Keith J. Mann

Hospital-Level Compliance With Asthma Care Quality Measures at Children's Hospitals and Subsequent Asthma-Related Outcomes

CONTEXT The Childrens Asthma Care (CAC) measure set evaluates whether children admitted to hospitals with asthma receive relievers (CAC-1) and systemic corticosteroids (CAC-2) and whether they are discharged with a home management plan of care (CAC-3). It is the only Joint Commission core measure applicable to evaluate the quality of care for hospitalized children. OBJECTIVES To evaluate longitudinal trends in CAC measure compliance and to determine if an association exists between compliance and outcomes. DESIGN, SETTING, AND PATIENTS Cross-sectional study using administrative data and CAC compliance data for 30 US childrens hospitals. A total of 37,267 children admitted with asthma between January 1, 2008, and September 30, 2010, with follow-up through December 31, 2010, accounted for 45,499 hospital admissions. Hospital-level CAC measure compliance data were obtained from the National Association of Childrens Hospitals and Related Institutions. Readmission and postdischarge emergency department (ED) utilization data were obtained from the Pediatric Health Information System. MAIN OUTCOME MEASURES Childrens Asthma Care measure compliance trends; postdischarge ED utilization and asthma-related readmission rates at 7, 30, and 90 days. RESULTS The minimum quarterly CAC-1 and CAC-2 measure compliance rates reported by any hospital were 97.1% and 89.5%, respectively. Individual hospital CAC-2 compliance exceeded 95% for 97.9% of the quarters. Lack of variability in CAC-1 and CAC-2 compliance precluded examination of their association with the specified outcomes. Mean CAC-3 compliance was 40.6% (95% CI, 34.1%-47.1%) and 72.9% (95% CI, 68.8%-76.9%) for the initial and final 3 quarters of the study, respectively. The mean 7-, 30-, and 90-day postdischarge ED utilization rates were 1.5% (95% CI, 1.3%-1.6%), 4.3% (95% CI, 4.0%-4.5%), and 11.1% (95% CI, 10.5%-11.7%) and the mean quarterly 7-, 30-, and 90-day readmission rates were 1.4% (95% CI, 1.2%-1.6%), 3.1% (95% CI, 2.8%-3.3%), and 7.6% (95% CI, 7.2%-8.1%). There was no significant association between overall CAC-3 compliance (odds ratio [OR] for 5% improvement in compliance) and postdischarge ED utilization rates at 7 days (OR, 1.00; 95% CI, 0.98-1.02), 30 days (OR, 0.97; 95% CI, 0.90-1.04), and 90 days (OR, 0.96; 95% CI, 0.77-1.18). In addition, there was no significant association between overall CAC-3 compliance (OR for 5% improvement in compliance) and readmission rates at 7 days (OR, 1.00; 95% CI, 0.99-1.02), 30 days (OR, 0.99; 95% CI, 0.96-1.02), and 90 days (OR, 1.01; 95% CI, 0.90-1.12). CONCLUSION Among children admitted to pediatric hospitals for asthma, there was high hospital-level compliance with CAC-1 and CAC-2 quality measures and moderate compliance with the CAC-3 measure but no association between CAC-3 compliance and subsequent ED visits and asthma-related readmissions.

Facilitated Peer Group Mentoring: A Case Study of Creating Leadership Skills Among the Associate Program Directors of the APPD

I t is well recognized that academic faculty benefit from mentoring relationships in order to achieve their professional goals, facilitate their scholarly productivity, and make meaningful contributions to their colleagues, trainees, institutions, and departments. Junior faculty are faced with many challenges in developing effective mentoring relationships, including lack of available senior faculty members with proper skill sets or interest in mentorship. Although many mentoring models exist, the most commonly pursued by academic faculty is dyadic mentoring. In traditional dyadic mentoring, one mentor is matched with one mentee (often geographically) based on common interests. Ideally, the dyad participates in a bidirectional relationship. There is a growing body of evidence that other innovative mentoring models, such as facilitated peer group mentoring (FPGM), may be more successful. In FPGM, a senior mentor is assigned to a small group of mentees. The group members serve as peer mentors to each other while working on common interests or projects. The process is facilitated by the senior mentor, who may or may not be a content expert. In this paper, we discuss a case study in which effective, productive mentoring was provided through the use of FPGM. This case study involving associate program directors is illustrative of a successful mentoring experience that resulted in academic productivity and enhanced leadership skills. Associate program directors are involved directly in the

