Ndidi Unaka

Utilizing improvement science methods to improve physician compliance with proper hand hygiene

OBJECTIVE: In 2009, The Joint Commission challenged hospitals to reduce the risk of health care–associated infections through hand hygiene compliance. At our hospital, physicians had lower compliance rates than other health care workers, just 68% on general pediatric units. We used improvement methods and reliability science to increase compliance with proper hand hygiene to >95% by inpatient general pediatric teams. METHODS: Strategies to improve hand hygiene were tested through multiple plan-do-study-act cycles, first by 1 general inpatient medical team and then spread to 4 additional teams. At the start of each rotation, residents completed an educational module and posttest about proper hand hygiene. Team compliance data were displayed daily in the resident conference room. Real-time identification and mitigation of failures by a hand-washing champion encouraged shared accountability. Organizational support ensured access to adequate hand hygiene supplies. The main outcome measure was percent compliance with acceptable hand hygiene, defined as use of an alcohol-based product or hand-washing with soap and turning off the faucet without using fingers or palm. Compliance was defined as acceptable hand hygiene before and after contact with the patient or care environment. Covert bedside observers recorded at least 8 observations of physicians’ compliance per day. RESULTS: Physician compliance with proper hand hygiene improved to >95% within 6 months and was sustained for 11 months. CONCLUSIONS: Instituting a hand-washing champion for immediate identification and mitigation of failures was key in sustaining results. Improving physician compliance with proper hand hygiene is achievable and a first step in decreasing health care–associated infections.

Assessment of readability, understandability, and completeness of pediatric hospital medicine discharge instructions.

&NA; The average American adult reads at an 8th‐grade level. Discharge instructions written above this level might increase the risk of adverse outcomes for children as they transition from hospital to home. We conducted a cross‐sectional study at a large urban academic childrens hospital to describe readability levels, understandability scores, and completeness of written instructions given to families at hospital discharge. Two hundred charts for patients discharged from the hospital medicine service were randomly selected for review. Written discharge instructions were extracted and scored for readability (Fry Readability Scale [FRS]), understandability (Patient Education Materials Assessment Tool [PEMAT]), and completeness (5 criteria determined by consensus). Descriptive statistics enumerated the distribution of readability, understandability, and completeness of written discharge instructions. Of the patients included in the study, 51% were publicly insured. Median age was 3.1 years, and median length of stay was 2.0 days. The median readability score corresponded to a 10th‐grade reading level (interquartile range, 8‐12; range, 1‐13). Median PEMAT score was 73% (interquartile range, 64%‐82%; range, 45%‐100%); 36% of instructions scored below 70%, correlating with suboptimal understandability. The diagnosis was described in only 33% of the instructions. Although explicit warning signs were listed in most instructions, 38% of the instructions did not include information on the person to contact if warning signs developed. Overall, the readability, understandability, and completeness of discharge instructions were subpar. Efforts to improve the content of discharge instructions may promote safe and effective transitions home.

Improving the readability of pediatric hospital medicine discharge instructions

BACKGROUND: Readable discharge instructions may help caregivers understand and implement care plans following hospitalization. Many caregivers of hospitalized children, however, have limited literacy. We aimed to increase the percentage of discharge instructions written at 7th grade level or lower for hospital medicine patients from 13% to 80% in 6 months. METHODS: Quality improvement efforts targeted a 42‐bed unit at the community satellite of our large, urban academic hospital. A multidisciplinary team of physicians, nurses, and parents focused on key drivers: family engagement in discharge process, standardization of discharge instructions, staff engagement in discharge preparedness, and audit and feedback of data. Improvement cycles included 1) education and implementation of a general discharge instruction template in the electronic health record (EHR); 2) visible reminders and tips for writing readable discharge instructions; 3) implementation of disease‐specific discharge instruction templates in the EHR; and 4) individualized feedback to staff on readability and content of their written discharge instructions. Instructions were individually scored for readability using an online platform. An annotated control chart assessed the impact of interventions over time. RESULTS: Through sequential interventions over 6 months, the percentage of discharge instructions written at 7th grade or lower readability level increased from 13% to 98% and has been sustained for 4 months. The reliable use of the EHR templates was associated with our largest improvements. CONCLUSION: Use of standardized discharge instruction templates and rapid feedback to staff improved the readability of instructions. Next steps include adaptation and spread to other patient populations.

