Peter Lachman

Development of an Electronic Pediatric All-Cause Harm Measurement Tool Using a Modified Delphi Method.

Objectives To have impact on reducing harm in pediatric inpatients, an efficient and reliable process for harm detection is needed. This work describes the first step toward the development of a pediatric all-cause harm measurement tool by recognized experts in the field. Methods An international group of leaders in pediatric patient safety and informatics were charged with developing a comprehensive pediatric inpatient all-cause harm measurement tool using a modified Delphi technique. The process was conducted in 5 distinct steps: (1) literature review of triggers (elements from a medical record that assist in identifying patient harm) for inclusion; (2) translation of triggers to likely associated harm, improving the ability for expert prioritization; (3) 2 applications of a modified Delphi selection approach with consensus criteria using severity and frequency of harm as well as detectability of the associated trigger as criteria to rate each trigger and associated harm; (4) developing specific trigger logic and relevant values when applicable; and (5) final vetting of the entire trigger list for pilot testing. Results Literature and expert panel review identified 108 triggers and associated harms suitable for consideration (steps 1 and 2). This list was pared to 64 triggers and their associated harms after the first of the 2 independent expert reviews. The second independent expert review led to further refinement of the trigger package, resulting in 46 items for inclusion (step 3). Adding in specific trigger logic expanded the list. Final review and voting resulted in a list of 51 triggers (steps 4 and 5). Conclusions Application of a modified Delphi method on an expert-constructed list of 108 triggers, focusing on severity and frequency of harms as well as detectability of triggers in an electronic medical record, resulted in a final list of 51 pediatric triggers. Pilot testing this list of pediatric triggers to identify all-cause harm for pediatric inpatients is the next step to establish the appropriateness of each trigger for inclusion in a global pediatric safety measurement tool.

Multi-method evaluation of a paediatric ambulatory care unit (PACU): impact on families and staff

Aim: To assess the impact of a purpose-built, short stay paediatric ambulatory care unit (PACU) on the patient journey and perceptions of parents, staff and referrers. Methods: Multi-method evaluation, including a parent survey (n = 104), patient journey mapping (n = 10), staff interviews (n = 10), a referrer survey (n = 16), routine activity analysis, and a comparison with the A&E service (A&E parent survey: n = 41). Results: Almost all parents attending PACU (94%) were satisfied with the service and significantly more likely to feel “very” satisfied than parents attending A&E (PACU: 51%, A&E: 31%; p = 0.03). Further, over three quarters (77%) of PACU parents preferred the new model to traditional A&E services. They reported receiving sufficient information (93%), reduced anxiety (55% anxious before service, 13% anxious after; p<0.001), “quick” waiting times (median: 35 min), and enhanced confidence (87%) and understanding (89%) in dealing with their ill child. The number of stages in the patient journey was reduced from six (“traditional” A&E pathway) to four (PACU pathway). Staff and referrers reported this was a “superior” model to A&E, but that improvements were required around appropriate referrals and the need for more multi-disciplinary protocols and liaison. Conclusion: Our study suggests that the PACU model is perceived to be an effective alternative to standard A&E services for the assessment and early management of acutely ill children and their families attending a hospital. It is highly valued by users, staff and referrers and enhances the patient journey. Lessons learnt include the need to enhance multi-disciplinary processes and clarify the role of this form of acute care provision in the wider healthcare system.

Quality of Health Care for Children in Australia, 2012-2013.