Quality Improvement Curricula in Pediatric Residency Education: Obstacles and Opportunities

From the Department of Pediatrics, University of Missouri – Kansas City School of Medicine (Dr Mann) and Quality and Safety, Children’s Mercy Hospitals and Clinics (Dr Mann), Kansas City, Mo; Department of Pediatrics, Boston University School of Medicine, Boston Medical Center (DrMoses) and BostonCombined ResidencyProgram in Pediatrics, (DrMoses), Boston,Mass; andDepartment of Pediatrics, Section of Critical Care Medicine, Drexel University College of Medicine, St. Christopher’s Hospital for Children, Philadelphia, Pa (Dr Shore) Conflict-of-interest disclosure: James Moses, MD, MPH is a faculty advisor to The Institute for Healthcare Improvement’s Open School. Address correspondence to: Keith J. Mann, MD, MEd, Associate Professor, Department of Pediatrics, University of Missouri – Kansas City School of Medicine, Children’s Mercy Hospitals and Clinics, 2401 Gillham Road, Kansas City, Missouri 64108 (e-mail: kjmann@cmh.edu).

Rates of ICU Transfers After a Scheduled Night-Shift Interprofessional Huddle.

OBJECTIVES To evaluate a scheduled interprofessional huddle among pediatric residents, nursing staff, and cardiologists on the number of high-risk transfers to the ICU. METHODS A daily, night-shift huddle intervention was initiated between the in-house pediatric residents and nursing staff covering the cardiology ward patients with the at-home attending cardiologist. Retrospective cohort chart review identified high-risk transfers from the inpatient floor to the ICU over a 24-month period (eg, inotropic support, intubation, and/or respiratory support within 1 hour of ICU transfer). Satisfaction with the intervention and the impact of the intervention on team-based communication and resident education was collected using a retrospective pre-post survey. RESULTS Ninety-three patients were identified as unscheduled transfers from the ward team to the ICU. Overall, 21 preintervention transfers were considered high risk, whereas only 8 patients were considered high risk after the intervention (P=.004). During the night shift, high risk transfers decreased from 8 of 17 (47%) to 3 of 21 patients (14%) (P=.03). Interprofessional communication improved with 12 of 14 nurses and 24 of 25 residents reporting effective communication after the intervention (P<.0001) compared with only 1 nurse and 15 residents reporting a positive experience before the intervention. Overall, all 3 provider groups stated an improved experience covering a high-risk cardiology patient population. CONCLUSIONS Implementation of an interprofessional huddle may contribute to decreasing high-risk transfers to the ICU. Initiating a daily huddle was well received and allowed for open lines of communication across all provider groups.

Strengthening the associate program director workforce: needs assessment and recommendations.

From the Department of Pediatrics, Duke University Medical Center, Durham, NC (Dr Narayan); Department of Pediatrics, University of Washington, Seattle,Wash (DrMcPhillips); Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo (Dr Anderson); Department of Pediatrics, Emory University School of Medicine, Atlanta, Ga (Dr Gardner); Department of Pediatrics, University of Vermont, Burlington, Vt (Dr Larrabee); Department of Pediatrics, Cincinnati Children’s Hospital, Cincinnati, Ohio (Dr Poynter); Department of Pediatrics, University of Missouri—Kansas City School of Medicine and Children’s Mercy Hospitals and Clinics, Kansas City, Mo (Dr Mann); and Department of Pediatrics Drexel University College of Medicine, Section of General Pediatrics St. Christopher’s Hospital for Children, Philadelphia, Pa (Dr Spector) The authors declare that they have no conflict of interest. Address correspondence to Aditee P. Narayan, MD, MPH, Duke University Medical Center, Pediatrics, DUMCBox 3127, Durham, NC 27710 (e-mail: aditee.narayan@duke.edu). Received for publication May 12, 2014; accepted May 12, 2014.

