATIENTS Twenty-two children diagnosed with septic shock and ten age-matched healthy control patients. INTERVENTIONS Patients diagnosed with septic shock had blood specimens taken on study entry and every 6 hrs for 72 hrs for methemoglobin and nitrite/nitrate determinations. Single blood specimens were obtained from controls. MEASUREMENTS AND MAIN RESULTS Circulating methemoglobin and nitrite/nitrate concentrations were significantly higher in children diagnosed with septic shock in comparison with healthy control children (p = .01 and .05, respectively). Peak nitrite/nitrate concentrations correlated with serum creatinine (r2 = .19; p = .04) and were inversely correlated with arterial pH (r2 = .28; p = .01) and urine output (r2 = .21; p = .03) when analyzed by log-linear regression. There were no significant relationships between methemoglobin and nitrite/nitrate or between methemoglobin and any other clinical variable. CONCLUSIONS Circulating methemoglobin and nitrite/nitrate concentrations are increased in children diagnosed with septic shock. Plasma nitrite/nitrate values correlate with selected clinical variables in these children. Circulating methemoglobin measurements are not superior to plasma nitrite/nitrate concentrations as an indicator of endogenous overproduction of nitric oxide in children diagnosed with septic shock. A need remains to develop markers of endogenous nitric oxide activity that have greater accuracy and reliability.
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Affiliation(s)
- B Krafte-Jacobs
- Division of Critical Care Medicine, Children's Hospital Medical Center, Cincinnati, OH 45229, USA
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Krafte-Jacobs B, Persinger M, Carver J, Moore L, Brilli R. Rapid placement of transpyloric feeding tubes: a comparison of pH-assisted and standard insertion techniques in children. Pediatrics 1996; 98:242-8. [PMID: 8692625] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVE To compare transpyloric feeding tube placement using a pH-assisted placement technique versus a standard placement technique in pediatric patients requiring enteral nutrition. METHODS Critically ill children younger than 4 years were prospectively and randomly assigned to either a pH-assisted or a standard feeding tube placement group. Identical pH-assisted feeding tubes were used in both groups; however, feeding tubes in the standard group were not attached to a portable pH meter. Successful transpyloric placement was confirmed by radiography before beginning feedings. If placement was not successful, a second placement attempt was made after metoclopramide administration. Information regarding tube placement success, number of radiographs, time to initiation of feedings, and daily caloric intake was collected. A cost comparison between the two groups was performed. RESULTS Thirty-four patients were enrolled in the pH-assisted group, and 34 were enrolled in the standard feeding tube group. Ninety-seven percent of patients in the pH-assisted group had successful placement after the first attempt, compared with 53% of patients in the standard group. The average time to successful placement of pH-assisted feeding tubes was 6 minutes. All patients in the pH-assisted group had successful placement after the second attempt, compared with 78% of patients in the standard group. A pH of greater than 5.6 accurately predicted transpyloric placement in 97% (33 of 34) of individuals in the pH-assisted group. Children in the pH-assisted group required significantly fewer radiographs than those in the standard group. Hospital costs were $114 per patient in the pH-assisted group and $135 per patient in the standard group. CONCLUSIONS Our findings indicate that bedside transpyloric placement of pH-assisted feeding tubes can be accomplished rapidly and with a high success rate. This method is associated with decreased radiation exposure and economic savings when compared with a standard placement technique.
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Affiliation(s)
- B Krafte-Jacobs
- Division of Critical Care Medicine, Children's Hospital Medical Center, Cincinnati, OH 45229, USA
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Carroll WL, Balistreri WF, Brilli R, Parish RA, Greenfield DJ. Spectrum of Salmonella-associated arthritis. Pediatrics 1981; 68:717-20. [PMID: 7031584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Arthritis is an uncommon extraintestinal manifestation of Salmonella infection. Three patients with Salmonella-associated arthritis with varying manifestations were seen at Children's Hospital Medical Center in an 11-month period: (1) a 12-year-old girl developed suppurative arthritis due to Salmonella typhimurium that required surgical drainage and prolonged parenteral antibiotic therapy; (2) a 12-year-old girl had migratory polyarthritis following gastrointestinal infection with S typhimurium; the acute synovitis subsided after a six-month period following anti-inflammatory medications; (3) a 14-year-old girl developed conjunctivitis, urethritis, and polyarthritis (Reiter's syndrome) in association with Salmonella gastroenteritis. These patients illustrate the distinct types of arthritis associated with Salmonella gastroenteritis. These patients illustrate that distinct types of arthritis associated with Salmonella, and the association of this organism with both suppurative joint disease and reactive arthritis is reemphasized.
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