Antonia Stang

Quality Indicators for High Acuity Pediatric Conditions

OBJECTIVE: Identifying gaps in care and improving outcomes for severely ill children requires the development of evidence-based performance measures. We used a systematic process involving multiple stakeholders to identify and develop evidence-based quality indicators for high acuity pediatric conditions relevant to any emergency department (ED) setting where children are seen. METHODS: A prioritized list of clinical conditions was selected by an advisory panel. A systematic review of the literature was conducted to identify existing indicators, as well as guidelines and evidence that could be used to inform the creation of new indicators. A multiphase, Rand-modified Delphi method consisting of anonymous questionnaires and a face-to-face meeting of an expert panel was used for indicator selection. Measure specifications and evidence grading were created for each indicator, and the feasibility and reliability of measurement was assessed in a tertiary care pediatric ED. RESULTS: The conditions selected for indicator development were diabetic ketoacidosis, status asthmaticus, anaphylaxis, status epilepticus, severe head injury, and sepsis. The majority of the 62 selected indicators reflect ED processes (84%) with few indicators reflecting structures (11%) or outcomes (5%). Thirty-seven percent (n = 23) of the selected indicators are based on moderate or high quality evidence. Data were available and interrater reliability acceptable for the majority of indicators. CONCLUSIONS: A systematic process involving multiple stakeholders was used to develop evidence-based quality indicators for high acuity pediatric conditions. Future work will test the reliability and feasibility of data collection on these indicators across the spectrum of ED settings that provide care for children.

Patients teaching patient safety: the challenge of turning negative patient experiences into positive learning opportunities

Educators have long relied on the use of patient cases to illustrate key patient safety concepts to learners.1–3 These efforts engage clinician learners by harnessing the tradition of clinically based educational fora, such as morbidity and mortality rounds and other such case conferences. Teaching about the systems approach to patient safety in the context of compelling cases—a patient taken for someone elses invasive cardiology procedure, or a patient who died after her arterial line was flushed with insulin instead of heparin1 ,4—will have more impact than just outlining the Swiss cheese model of accident causation and describing the human factors perspective in investigating critical incidents.nnEngaging as these case-based approaches to teaching patient safety may be, they tend to focus on the more ‘technical’ aspects of patient safety such as teamwork and communication, principles of human factors engineering or the different stages of the medication management process in which errors can arise. Lost in such learning sometimes is the patient perspective, the voice that emphasises the importance of keeping the patients and families central to conversations about patient safety. More recently, published accounts of patient and provider stories relate their personal experiences with patient safety incidents.5–7 However, having actual patients tell their stories and interact directly with learners is a novel educational approach for patient safety training that warrants consideration for several important reasons.nnFirst, there is an obvious appeal to involving patients and families in health professions education because they provide an authentic perspective on avoidable harm resulting from patient safety incidents. Beyond that however, their involvement may serve to address some important challenges that educators face when implementing a patient safety educational programme. Some programmes struggle to make leaning about patient safety engaging or interesting, or find that learners fail to see the …

A systematic review of adverse drug events associated with administration of common asthma medications in children

Objective To systematically review the literature and determine frequencies of adverse drug events (ADE) associated with pediatric asthma medications. Methods Following PRISMA guidelines, we systematically searched six bibliographic databases between January 1991 and January 2017. Study eligibility, data extraction and quality assessment were independently completed and verified by two reviewers. We included randomized control trials (RCT), case-control, cohort, or quasi-experimental studies where the primary objective was identifying ADE in children 1 month– 18 years old exposed to commercial asthma medications. The primary outcome was ADE frequency. Findings Our search identified 14,540 citations. 46 studies were included: 24 RCT, 15 cohort, 4 RCT pooled analyses, 1 case-control, 1 open-label trial and 1 quasi-experimental study. Studies examined the following drug classes: inhaled corticosteroids (ICS) (n = 24), short-acting beta-agonists (n = 10), long-acting beta-agonists (LABA) (n = 3), ICS + LABA (n = 3), Leukotriene Receptor Antagonists (n = 3) and others (n = 3). 29 studies occurred in North America, and 29 were industry funded. We report a detailed index of 406 ADE descriptions and frequencies organized by drug class. The majority of data focuses on ICS, with 174 ADE affecting 13 organ systems including adrenal and growth suppression. We observed serious ADE, although they were rare, with frequency ranging between 0.9–6% per drug. There were no confirmed deaths, except for 13 potential deaths in a LABA study including combined adult and pediatric participants. We identified substantial methodological concerns, particularly with identifying ADE and determining severity. No studies utilized available standardized causality, severity or preventability assessments. Conclusion The majority of studies focus on ICS, with adrenal and growth suppression described. Serious ADE are relatively uncommon, with no confirmed pediatric deaths. We identify substantial methodological concerns, highlighting need for standardization with future research examining pediatric asthma medication safety.

Republished: Patients teaching patient safety: the challenge of turning negative patient experiences into positive learning opportunities.

