James Moses

Patient Handoffs: Pediatric Resident Experiences and Lessons Learned

Background: Within pediatrics, there is a paucity of data on pediatric resident handoff systems. Methods: Seventy-seven of 139 eligible pediatric housestaff participated in a cross-sectional survey that was distributed at an annual residency fall retreat in September 2007. Results: Seventy-three percent of the respondents noted uncertainty regarding patient care plans due to receipt of an incomplete verbal handoff. Nursing questions, phone, and page interruptions were noted barriers to giving an effective verbal sign-out. Personal fatigue was also reported to affect the accuracy of housestaff’s written sign-outs more than verbal sign-outs (43% vs 23%, P = .026). Only 19% of the residents reported that written sign-outs were reflective of current patient information and care plans. Conclusion: Written and verbal patient handoffs were perceived by pediatric housestaff to be important parts of patient care but often incomplete. New systems that provide a more protected handoff environment, reduce housestaff fatigue, and standardize the handoff procedure may be useful.

Improving the Management of Vaso-Occlusive Episodes in the Pediatric Emergency Department.

OBJECTIVES: Vaso-occlusive episodes (VOEs) account for the majority of emergency department (ED) visits for children with sickle cell disease (SCD). We hypothesized that addressing key barriers to VOE care would improve receipt of analgesics and outcomes. METHODS: A quality improvement (QI) initiative was conducted from September 2010 to April 2014 to streamline VOE care in an urban pediatric ED. Four interventions were used: a standardized time-specific VOE protocol; intranasal fentanyl as the first parenteral pain medication; an SCD pain medication calculator; and provider and patient/family education. Data were collected for 3 outcome measures (mean time from triage to first parenteral opioid and admission/discharge decision, and proportion discharged from the ED); 1 process measure (mean time from triage to initiation of patient-controlled analgesia); and 4 balancing measures (mean time from triage to second intravenous opioid dose, 24-hour ED readmission, respiratory depression, and length of stay). RESULTS: There were 289 ED visits in the study period. Improvements were seen in mean time to: first dose of parenteral opioid (56 to 23 minutes); second opiate intravenous dose (106 to 83 minutes); admission and discharge decisions (163 to 109 minutes and 271 to 178 minutes, respectively); and initiation of patient-controlled analgesia (216 to 141 minutes). The proportion discharged from the ED increased from 32% to 48% (χ2 = 6.5402, P = .01). No increase in 24-hour readmission, respiratory depression, or inpatient length of stay was observed. CONCLUSIONS: Using VOE-specific interventions, we significantly improved VOE care for children. Studies are needed to determine if these results can be replicated.

Impact of Parental Presence at Infants’ Bedside on Neonatal Abstinence Syndrome

BACKGROUND Despite increased incidence of neonatal abstinence syndrome (NAS) over the past decade, minimal data exist on benefits of parental presence at the bedside on NAS outcomes. OBJECTIVE To examine the association between rates of parental presence and NAS outcomes. METHODS This was a retrospective, single-center cohort study of infants treated pharmacologically for NAS using a rooming-in model of care. Parental presence was documented every 4 hours with nursing cares. We obtained demographic data for mothers and infants and assessed covariates confounding NAS severity and time spent at the bedside. Outcomes included length of stay (LOS) at the hospital, extent of pharmacotherapy, and mean Finnegan withdrawal score. Multiple linear regression modeling assessed the association of parental presence with outcomes. RESULTS For the 86 mother-infant dyads, the mean parental presence during scoring was on average 54.4% (95% confidence interval [CI], 48.8%-60.7%) of the infants hospitalization. Maximum (100%) parental presence was associated with a 9 day shorter LOS (r = -0.31; 95% CI, -0.48 to -0.10; P < .01), 8 fewer days of infant opioid therapy (r = -0.34; 95% CI, -0.52 to -0.15; P < .001), and 1 point lower mean Finnegan score (r = -0.35; 95% CI, -0.52 to -0.15; P < .01). After adjusting for breastfeeding, parental presence remained significantly associated with reduced NAS score and opioid treatment days. CONCLUSIONS More parental time spent at the infants bedside was associated with decreased NAS severity. This has important implications for clinical practice guidelines for NAS.

Increasing Medication Possession at Discharge for Patients With Asthma: The Meds-in-Hand Project.

