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Uthappa DM, Ellett TL, Nyarko T, Rikhi A, Parente VM, Ming DY, White MJ. Interfacility Transfer Outcomes Among Children With Complex Chronic Conditions: Associations Between Patient-Level and Hospital-Level Factors and Transfer Outcomes. Hosp Pediatr 2024; 14:e91-e97. [PMID: 38213279 PMCID: PMC10823183 DOI: 10.1542/hpeds.2023-007425] [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: 01/13/2024]
Abstract
OBJECTIVES Determine patient- and referring hospital-level predictors of transfer outcomes among children with 1 or more complex chronic conditions (CCCs) transferred to a large academic medical center. METHODS We conducted a retrospective chart review of 2063 pediatric inpatient admissions from 2017 to 2019 with at least 1 CCC defined by International Classification of Diseases, Tenth Revision codes. Charts were excluded if patients were admitted via any route other than transfer from a referring hospital's emergency department or inpatient ward. Patient-level factors were race/ethnicity, payer, and area median income. Hospital-level factors included the clinician type initiating transfer and whether the referring-hospital had an inpatient pediatric ward. Transfer outcomes were rapid response within 24 hours of admission, Pediatric Early Warning Score at admission, and hours to arrival. Regression analyses adjusted for age were used to determine association between patient- and hospital-level predictors with transfer outcomes. RESULTS There were no significant associations between patient-level predictors and transfer outcomes. Hospital-level adjusted analyses indicated that transfers from hospitals without inpatient pediatrics wards had lower odds of ICU admission during hospitalization (odds ratio, 0.46; 95% confidence interval, 0.22-0.97) and shorter transfer times (β-coefficient, -2.54; 95% CI, -3.60 to -1.49) versus transfers from hospitals with inpatient pediatrics wards. There were no significant associations between clinician type and transfer outcomes. CONCLUSIONS For pediatric patients with CCCs, patient-level predictors were not associated with clinical outcomes. Transfers from hospitals without inpatient pediatric wards were less likely to require ICU admission and had shorter interfacility transfer times compared with those from hospitals with inpatient pediatrics wards.
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Affiliation(s)
| | | | | | - Aruna Rikhi
- Duke Clinical Research Institute, Durham, North Carolina
| | | | - David Y. Ming
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, North Carolina
- Division of Hospital Medicine, Department of Pediatrics
- Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, Durham, North Carolina
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Abu-Rish Blakeney E, Baird J, Beaird G, Khan A, Parente VM, O’Brien KD, Zierler BK, O’Leary KJ, Weiner BJ. How and why might interprofessional patient- and family-centered rounds improve outcomes among healthcare teams and hospitalized patients? A conceptual framework informed by scoping and narrative literature review methods. Front Med (Lausanne) 2023; 10:1275480. [PMID: 37886364 PMCID: PMC10598853 DOI: 10.3389/fmed.2023.1275480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 09/08/2023] [Indexed: 10/28/2023] Open
Abstract
Poor communication within healthcare contributes to inefficiencies, medical errors, conflict, and other adverse outcomes. A promising model to improve outcomes resulting from poor communication in the inpatient hospital setting is Interprofessional Patient- and Family-Centered rounds (IPFCR). IPFCR brings two or more health professions together with hospitalized patients and families as part of a consistent, team-based routine to share information and collaboratively arrive at a daily plan of care. A growing body of literature focuses on implementation and outcomes of IPFCR to improve healthcare quality and team and patient outcomes. Most studies report positive changes following IPFCR implementation. However, conceptual frameworks and theoretical models are lacking in the IPFCR literature and represent a major gap that needs to be addressed to move this field forward. The purpose of this two-part review is to propose a conceptual framework of how IPFCR works. The goal is to articulate a framework that can be tested in subsequent research studies. Published IPFCR literature and relevant theories and frameworks were examined and synthesized to explore how IPFCR works, to situate IPFCR in relation to existing models and frameworks, and to postulate core components and underlying causal mechanisms. A preliminary, context-specific, conceptual framework is proposed illustrating interrelationships between four core components of IPFCR (interprofessional approach, intentional patient and family engagement, rounding structure, shared development of a daily care plan), improvements in communication, and better outcomes.