Educators have long relied on the use of patient cases to illustrate key patient safety concepts to learners.1–3 These efforts engage clinician learners by harnessing the tradition of clinically based educational fora, such as morbidity and mortality rounds and other such case conferences. Teaching about the systems approach to patient safety in the context of compelling cases—a patient taken for someone elses invasive cardiology procedure, or a patient who died after her arterial line was flushed with insulin instead of heparin1 ,4—will have more impact than just outlining the Swiss cheese model of accident causation and describing the human factors perspective in investigating critical incidents.nnEngaging as these case-based approaches to teaching patient safety may be, they tend to focus on the more ‘technical’ aspects of patient safety such as teamwork and communication, principles of human factors engineering or the different stages of the medication management process in which errors can arise. Lost in such learning sometimes is the patient perspective, the voice that emphasises the importance of keeping the patients and families central to conversations about patient safety. More recently, published accounts of patient and provider stories relate their personal experiences with patient safety incidents.5–7 However, having actual patients tell their stories and interact directly with learners is a novel educational approach for patient safety training that warrants consideration for several important reasons.nnFirst, there is an obvious appeal to involving patients and families in health professions education because they provide an authentic perspective on avoidable harm resulting from patient safety incidents. Beyond that however, their involvement may serve to address some important challenges that educators face when implementing a patient safety educational programme. Some programmes struggle to make leaning about patient safety engaging or interesting, or find that learners fail to see the …

Treating and reducing anxiety and pain in the paediatric emergency department—TIME FOR ACTION—the TRAPPED quality improvement collaborative

Background/ObjectivesnIn 2013, the TRAPPED-1 survey reported inconsistent availability of pain and distress management strategies across all 15 Canadian paediatric emergency department (PEDs). The objective of the TRAPPED-2 study was to utilize a procedural pain quality improvement collaborative (QIC) and evaluate the number of newly introduced pain and distress-reducing strategies in Canadian PEDs over a 2-year period.nnnMethodsnA QIC was created to increase implementation of new strategies, through collaborative information sharing among PEDs. In 2015, 11 of the 15 Canadian PEDs participated in the TRAPPED QIC. At the end of the year, the TRAPPED-2 survey was electronically sent to a representative member at each of the 15 PEDs. The successful introduction of the chosen strategies by the QIC was assessed as well as the addition of new strategies per site. The number of new strategies introduced in the participating and nonparticipating QIC sites were described.nnnResultsnAll 15 PEDs (100%) completed the TRAPPED-2 survey. Overall, 10/11 of QIC-participating sites implemented the strategy they had initially identified. All 15 Canadian PEDs implemented some new strategies during the study period; participants in the QIC reported a mean of 5.2 (1-11) new strategies compared to 2.5 (1-4) in the nonactively participating sites.nnnConclusionnWhile all PEDs introduced new strategies during the study, QIC-participating sites successfully introduced the majority of their previously identified new strategies in a short time period. Sharing deadlines and information between centres may have contributed to this success.

Diagnostic Interpretation Guidance for Pediatric Enteric Pathogens: A Modified Delphi Consensus Process

Background We sought to develop diagnostic test guidance definitions for pediatric enteric infections to facilitate the interpretation of positive test results in the era of multianalyte molecular diagnostic test platforms. Methods We employed a systematic, two-phase, modified Delphi consensus process consisting of three web-based surveys and an expert panel face-to-face meeting. In phase 1, we surveyed an advisory panel of North American experts to select pathogens requiring diagnostic test guidance definition development. In phase 2, we convened a 14-member expert panel to develop, refine, and select the final definitions through two web-based questionnaires interspersed with a face-to-face meeting. Both questionnaires asked panelists to rate the degree to which they agreed that if the definition is met the pathogen is likely to be causative of clinical illness. Results The advisory panel survey identified 19 pathogens requiring definitions. In the expert panel premeeting survey, 13 of the 19 definitions evaluated were rated as being highly likely (“agree” or “strongly agree”) to be responsible for acute gastroenteritis symptoms by ≥67% of respondent panel members. The definitions for the remaining six pathogens (Aeromonas, Clostridium difficile, Edwardsiella, nonenteric adenovirus, astrovirus, and Entamoeba histolytica) were indeterminate. After the expert panel meeting, only two of the modified definitions, C. difficile and E. histolytica/dispar, failed to achieve the a priori specified threshold of ≥67% agreement. Conclusions We developed diagnostic test guidance definitions to assist healthcare providers for 17 enteric pathogens. We identified two pathogens that require further research and definition development.

Pediatric Emergency Research Canada (PERC): Patient/Family-Informed Research Priorities for Pediatric Emergency Medicine.

BACKGROUNDnA growing body of literature supports patient and public involvement in the design, prioritization, and dissemination of research and evidence-based medicine. The objectives of this project were to engage patients and families in developing a prioritized list of research topics for pediatric emergency medicine (PEM) and to compare results with prior research prioritization initiatives in the emergency department (ED) setting.nnnMETHODSnWe utilized a systematic process to combine administrative data on frequency of patient presentations to the ED with multiple stakeholder input including an initial stakeholder survey followed by a modified Delphi consensus methodology consisting of two Web-based surveys and a face-to-face meeting.nnnRESULTSnThe prioritization process resulted in a ranked list of 15 research priorities. The top five priorities were mental health presentations, pain and sedation, practice tools, quality of care delivery, and resource utilization. Mental health, pain and sedation, clinical prediction rules, respiratory illnesses/wheeze, patient safety/medication error, and sepsis were identified as shared priorities with prior initiatives. Topics identified in our process that were not identified in prior work included resource utilization, ED communication, antibiotic stewardship, and patient/family adherence with recommendations.nnnCONCLUSIONSnThis work identifies key priorities for research in PEM. Comparing our results with prior initiatives in the ED setting identified shared research priorities and opportunities for collaboration among PEM research networks. This work in particular makes an important contribution to the existing literature by including the patient/family perspective missing from prior work.