BACKGROUND AND OBJECTIVES: Many patients recently discharged from an asthma admission do not fill discharge prescriptions. If unable to adhere to a discharge plan, patients with asthma are at risk for re-presentation to care. We sought to increase the proportion of patients discharged from an asthma admission in possession of their medications (meds in hand) from a baseline of 0% to >75%. METHODS: A multidisciplinary improvement team performed 3 plan–do–study–act cycles over 2 years and, using a statistical process control chart, tracked the proportion of patients admitted with asthma discharged with meds in hand as the primary outcome. An exploratory, retrospective analysis of insurance data was conducted with a convenience sample of Medicaid-insured patients, comparing postdischarge utilization between patients discharged with meds in hand and usual care. Generalized estimating equations accounted for nonindependence in the data. RESULTS: Changes to the discharge process culminated in the development of a discharge medication delivery service. Outpatient pharmacist delivery of discharge medications to patient rooms achieved the project aim of 75% of patients discharged with meds in hand. In a subset of patients for whom all insurance claims were available, those discharged with meds in hand had lower odds of all-cause re-presentation to the emergency department within 30 days of discharge, compared with patients discharged with usual care (odds ratio, 0.22; 95% confidence interval, 0.05–0.99). CONCLUSIONS: Our initiative led to several discharge process improvements, including the creation of a medication delivery service that increased the proportion of patients discharged in possession of their medications and may have decreased unplanned visits after discharge.

Leveraging Trainees to Improve Quality and Safety at the Point of Care: Three Models for Engagement.

Trainees, as frontline providers who are acutely aware of quality improvement (QI) opportunities and patient safety (PS) issues, are key partners in achieving institutional quality and safety goals. However, as academic medical centers accelerate their initiatives to prioritize QI and PS, trainees have not always been engaged in these efforts. This article describes the development of an organizing framework with three suggested models of varying scopes and time horizons to effectively involve trainees in the quality and safety work of their training institutions. The proposed models, which were developed through a literature review, expert interviews with key stakeholders, and iterative testing, are (1) short-term, team-based, rapid-cycle initiatives; (2) medium-term, unit-based initiatives; and (3) long-term, health-system-wide initiatives. For each, the authors describe the objective, scope, duration, role of faculty leaders, steps for implementation in the clinical setting, pros and cons, and examples in the clinical setting. There are many barriers to designing the ideal training environments that fully engage trainees in QI/PS efforts, including lack of protected time for faculty mentors, time restrictions due to rotation-based training, and structural challenges. However, one of the most promising strategies for overcoming these barriers is integrating QI/PS principles into routine clinical care. These models provide opportunities for trainees to successfully learn and apply quality and safety principles to routine clinical care at the team, unit, and system level.

Radiology Residency Quality Improvement Curriculum: Lessons Learned

Quality improvement (QI) skills in radiology are required as part of the Accreditation Council for Graduate Medical Education Diagnostic Radiology Milestones competencies. Although feasibility of QI curricula has been demonstrated in radiology before, there are still barriers to widespread implementation. Here, we share our experience with designing the curriculum structure and selecting content. We describe the QI projects that have been performed and discuss lessons learned, including successes, challenges, and future directions. This information is relevant for many radiology programs currently planning to implement or revise existing QI curricula.

Improving Asthma Care in the Hospital: an Overview of Treatments and Quality Improvement Interventions for Children Hospitalized for Status Asthmaticus

Opinion StatementAsthma is one of the leading causes of pediatric hospitalization in the USA. This review summarizes evidence-based practices for inpatient pediatric asthma treatment, including routine care, care escalation, and discharge care, along with established and emerging inpatient quality improvement approaches. Intermittent inhaled beta agonists, systemic steroids, and, for patients with low oxygen saturation, supplemental oxygen remain the cornerstones of routine inpatient asthma care. Compared to nebulization, metered-dose inhaler delivery of intermittent beta agonist therapy is more effective and underused. Oral prednisone produces similar clinical outcomes and is more cost-effective when compared with intravenous methylprednisolone. Standardized respiratory assessment scores should supplement clinical judgment in evaluating response to therapy. There are no studies that demonstrate the effectiveness of routine adjuvant anticholinergic therapy outside of the emergency room, though it may be effective in a subset of inpatients. Evidence for inpatient care escalation is limited. With respect to discharge care, simple provision of asthma care plans does not appear to reduce readmissions, though individually tailored asthma care plans remain a standard of discharge care, along with systemic steroids, beta agonists, and, when indicated, inhaled corticosteroids. To avoid medication access barriers for high-risk patients, clinicians can ensure that discharge medications are in-hand before the patient leaves the hospital. A number of quality improvement strategies have shown promise in the inpatient setting. Clinical pathways reduce length of stay and costs associated with care without an associated increase in readmissions. Inpatient family education programs can be effective but should incorporate multiple strategies, including individualized management strategies and post-discharge follow-up. Inpatient care also serves as a useful opportunity to assess home environmental risk and to refer high-risk families to outpatient and community resources.