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Affiliation(s)
- Erin Abu-Rish Blakeney
- Department of Biobehavioral Nursing and Health Informatics, School of Nursing, University of Washington, Seattle, WA, United States
| | - Jennifer Baird
- Children's Hospital Los Angeles, Los Angeles, CA, United States
| | - Genevieve Beaird
- School of Nursing, Virginia Commonwealth University, Richmond, VA, United States
| | - Alisa Khan
- Department of Pediatrics, Harvard Medical School, Boston, MA, United States
- Boston Children's Hospital, Boston, MA, United States
| | | | - Kevin D. O’Brien
- Department of Cardiology, School of Medicine, University of Washington, Seattle, WA, United States
| | - Brenda K. Zierler
- Department of Biobehavioral Nursing and Health Informatics, School of Nursing, University of Washington, Seattle, WA, United States
| | - Kevin J. O’Leary
- Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Bryan J. Weiner
- Department of Global Health, School of Public Health, University of Washington, Seattle, WA, United States
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Schaps D, Dever R, Parente VM, Anderson DJ, Kalu IC. Methicillin-resistant Staphylococcus aureus nasal colonization in children with cerebral palsy. Infect Control Hosp Epidemiol 2023; 44:985-987. [PMID: 35732616 PMCID: PMC10461431 DOI: 10.1017/ice.2022.149] [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: 11/07/2022]
Abstract
A retrospective cohort of children admitted to the pediatric intensive care unit (PICU) with cerebral palsy was matched 1:3 by age and admission year to determine odds of methicillin-resistant Staphylococcus aureus (MRSA) nasal colonization. Adjusted odds of MRSA nasal colonization at PICU admission were 2.6-fold higher among children with cerebral palsy.
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Affiliation(s)
- Diego Schaps
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Reilly Dever
- Duke University School of Medicine, Durham, North Carolina
| | | | - Deverick J. Anderson
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University School of Medicine, Durham, North Carolina
| | - Ibukunoluwa C. Kalu
- Division of Pediatric Infectious Disease, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
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Parente VM, Nagy G, Pollak KI. Patient- and Family-Centered Hospital Care-The Need for Structural Humility. JAMA Pediatr 2023; 177:553-554. [PMID: 37010842 PMCID: PMC10947776 DOI: 10.1001/jamapediatrics.2023.0269] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2023]
Abstract
This Viewpoint discusses communication between clinicians and caregivers of racial and ethnic minoritized groups.
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Affiliation(s)
- Victoria M Parente
- Division of Hospital Medicine, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - Gabriela Nagy
- Department of Psychology, University of Wisconsin-Milwaukee, Milwaukee
| | - Kathryn I Pollak
- Department of Population Health Sciences, Duke University, Durham, North Carolina
- Cancer Prevention and Control, Duke Cancer Institute, Durham, North Carolina
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Lin K, White MJ, Holliday KM, Parnell LS, Parente VM. Protective and Unequal? Caregiver Presence During Pediatric Hospitalizations. Hosp Pediatr 2023; 13:e1-e5. [PMID: 36482776 PMCID: PMC9881426 DOI: 10.1542/hpeds.2022-006590] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Describe the association between caregiver presence on hospital day 1 and outcomes related to readmissions, pain, and adverse events (AE). METHODS Caregiver presence during general pediatrics rounds on hospital day 1 was recorded, along with demographic data and clinical outcomes via chart review. AE data were obtained from the safety reporting system. χ2 tests compared demographic characteristics between present and absent caregivers. Background elimination determined significant predictors of caregiver presence and their association with outcomes. RESULTS A total of 324 families were assessed (34.9% non-Hispanic white, 41.4% Black, 17% Hispanic or Latinx, 6.8% other race or ethnicity). Adolescents (aged ≥14 years) had increased odds of not having a caregiver present compared with 6- to 13-year-olds (36.2% vs 10%; adjusted odds ratio [aOR] 5.11 [95% confidence interval (CI) 1.88-13.87]). Publicly insured children were more likely to not have a caregiver present versus privately insured children (25.1% vs 12.4%; aOR 2.38 [95% CI 1.19-4.73]). Compared with having a caregiver present, children without caregivers were more likely to be readmitted at 7 days (aOR 3.6 [95% CI 1.0-12.2]), receive opiates for moderate/severe pain control (aOR 11.5 [95% CI 1.7-75.7]), and have an AE reported (aOR 4.0 [95% CI 1.0-15.1]). CONCLUSIONS Adolescents and children with public insurance were less likely to have a caregiver present. Not having a caregiver present was associated with increased readmission, opiate prescription, and AE reporting. Further research is needed to delineate whether associations with clinical outcomes reflect differences in quality of care and decrease barriers to caregiver presence.