View From the Association of Pediatric Program DirectorsStrengthening the Associate Program Director Workforce: Needs Assessment and Recommendations

From the Department of Pediatrics, Duke University Medical Center, Durham, NC (Dr Narayan); Department of Pediatrics, University of Washington, Seattle,Wash (DrMcPhillips); Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo (Dr Anderson); Department of Pediatrics, Emory University School of Medicine, Atlanta, Ga (Dr Gardner); Department of Pediatrics, University of Vermont, Burlington, Vt (Dr Larrabee); Department of Pediatrics, Cincinnati Children’s Hospital, Cincinnati, Ohio (Dr Poynter); Department of Pediatrics, University of Missouri—Kansas City School of Medicine and Children’s Mercy Hospitals and Clinics, Kansas City, Mo (Dr Mann); and Department of Pediatrics Drexel University College of Medicine, Section of General Pediatrics St. Christopher’s Hospital for Children, Philadelphia, Pa (Dr Spector) The authors declare that they have no conflict of interest. Address correspondence to Aditee P. Narayan, MD, MPH, Duke University Medical Center, Pediatrics, DUMCBox 3127, Durham, NC 27710 (e-mail: aditee.narayan@duke.edu). Received for publication May 12, 2014; accepted May 12, 2014.

Improving Guideline-Based Streptococcal Pharyngitis Testing: A Quality Improvement Initiative

The implementation of a QI initiative improved guideline-based testing for GAS pharyngitis in a large community pediatrics practice. BACKGROUND AND OBJECTIVES: Acute pharyngitis is a common diagnosis in ambulatory pediatrics. The Infectious Diseases Society of America (IDSA) clinical practice guideline for group A streptococcal (GAS) pharyngitis recommends strict criteria for GAS testing to avoid misdiagnosis and unnecessary treatment of children who are colonized with group A Streptococcus. We sought to improve adherence to the IDSA guideline for testing and treatment of GAS pharyngitis in a large community pediatrics practice. METHODS: The Model for Improvement was used, and iterative Plan-Do-Study-Act cycles were completed. The quality improvement project was approved for American Board of Pediatrics Part 4 Maintenance of Certification credit. Interventions included provider education, modification of existing office procedure, communication strategies, and patient and family education. Outcomes were assessed by using statistical process control charts. RESULTS: An absolute reduction in unnecessary GAS testing of 23.5% (from 64% to 40.5%) was observed during the project. Presence of viral symptoms was the primary reason for unnecessary testing. Appropriate antibiotic use for GAS pharyngitis did not significantly change during the project; although, inappropriate use was primarily related to unnecessary testing. At the end of the intervention period, the majority of providers perceived an improvement in their ability to communicate with families about the need for GAS pharyngitis testing and about antibiotic use. CONCLUSIONS: The majority of GAS pharyngitis testing in this practice before intervention was inconsistent with IDSA guideline recommendations. A quality improvement initiative, which was approved for Part 4 Maintenance of Certification credit, led to improvement in guideline-based testing for GAS pharyngitis.