Integrating the Learner's Perspective in the Refinement of Competency-Based Assessments

From the Department of Pediatrics, University of California, San Francisco, Calif (Drs Robson and Henry); and Department of Pediatrics, Boston Medical Center, Boston, Mass (Drs Moses, Vinci, and Schumacher) The authors declare that they have no conflict of interest. Address correspondence to Jacob Robson, MD, Department of Pediatrics, University of California, San Francisco, 550 16th St, 5th Floor, Mail Box 0136, San Francisco, CA 94914 (e-mail: jacob.robson@ucsf.edu).

Evaluating the Feasibility of Incorporating In-Person Interpreters on Family-Centered Rounds: A QI Initiative

OBJECTIVES No best practice has been defined for incorporating in-person interpreters into family-centered rounds (FCRs) for patients with limited English proficiency (LEP). We hypothesized that addressing barriers to scheduling in-person interpreters would make FCR encounters more likely, and thus ensure more equitable care for LEP patients. METHODS A quality improvement initiative was conducted from October 2014 to March 2016 to arrange in-person interpreters for LEP patients during FCRs on the inpatient pediatric service of a large, urban, tertiary care center in Boston. Main interventions included establishing a protocol for scheduling interpreters for rounds and the implementation of a form to track process adherence. Our primary outcome was the percentage of FCR encounters with LEP patients with an interpreter present. Our balancing measures were patient satisfaction, which was assessed using validated surveys administered weekly by nonphysician team members through convenience sampling of families present on the wards, and rounds duration. RESULTS There were 614 encounters with LEP patients during the intervention, 367 of which included in-person interpreters. The percentage of encounters with LEP patients involving interpreters increased from 0% to 63%. Form completion, our primary process measure, reached 87% in the most recent phase. English-proficient and LEP patients reported similar satisfaction with their rounding experience amid a modest increase in rounds duration (preintervention, 105 minutes; postintervention, 130 minutes; P = .056). CONCLUSIONS Using quality improvement as a framework to address key barriers, we successfully implemented a process that increased the participation of in-person interpreters on FCRs on a busy pediatric service.

Aortic Stenosis Gradients and a Case for Quality Improvement.

Paul Batalden,1 a world-renowned quality expert, is quoted to have said “Every system is perfectly designed to get the results it gets.” Implied from his quote is when different results are desired the processes of care that make up the system producing those results need to change. Too often in health care today we struggle with process deficiencies or inadequacies that negatively affect the care patients receive. Commonly, providers and other members of the multidisciplinary team do not have a framework or methodology to address those deficiencies. In academic settings, providers will often turn to research to identify solutions to address them. However, this approach comes at a cost. Research requires heavy resource investment and its measurement approach is unrealistic for improvement purposes. Research’s timeline is not conducive to addressing quality problems in a timely manner nor does it take into consideration the sustainability of solutions identified. Instead, a different approach is needed for improvement work. An approach that allows for a logical and practical method in identifying solutions that work in actual clinical settings and leads to the true north of realizing sustained improvement. If you will, the approach needed is one that works in vivo not in vitro. See Article by Samad et al In their article in this issue of Circulation: Cardiovascular Imaging , Samad et al2 have successfully demonstrated how continuous quality improvement (QI) can be applied to address an important clinical issue, namely the variation in echocardiographic determination of aortic stenosis (AS) gradients that leads to overtesting via cardiac catheterization. Using continuous quality improvement methodology, they were able to identify modifications in their echocardiography approach that improved the agreement between cath- and echo-derived mean AS gradients. The subsequent improvement in correlation leads to a decrease in unnecessary referrals for evaluation by invasive valve …