David G. Bundy

Open Access in Primary Care: Results of a North Carolina Pilot Project

Objective. Appointment delays impede access to primary health care. By reducing appointment delays, open access (OA) scheduling may improve access to and the quality of primary health care. The objective of this pilot study was to assess the potential impact of OA on practice and patient outcomes by using pilot-study data from 4 North Carolina primary care practices. Methods. We conducted an interrupted time-series pilot study of 4 North Carolina primary care practices (2 family medicine and 2 pediatric practices) participating in a quality-improvement (QI) collaborative from May 2001 to May 2002. The year-long collaborative comprised 25 practices and consisted of three 2-day meetings led by expert faculty, monthly data feedback, and monthly conference calls. Our main outcome measures were appointment delays, appointment no-shows, patient satisfaction, continuity of care, and staff satisfaction during the 12-month study period. Results. Providers in all 4 practices successfully implemented OA. On average, providers reduced their delay to the third available preventive care appointment from 36 to 4 days. No-show rates declined (first quarter [Q1] rate: 16%; fourth quarter [Q4] rate: 11%; no-show reduction: 5% [95% confidence interval: 1%, 10%]), and overall patient satisfaction improved (Q1: 45% rated overall visit quality as excellent; Q4: 61% rated overall visit quality as excellent; change in satisfaction: 16% [95% confidence interval: 0.2%, 30%]). Continuity of care followed a similar pattern of improvement, but the change was not statistically significant. Staff satisfaction neither improved nor declined. Conclusions. This pilot study suggests that primary care practices can implement OA successfully by using QI-collaborative methods. These results provide preliminary evidence that OA may improve practice and patient outcomes in primary care. These analyses should be repeated in larger groups of practices with longer follow-up.

Implementation of a Central Line Maintenance Care Bundle in Hospitalized Pediatric Oncology Patients

OBJECTIVE: To investigate whether a multidisciplinary, best-practice central line maintenance care bundle reduces central line-associated blood stream infection (CLABSI) rates in hospitalized pediatric oncology patients and to further delineate the epidemiology of CLABSIs in this population. METHODS: We performed a prospective, interrupted time series study of a best-practice bundle addressing all areas of central line care: reduction of entries, aseptic entries, and aseptic procedures when changing components. Based on a continuous quality improvement model, targeted interventions were instituted to improve compliance with each of the bundle elements. CLABSI rates and epidemiological data were collected for 10 months before and 24 months after implementation of the bundle and compared in a Poisson regression model. RESULTS: CLABSI rates decreased from 2.25 CLABSIs per 1000 central line days at baseline to 1.79 CLABSIs per 1000 central line days during the intervention period (incidence rate ratio [IRR]: 0.80, P = .58). Secondary analyses indicated CLABSI rates were reduced to 0.81 CLABSIs per 1000 central line days in the second 12 months of the intervention (IRR: 0.36, P = .091). Fifty-nine percent of infections resulted from Gram-positive pathogens, 37% of patients with a CLABSI required central line removal, and patients with Hickman catheters were more likely to have a CLABSI than patients with Infusaports (IRR: 4.62, P = .02). CONCLUSIONS: A best-practice central line maintenance care bundle can be implemented in hospitalized pediatric oncology patients, although long ramp-up times may be necessary to reap maximal benefits. Further research is needed to determine if this CLABSI rate reduction can be sustained and spread.

NICU medication errors: identifying a risk profile for medication errors in the neonatal intensive care unit

Objective:To identify a risk profile for harmful medication errors in the neonatal intensive care unit (NICU).Study Design:A retrospective cross-sectional study on NICU medication error reports submitted to MEDMARX between 1 January 1999, and 31 December 2005. The Rao–Scott modified χ2 test was used for analysis.Result:6749 NICU medication error reports were submitted by 163 health-care facilities. Administering errors accounted for approximately one half of errors, and human factors were the most frequently cited cause of error. Patient age was not associated with an increased likelihood of an error being harmful (P=0.11). Error reports involving Institute for Safe Medication Practices (ISMP) High-Alert Medications, occurring in the prescribing phase of medication processing, or involving equipment/delivery device failures were more likely to be harmful (P⩽0.05).Conclusion:Risk factors for harmful medication error reports include use of ISMP High-Alert Medications, the prescribing phase of the medication use process, and failure of equipment/delivery devices.