Preparing from the Outside Looking In for Safely Transitioning Pediatric Inpatients to Home

The transition of children from hospital to home introduces a unique set of challenges to patients and families who may not be well-versed in the healthcare system. In addition to juggling the stress and worry of a sick child, which can inhibit the ability to understand complicated discharge instructions prior to leaving the hospital,1 caregivers need to navigate the medical system to ensure continued recovery. The responsibility to fill and administer medications, arrange follow up appointments, and determine when to seek care if the child’s condition changes are burdens we as healthcare providers expect caregivers to manage but may underestimate how frequently they are reliably completed.2-4 In this issue of the Journal of Hospital Medicine, the article by Rehm et al.5 adds to the growing body of evidence highlighting challenges that caregivers of children face upon discharge from the hospital. The multicenter, retrospective study of postdischarge encounters for over 12,000 patients discharged from 4 children’s hospitals aimed to evaluate the following: (1) various methods for hospital-initiated postdischarge contact of families, (2) the type and frequency of postdischarge issues, and (3) specific characteristics of pediatric patients most commonly affected by postdischarge issues. Using standardized questions administered through telephone, text, or e-mail contact, postdischarge issues were identified in 25% of discharges across all hospitals. Notably, there was considerable variation of rates of postdischarge issues among hospitals (from 16% to 62.8%). The hospital with the highest rate of postdischarge issues identified had attending hospitalists calling families after discharge. Thus, postdischarge issues may be most easily identified by providers who are familiar with both the patient and the expected postdischarge care. Often, postdischarge issues represented events that could be mitigated with intentional planning to better anticipate and address patient and family needs prior to discharge. The vast majority of postdischarge issues identified across all hospitals were related to appointments, accounting for 76.3% of postdischarge issues, which may be attributed to a variety of causes, from inadequate or unclear provider recommendations to difficulty scheduling the appointments. The most common medication postdischarge issue was difficulty filling prescriptions, accounting for 84.8% of the medication issues. “Other” postdischarge issues (12.7%) as reported by caregivers included challenges with understanding discharge instructions and concerns about changes in their child’s clinical status. Forty percent of included patients had a chronic care condition. Older children, patients with more medication classes, shorter length of stay, and neuromuscular chronic care conditions had higher odds of postdischarge issues. Although a high proportion of postdischarge issues suggests a systemic problem addressing the needs of patients and families after hospital discharge, these data likely underestimate the magnitude of the problem; as such, the need for improvement may be higher. Postdischarge challenges faced by families are not unique to pediatrics. Pediatric and adult medical patients face similar rates of challenges after hospital discharge.6,7 In adults, the preventable nature of unexpected incidents, such as adverse drug events, occur most frequently.6 The inability to keep appointments and troubleshoot problems by knowing who to contact after discharge also emerged in adult studies as factors that may lead to preventable readmissions.8 Furthermore, a lack of direct, effective communication between inpatient and outpatient providers has been cited as a driving force behind poor care transitions.6,9 Given the prevalence of postdischarge issues after both pediatric and adult hospitalizations, how should hospitalists proceed? Physicians and health systems should explore approaches to better prepare caregivers, perhaps using models akin to the Seamless Transitions and (Re)admissions Network model of enhanced communication, care coordination, and family engagement.10 Pediatric hospitalists can prepare children for discharge long before departure by delivering medications to patients prior to discharge,11,12 providing discharge instructions that are clear and readable,13,14 as well as utilizing admission-discharge teaching nurses,15 inpatient care managers,16,17 and pediatric nurse practitioners18 to aid transition. While a variety of interventions show promise in securing a successful transition to home from the hospitalist vantage point, a partnership with primary care physicians (PCPs) in our communities is paramount. Though the evidence linking gaps in primary care after discharge and readmission rates remain elusive, effective partnerships with PCPs are important for ensuring discharge plans are carried out, which may ultimately *Address for correspondence: Angela M. Statile, MD, MEd, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue MLC 5018, Cincinnati, OH 45229; Telephone: 513-803-3237; Fax: 513-803-9244; E-mail: angela.statile@ cchmc.org

959 Improving timely transition of parenteral to enteral antibiotics in paediatric patients with pneumonia and cellulitis using quality improvement methods

Background Early transition of parenteral (IV) to enteral antibiotics is recommended to decrease hospital length of stay and healthcare costs. Without clear criteria to guide transition, patients at our hospital often remained on IV antibiotics until discharge despite clinical improvement. Objectives Increase the percentage of timely-transitioned anti-biotic doses (total enteral antibiotic doses divided by all anti-biotic doses in patients receiving other enteral medications) for Hospital Medicine (HM) patients admitted for uncomplicated pneumonia or skin and soft tissue infections (SSTI) from 44% to 75% by August 31, 2017. Methods Improvement efforts targeted five HM teams at a large paediatric academic hospital. Our multidisciplinary team included HM attendings, fellows, residents, and pharmacists. Several key drivers (Figure 1) informed our interventions. Interventions included education on IV and enteral antibiotic cost differential, incorporation of antibiotic transition plan in electronic health record (EHR) note templates, structured discussions of transition criteria for patients on IV antibiotics, and real-time identification of failures and feedback. An automated system that interfaced with our EHR provided data on medication administration route and missed opportunities for timely-transitioned antibiotic doses. An annotated statistical process control chart assessed the impact of interventions over time (figure 2). Results The percentage of timely-transitioned antibiotic doses increased from 44% to 80% within 8 months. The most effective interventions were early identification of transition criteria through structured huddles and real-time identification and mitigation of failures. Conclusions Identification of clear criteria for transition from IV to enteral antibiotics can increase timely transitions for patients with uncomplicated pneumonia and SSTI.Abstract 859 Figure 1 Key driver diagramAbstract 859 Figure 2 Control chart

Five Steps for Success in Building Your Own Educational Web Site

AS MILLENNIAL LEARNERS enter the medical field, they note a lag in innovation of medical education curricula, compared with peers in other fields. Whereas physician trainees conduct most of their self-directed learning using online and mobile resources, formalized medical education tends to be in lecture format. Most physician trainees use smartphones to query information and use electronic tablets to improve daily workflow in patient care and learning. Millennial physician trainees also prefer educational engagement beyond textbooks and journals, including multimedia and hands-on practice. Furthermore, learning spread across multiple modalities might enhance memory transfer and retention. Medical educators might be illprepared to adapt to the emerging digital shift in content creation, distribution, and consumption. Today’s educators must respond to the needs of our learners and move toward developing educational tools, such as Web sites, that allow for live and asynchronous learning.