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Affiliation(s)
- Karen Lin
- Department of Graduate Medical Education, Duke University Health System, Durham, North Carolina
| | - Michelle J. White
- Department of Pediatrics, Duke University Health System, Durham, North Carolina
| | - Katelyn M. Holliday
- Family Medicine and Community Health at Duke University Health System, Durham, North Carolina
| | - Lisa S. Parnell
- Department of Pediatrics, Duke University Health System, Durham, North Carolina
| | - Victoria M. Parente
- Department of Pediatrics, Duke University Health System, Durham, North Carolina
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Parente VM, Reid HW, Robles J, Johnson KS, Svetkey LP, Sanders LL, Olsen MK, Pollak KI. Racial and Ethnic Differences in Communication Quality During Family-Centered Rounds. Pediatrics 2022; 150:e2021055227. [PMID: 36345704 PMCID: PMC9724176 DOI: 10.1542/peds.2021-055227] [Citation(s) in RCA: 4] [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] [Accepted: 08/29/2022] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES To evaluate racial and ethnic differences in communication quality during family centered rounds. METHODS We conducted an observational study of family-centered rounds on hospital day 1. All enrolled caregivers completed a survey following rounds and a subset consented to audio record their encounter with the medical team. We applied a priori defined codes to transcriptions of the audio-recorded encounters to assess objective communication quality, including medical team behaviors, caregiver participatory behaviors, and global communication scores. The surveys were designed to measure subjective communication quality. Incident Rate Ratios (IRR) were calculated with regression models to compare the relative mean number of behaviors per encounter time minute by race and ethnicity. RESULTS Overall, 202 of 341 eligible caregivers completed the survey, and 59 had accompanying audio- recorded rounds. We found racial and ethnic differences in participatory behaviors: English-speaking Latinx (IRR 0.5; 95% confidence interval [CI] 0.3-0.8) Black (IRR 0.6; 95% CI 0.4-0.8), and Spanish-speaking Latinx caregivers (IRR 0.3; 95% CI 0.2-0.5) participated less than white caregivers. Coder-rated global ratings of medical team respect and partnership were lower for Black and Spanish-speaking Latinx caregivers than white caregivers (respect 3.1 and 2.9 vs 3.6, P values .03 and .04, respectively: partnership 2.4 and 2.3 vs 3.1, P values .03 and .04 respectively). In surveys, Spanish-speaking caregivers reported lower subjective communication quality in several domains. CONCLUSIONS In this study, Black and Latinx caregivers were treated with less partnership and respect than white caregivers.
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Affiliation(s)
| | - Hadley W. Reid
- Duke University School of Medicine, Durham, North Carolina
| | - Joanna Robles
- Hematology/Oncology, Department of Pediatrics
- Cancer Prevention and Control, Duke Cancer Institute, Durham, North Carolina
| | - Kimberly S. Johnson
- Division of Geriatrics, Department of Medicine
- Center for Aging and Human Development
- Geriatrics Research Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | | | | | - Maren K. Olsen
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina
- Departments of Biostatistics and Bioinformatics
| | - Kathryn I. Pollak
- Population Health Sciences, Duke University, Durham, North Carolina
- Cancer Prevention and Control, Duke Cancer Institute, Durham, North Carolina
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Parente VM, Khan A, Robles JM. Belonging on Rounds: Translating Research Into Inclusive Practices for Families With Limited English Proficiency to Promote Safety, Equity, and Quality. Hosp Pediatr 2022; 12:e171-e173. [PMID: 35411380 DOI: 10.1542/hpeds.2022-006581] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Victoria M Parente
- aDivisions of Hospital Medicine.,bDuke University School of Medicine, Durham, North Carolina
| | - Alisa Khan
- cDivision of General Pediatrics, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts.,dHarvard Medical School, Boston, Massachusetts
| | - Joanna M Robles
- eHematology/Oncology, Department of Pediatrics, Duke Children's Hospital, Durham, North Carolina.,bDuke University School of Medicine, Durham, North Carolina.,fDuke Cancer Institute, Durham, North Carolina