Preventing CLABSIs Among Pediatric Hematology/Oncology Inpatients: National Collaborative Results

OBJECTIVES: Central lines (CLs) are essential for the delivery of modern cancer care to children. Nonetheless, CLs are subject to potentially life-threatening complications, including central line–associated bloodstream infections (CLABSIs). The objective of this study was to assess the feasibility of a multicenter effort to standardize CL care and CLABSI tracking, and to quantify the impact of standardizing these processes on CLABSI rates among pediatric hematology/oncology inpatients. METHODS: We conducted a multicenter quality improvement collaborative starting in November 2009. Multidisciplinary teams at participating sites implemented a standardized bundle of CL care practices and adopted a common approach to CLABSI surveillance. RESULTS: Thirty-two units participated in the collaborative and reported a mean, precollaborative CLABSI rate of 2.85 CLABSIs per 1000 CL-days. Self-reported adoption of the CL care bundle was brisk, with average compliance approaching 80% by the end of the first year of the collaborative and exceeding 80% thereafter. As of August 2012, the mean CLABSI rate during the collaborative was 2.04 CLABSIs per 1000 CL-days, a reduction of 28% (relative risk: 0.71 [95% confidence interval: 0.55–0.92]). Changes in self-reported CL care bundle compliance were not statistically associated with changes in CLABSI rates, although there was little variability in bundle compliance rates after the first year of the collaborative. CONCLUSIONS: A multicenter quality improvement collaborative found significant reductions in observed CLABSI rates in pediatric hematology/oncology inpatients. Additional interventions will likely be required to bring and sustain CLABSI rates closer to zero for this high-risk population.

Interventions to Reduce Pediatric Medication Errors: A Systematic Review

BACKGROUND AND OBJECTIVE: Medication errors cause appreciable morbidity and mortality in children. The objective was to determine the effectiveness of interventions to reduce pediatric medication errors, identify gaps in the literature, and perform meta-analyses on comparable studies. METHODS: Relevant studies were identified from searches of PubMed, Embase, Scopus, Web of Science, the Cochrane Library, and the Cumulative Index to Nursing Allied Health Literature and previous systematic reviews. Inclusion criteria were peer-reviewed original data in any language testing an intervention to reduce medication errors in children. Abstract and full-text article review were conducted by 2 independent authors with sequential data extraction. RESULTS: A total of 274 full-text articles were reviewed and 63 were included. Only 1% of studies were conducted at community hospitals, 11% were conducted in ambulatory populations, 10% reported preventable adverse drug events, 10% examined administering errors, 3% examined dispensing errors, and none reported cost-effectiveness data, suggesting persistent research gaps. Variation existed in the methods, definitions, outcomes, and rate denominators for all studies; and many showed an appreciable risk of bias. Although 26 studies (41%) involved computerized provider order entry, a meta-analysis was not performed because of methodologic heterogeneity. Studies of computerized provider order entry with clinical decision support compared with studies without clinical decision support reported a 36% to 87% reduction in prescribing errors; studies of preprinted order sheets revealed a 27% to 82% reduction in prescribing errors. CONCLUSIONS: Pediatric medication errors can be reduced, although our understanding of optimal interventions remains hampered. Research should focus on understudied areas, use standardized definitions and outcomes, and evaluate cost-effectiveness.

Burden of Influenza-Related Hospitalizations Among Children With Sickle Cell Disease

OBJECTIVE: Children with sickle cell disease (SCD) are considered to be at high risk for complications from influenza infection despite minimal published data that characterize the burden of influenza in this population. Our objectives were to (1) estimate the rate of influenza-related hospitalizations (IRHs) among children with SCD, (2) compare this rate with rates of children with cystic fibrosis (CF) and children with neither SCD nor CF, and (3) explore mechanisms that underlie these potentially preventable hospitalizations. METHODS: We analyzed hospitalizations from 4 states (California, Florida, Maryland, and New York) across 2 influenza seasons (2003–2004 and 2004–2005) from the Healthcare Cost and Utilization Project State Inpatient Databases. We included hospitalizations with a discharge diagnosis code for influenza in a child <18 years of age. We used census data and disease prevalence estimates to calculate denominators and compare rates of IRH among children with SCD, CF, and neither disease. RESULTS: There were 7896 pediatric IRHs during the 2 influenza seasons. Of these, 159 (2.0%) included a co-occurring diagnosis of SCD. Annual rates of IRHs were 112 and 2.0 per 10 000 children with and without SCD, respectively, across both seasons. Children with SCD were hospitalized with influenza at 56 times (95% confidence interval: 48–65) the rate of children without SCD. Children with SCD had approximately double the risk of IRH compared with children with CF (risk ratio: 2.1 [95% confidence interval: 1.5–2.9]). IRHs among children with SCD were not longer, more costly, or more severe than IRHs among children without SCD; they were also rarely nosocomial and co-occurred with a diagnosis of asthma in 14% of cases. CONCLUSIONS: IRHs are substantially more common among children with SCD than among those without the disease, which supports the potential importance of vigorous influenza vaccination efforts that target children with SCD.