Revisiting the History: Hypereosinophilia in a 4-Year-Old With Purpura

A 4-year-old boy with developmental delay was admitted for evaluation of a new rash in the setting of leukocytosis and eosinophilia. The patient was healthy until 1 week before admission when he developed cough, congestion, and malaise. Upon presentation, he was on day 5 of amoxicillin, prescribed by an outside provider for unclear indications, but he took no other medications on a regular basis. The day before presentation, his mother noted “red, flat, pimple-like” lesions on his upper thighs that progressively spread down his legs and resembled “bruises.” At a local hospital, a complete blood count (CBC) demonstrated a white blood cell (WBC) count of 66 600/mm3. Although the patient was afebrile and non–toxic appearing, a blood culture was obtained, and he received intramuscular ceftriaxone due to the profound leukocytosis and concerns for possible infection. He was subsequently transferred to the emergency department of our hospital for further evaluation. In the emergency department, vitals were notable for a pulse of 100 beats per minute, temperature of 35.2°C, respiratory rate of 32 breaths per minute, and oxygen saturation of 98% on room air and normal BMI for age. Physical examination was notable for a nontender, nonpruritic rash consisting of purpuric papules and macules of various stages of development on the bilateral lower extremities (Fig 1). He was otherwise well appearing with no joint or abdominal tenderness and no hepatosplenomegaly. Initial laboratories were notable for WBC count of 56 100/mm3 with 59% eosinophils and an absolute eosinophil count (AEC) of 33 100/mm3, a normal hematocrit of 37.2%, normal platelet count of 300 K/mcL, and normal coagulation markers. The patient was noted to have an elevated lactate dehydrogenase of 555 unit/L but normal uric acid level. A urinalysis obtained via a catheterized specimen was notable for trace protein and moderate blood; …

A Rare Case of Pulmonary Artery Sling and Complete Atrioventricular Canal Defect in an Infant With Trisomy 21.

Pulmonary artery sling is a very rare congenital vascular anomaly. Patients usually present in infancy with symptoms of airway compression. Patients with trisomy 21 often have upper airway obstruction, most commonly related to pharyngeal causes or subglottic stenosis. Although the incidence of congenital heart defects in patients with trisomy 21 is very high, a review of the literature showed only one previously reported case of pulmonary artery sling in an infant with trisomy 21. We report a case of pulmonary artery sling and complete atrioventricular canal defect in a one-month-old female with trisomy 21. Echocardiography is an important diagnostic method for pulmonary artery sling, but this anomaly may be easily overlooked in the presence of more commonly anticipated defects in this population.

Henoch-Schönlein Purpura With Hemoptysis: Is It Pneumonia or Something Else?

Case: An 18-year-old male presented to the emergency department with a 5-day history of a palpable purpuric rash, arthralgias, dark-colored urine, and severe abdominal pain. The patient was admitted to the hospital medicine service for further management. A urinalysis showed mild hematuria and trace proteinuria. An abdominal ultrasound was normal. He was diagnosed with Henoch-Schonlein purpura (HSP) and was started on prednisone by the hospital medicine team. His symptoms improved significantly, and he was subsequently discharged from the hospital on hospital day 4 (day 9 of illness) to complete a 2-week taper of prednisone (initially started on 80 mg/day with instructions to decrease the dose by 20 mg every 5 days) and to follow up with his primary care physician. On day 15 of illness, the patient presented to the emergency department with worsening upper and lower extremity edema, arthralgia, and palpable purpura, new-onset shortness of breath, hemoptysis, and epistaxis. No fever was reported. He was at the time taking 60 mg of oral prednisone per day. On physical examination, the patient was pale in appearance but was not in acute distress. Vital signs showed elevated blood pressure of 148/69 mm Hg, temperature of 36°C (96.8°F), heart rate of 89 beats per minute, respiratory rate of 18 breaths per minute, and oxygen saturation of 99% on room air. He had normal respiratory effort, and lungs were clear on auscultation with good air movement. A new systolic ejection murmur best heard at the left upper sternal border was appreciated, and the patient was also noted to have pitting edema in the lower extremities bilaterally. Abdominal examination was reassuring, and there were normal bowel sounds with no abdominal tenderness or distention. Laboratory evaluation revealed a slight increase in the serum creatinine level from 0.59 to 0.68 mg/dL, significant proteinuria (300 mg/dL; urine …