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Wildman-Tobriner B, Parente VM, Maxfield CM. Pediatric providers and radiology examinations: knowledge and comfort levels regarding ionizing radiation and potential complications of imaging. Pediatr Radiol 2017; 47:1730-1736. [PMID: 28852812 DOI: 10.1007/s00247-017-3969-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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: 05/04/2017] [Revised: 07/12/2017] [Accepted: 08/16/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Pediatric providers should understand the basic risks of the diagnostic imaging tests they order and comfortably discuss those risks with parents. Appreciating providers' level of understanding is important to guide discussions and enhance relationships between radiologists and pediatric referrers. OBJECTIVE To assess pediatric provider knowledge of diagnostic imaging modalities that use ionizing radiation and to understand provider concerns about risks of imaging. MATERIALS AND METHODS A 6-question survey was sent via email to 390 pediatric providers (faculty, trainees and midlevel providers) from a single academic institution. A knowledge-based question asked providers to identify which radiology modalities use ionizing radiation. Subjective questions asked providers about discussions with parents, consultations with radiologists, and complications of imaging studies. RESULTS One hundred sixty-nine pediatric providers (43.3% response rate) completed the survey. Greater than 90% of responding providers correctly identified computed tomography (CT), fluoroscopy and radiography as modalities that use ionizing radiation, and ultrasound and magnetic resonance imaging (MRI) as modalities that do not. Fewer (66.9% correct, P<0.001) knew that nuclear medicine utilizes ionizing radiation. A majority of providers (82.2%) believed that discussions with radiologists regarding ionizing radiation were helpful, but 39.6% said they rarely had time to do so. Providers were more concerned with complications of sedation and cost than they were with radiation-induced cancer, renal failure or anaphylaxis. CONCLUSION Providers at our academic referral center have a high level of basic knowledge regarding modalities that use ionizing radiation, but they are less aware of ionizing radiation use in nuclear medicine studies. They find discussions with radiologists helpful and are concerned about complications of sedation and cost.
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Affiliation(s)
| | | | - Charles M Maxfield
- Department of Radiology, Duke University Hospital, 2301 Erwin Road, Durham, NC, 27710, USA
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Bartlett KW, Parente VM, Morales V, Hauser J, McLean HS. Improving the Efficiency of Care for Pediatric Patients Hospitalized With Asthma. Hosp Pediatr 2016; 7:31-38. [PMID: 27932381 DOI: 10.1542/hpeds.2016-0108] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [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 Asthma exacerbations are a leading cause of hospitalization among children. Despite the existence of national pediatric asthma guidelines, significant variation in care persists. At Duke Children's Hospital, we determined that our average length of stay (ALOS) and cost for pediatric asthma admissions exceeded that of our peers. Our aim was to reduce the ALOS of pediatric patients hospitalized with asthma from 2.9 days to 2.6 days within 12 months by implementing an asthma pathway within our new electronic health record. METHODS We convened a multidisciplinary committee charged with reducing variability in practice, ALOS, and cost of inpatient pediatric asthma care, while adhering to evidence-based guidelines. Interventions were tested through multiple "plan-do-study-act" cycles. Control charts of the ALOS were constructed and annotated with interventions, including testing of an asthma score, implementation of order sets, use of a respiratory therapy-driven albuterol treatment protocol, and provision of targeted education. Order set usage was audited as a process measure. Readmission rates were monitored as a balancing measure. RESULTS The ALOS of pediatric patients hospitalized with asthma decreased significantly from 2.9 days to 2.3 days. Comparing baseline with intervention variable direct cost data revealed a savings of $1543 per case. Improvements occurred in the context of high compliance with the asthma pathway order sets. Readmission rates remained stable throughout the study period. CONCLUSIONS Implementation of an asthma care pathway based on the electronic health record improved the efficiency and variable direct costs of hospital care, reduced variability in practice, and ensured adherence to high-quality national guidelines.
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Affiliation(s)
- Kathleen W Bartlett
- Division of Pediatric Hospital and Emergency Medicine, and .,Department of Pediatrics, Duke Children's Hospital, and
| | | | - Vanessa Morales
- Performance Services, Duke University Health System, Durham, North Carolina
| | - Jillian Hauser
- Performance Services, Duke University Health System, Durham, North Carolina
| | - Heather S McLean
- Division of Pediatric Hospital and Emergency Medicine, and.,Department of Pediatrics, Duke Children's Hospital, and
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