Severe pandemic H1N1 and seasonal influenza in children and young adults with sickle cell disease.

Influenza causes excess morbidity in sickle cell disease (SCD). H1N1 pandemic influenza has been severe in children. To compare H1N1 with seasonal influenza in SCD (patients younger than 22), we reviewed medical records (1993-2009). We identified 123 cases of laboratory-confirmed influenza (94 seasonal, 29 H1N1). Those with seasonal influenza were younger (median 4.4 vs 8.7 years old, P = .006) and had less asthma (24% vs 56%, P = .002). Those with H1N1 influenza more often had acute chest syndrome (ACS; 34% vs 13%, P = .01) and required intensive care (17% vs 3%, P = .02), including mechanical ventilation (10% vs 0%, P = .02). In multivariate analysis, older age (odds ratio [OR] 1.1 per year, P = .04) and H1N1 influenza (OR 3.0, P = .04) were associated with ACS, and older age (OR 1.1 per year, P = .02) and prior ACS (OR 3.3 per episode in last year, P < .006) with intensive care. Influenza, especially H1N1, causes critical illness in SCD and should be prevented.

Medication adherence among pediatric patients with sickle cell disease: A systematic review

OBJECTIVES: Describe rates of adherence for sickle cell disease (SCD) medications, identify patient and medication characteristics associated with nonadherence, and determine the effect of nonadherence and moderate adherence (defined as taking 60%–80% of doses) on clinical outcomes. METHODS: In February 2012 we systematically searched 6 databases for peer-reviewed articles published after 1940. We identified articles evaluating medication adherence among patients <25 years old with SCD. Two authors reviewed each article to determine whether it should be included. Two authors extracted data, including medication studied, adherence measures used, rates of adherence, and barriers to adherence. RESULTS: Of 24 articles in the final review, 23 focused on 1 medication type: antibiotic prophylaxis (13 articles), iron chelation (5 articles), or hydroxyurea (5 articles). Adherence rates ranged from 16% to 89%; most reported moderate adherence. Medication factors contributed to adherence. For example, prophylactic antibiotic adherence was better with intramuscular than oral administration. Barriers included fear of side effects, incorrect dosing, and forgetting. Nonadherence was associated with more vaso-occlusive crises and hospitalizations. The limited data available on moderate adherence to iron chelation and hydroxyurea indicates some clinical benefit. CONCLUSIONS: Moderate adherence is typical among pediatric patients with SCD. Multicomponent interventions are needed to optimally deliver life-changing medications to these children and should include routine monitoring of adherence, support to prevent mistakes, and education to improve understanding of medication risks and benefits.

Central Line Maintenance Bundles and CLABSIs in Ambulatory Oncology Patients

OBJECTIVE: Pediatric oncology patients are frequently managed with central lines as outpatients, and these lines confer significant morbidity in this immune-compromised population. We aimed to investigate whether a multidisciplinary, central line maintenance care bundle reduces central line–associated bloodstream infections (CLABSIs) and bacteremias in ambulatory pediatric oncology patients. METHODS: We conducted an interrupted time-series study of a maintenance bundle concerning all areas of central line care. Each of 3 target groups (clinic staff, homecare agency nurses, and patient families) (1) received training on the bundle and its importance, (2) had their practice audited, and (3) were shown CLABSI rates through graphs, in-service training, and bulletin boards. CLABSI and bacteremia person-time incidence rates were collected for 23 months before and 24 months after beginning the intervention and were compared by using a Poisson regression model. RESULTS: The mean CLABSI rate decreased by 48% from 0.63 CLABSIs per 1000 central line days at baseline to 0.32 CLABSIs per 1000 central line days during the intervention period (P = .005). The mean bacteremia rate decreased by 54% from 1.27 bacteremias per 1000 central line days at baseline to 0.59 bacteremias per 1000 central line days during the intervention period (P < .001). CONCLUSIONS: Implementation of a multidisciplinary, central line maintenance care bundle significantly reduced CLABSI and bacteremia person-time incidence rates in ambulatory pediatric oncology patients with central lines. Further research is needed to determine if maintenance care bundles reduce ambulatory CLABSIs and bacteremia in other adult and pediatric populations.

Ambulatory pediatric oncology CLABSIs: Epidemiology and risk factors

To compare the burden of central line‐associated bloodstream infections (CLABSIs) in ambulatory versus inpatient pediatric oncology patients, and identify the epidemiology of and risk factors associated with ambulatory CLABSIs.