Promoting Oral Health in Childhood: A Quality Improvement Project

A systematic approach to improving oral health through EMR-based interventions resulted in improved documentation of oral health status, FV application, and dental referrals. BACKGROUND AND OBJECTIVES: The American Academy of Pediatrics recommends periodic oral health risk assessments (OHRAs) for young children to prevent early childhood caries and promote oral health. The objective of this quality improvement project was to incorporate OHRAs, including documentation of the oral screening examination, into well-child visits for patients aged 12 to 47 months to drive (1) improved rates of preventive fluoride varnish (FV) application and (2) improved dental referrals for children at high risk for caries. METHODS: We identified a quality gap in our OHRAs, oral examination completion, FV application rates, and dental referral rates via retrospective data collection. Plan-Do-Study-Act cycles targeted modification of electronic medical record templates, oral health education, and standardization of work processes. Process and outcome measures were analyzed with statistical process control charts. RESULTS: At baseline, OHRAs and oral screening examinations were documented in <2% of patients. Of eligible children, 42% had FV applied. Routine dental referrals before age 3 years were uncommon. After multiple Plan-Do-Study-Act cycles, documentation of OHRAs and oral screening examinations (process measures) improved to 45% and 73%, respectively. The primary outcome measure, FV rates, improved to 86%. Referral of high-risk patients to a dentist improved to 54%. CONCLUSIONS: A systematic, evidence-based approach to improving oral health, including electronic medical record–based interventions, resulted in improved documentation of oral health risks and oral screening, improved rates of FV application in young children, and increased identification and referral of high-risk patients.

Evaluating the Impact of Implementing a Clinical Practice Guideline for Febrile Infants With Positive Respiratory Syncytial Virus or Enterovirus Testing

OBJECTIVES To evaluate clinical practice patterns and patient outcomes among febrile low-risk infants with respiratory syncytial virus (RSV) infection or enterovirus (EV) meningitis after implementing a clinical practice guideline (CPG) that provides recommendations for managing febrile infants with RSV infection and EV meningitis. METHODS Our institution implemented a CPG for febrile infants, which gives explicit recommendations for managing both RSV-positive and EV-positive infants in 2011. We retrospectively analyzed medical records of febrile infants ≤60 days old from June 2008 to January 2013. Among 134 low-risk RSV-positive infants, we compared the proportion of infants who underwent lumbar puncture (LP), the proportion of infants who received antibiotics, antibiotic hours of therapy (HOT), and length of stay (LOS) pre- and post-CPG implementation. Among 274 low-risk infants with EV meningitis, we compared HOT and LOS pre- and post-CPG implementation. RESULTS Among low-risk RSV-positive patients, the proportion of infants undergoing LP, the proportion of infants receiving antibiotics, HOT, and LOS were unchanged post-CPG. Among low-risk infants with EV meningitis, HOT (79 hours pre-CPG implementation versus 46 hours post-CPG implementation, P < .001) and LOS (47 hours pre-CPG implementation versus 43 hours post-CPG implementation, P = .01) both decreased post-CPG. CONCLUSIONS CPG implementation is associated with decreased antibiotic exposure and hospital LOS among low-risk infants with EV meningitis; however, there were no associated changes in the proportion of infants undergoing LP, antibiotic exposure, or LOS among low-risk infants with RSV. Further studies are needed to determine specific barriers and facilitators to effectively incorporate diagnostic viral testing into medical decision-making for these infants.

Asthma care quality measures at children's hospitals and asthma-related outcomes

Objective: The Joint Commission requires hospitals to report on Childrens Asthma Care (CAC) measures, although their relationship to outcomes is not clear. The objective of this study was to (1) characterize metrics hospitals use for asthma, and to (2) determine if the number and type of metrics used is associated with readmission rates. Study Design: Pediatric hospital quality leaders were asked to identify asthma metrics utilized by their respective organizations via an online survey. “Use” of metrics was defined as periodically measuring data regardless of performance. Linear regression was used to determine if the number or domain of metrics grouped by topic used was associated with 7-, 30-, and 90-day same-cause readmission rates obtained from the Pediatric Health Information System (PHIS). Results: Among respondents (n = 27, 62.7%), the mean number of metrics used was 20.5 (SD = 9.1, range = 4–38). There was no association between the number or domain type of metrics used and 7-, 30-, or 90-day readmission rates. Conclusions: Despite using a wide variety of asthma metrics, there was no association between use of any metric or domain of metrics and asthma-related readmission rates. Additional work should identify asthma process measures that are associated with meaningful outcomes.