Importance The quality of routine care for children is rarely assessed, and then usually in single settings or for single clinical conditions. Objective To estimate the quality of health care for children in Australia in inpatient and ambulatory health care settings. Design, Setting, and Participants Multistage stratified sample with medical record review to assess adherence with quality indicators extracted from clinical practice guidelines for 17 common, high-burden clinical conditions (noncommunicable [n = 5], mental health [n = 4], acute infection [n = 7], and injury [n = 1]), such as asthma, attention-deficit/hyperactivity disorder, tonsillitis, and head injury. For these 17 conditions, 479 quality indicators were identified, with the number varying by condition, ranging from 9 for eczema to 54 for head injury. Four hundred medical records were targeted for sampling for each of 15 conditions while 267 records were targeted for anxiety and 133 for depression. Within each selected medical record, all visits for the 17 targeted conditions were identified, and separate quality assessments made for each. Care was evaluated for 6689 children 15 years of age and younger who had 15 240 visits to emergency departments, for inpatient admissions, or to pediatricians and general practitioners in selected urban and rural locations in 3 Australian states. These visits generated 160 202 quality indicator assessments. Exposures Quality indicators were identified through a systematic search of local and international guidelines. Individual indicators were extracted from guidelines and assessed using a 2-stage Delphi process. Main Outcomes and Measures Quality of care for each clinical condition and overall. Results Of 6689 children with surveyed medical records, 53.6% were aged 0 to 4 years and 55.5% were male. Adherence to quality of care indicators was estimated at 59.8% (95% CI, 57.5%-62.0%; n = 160 202) across the 17 conditions, ranging from a high of 88.8% (95% CI, 83.0%-93.1%; n = 2638) for autism to a low of 43.5% (95% CI, 36.8%-50.4%; n = 2354) for tonsillitis. The mean adherence by condition category was estimated as 60.5% (95% CI, 57.2%-63.8%; n = 41 265) for noncommunicable conditions (range, 52.8%-75.8%); 82.4% (95% CI, 79.0%-85.5%; n = 14 622) for mental health conditions (range, 71.5%-88.8%); 56.3% (95% CI, 53.2%-59.4%; n = 94 037) for acute infections (range, 43.5%-69.8%); and 78.3% (95% CI, 75.1%-81.2%; n = 10 278) for injury. Conclusions and Relevance Among a sample of children receiving care in Australia in 2012-2013, the overall prevalence of adherence to quality of care indicators for important conditions was not high. For many of these conditions, the quality of care may be inadequate.

CareTrack Kids-part 3. Adverse events in children's healthcare in Australia: study protocol for a retrospective medical record review.

Introduction A high-quality health system should deliver care that is free from harm. Few large-scale studies of adverse events have been undertaken in childrens healthcare internationally, and none in Australia. The aim of this study is to measure the frequency and types of adverse events encountered in Australian paediatric care in a range of healthcare settings. Methods and analysis A form of retrospective medical record review, the Institute of Healthcare Improvements Global Trigger Tool, will be modified to collect data. Records of children aged <16 years managed during 2012 and 2013 will be reviewed. We aim to review 6000–8000 records from a sample of healthcare practices (hospitals, general practices and specialists). Ethics and dissemination Human Research Ethics Committee approvals have been received from the Sydney Childrens Hospital Network, Childrens Health Queensland Hospital and Health Service, and the Womens and Childrens Hospital Network in South Australia. An application is under review with the Royal Australian College of General Practitioners. The authors will submit the results of the study to relevant journals and undertake national and international oral presentations to researchers, clinicians and policymakers.

From harm to hope and purposeful action: what could we do after Francis?

Responses to the reports on the inquiry into Mid Staffordshire have resulted in calls from politicians, NHS leaders and the public to improve care across the NHS in England. However, the substance of what needs to be done remains unclear. In this paper, we offer seven key ‘ingredients’ required to sustain improvement of care, supported by evidence drawn from published literature. We believe that empowering and upskilling the front-line workforce in understanding and implementing improvement techniques, supported by changes at system and policy level and reinforced by what leaders say and do, will result in sustainable benefit for patients and families, as well as greater satisfaction for staff.

Paediatric trainees and the quality improvement agenda: don't just do another audit.

Over the past century, medicine and the delivery of healthcare have undergone constant change with a predilection for some common populist themes. Most of these have been driven by direct need – the Public Health agenda in Victorian times, development of triage and infection control in the Great Wars, and recently the explosion of the need to justify the way we do things with a strong evidence base. Over the past 10 years Quality Improvement has become the new challenge, a theme which is supported by both governments and health leaders. In some ways paediatricians have been at the forefront of quality improvement methodology. The need for clinical practice guidelines and standards of care, for example in neonatology, have been evident. However the implementation of new theories and practices in large health systems has always been a complex and frustrating process. Clinicians seldom embrace change easily and have not been trained in the theories and methodologies commonly used in other industries. Often intervention at an early stage of training is the key to enabling change to become ingrained in a clinicians day-to-day work. Trainee doctors are integral to delivering patient care in many healthcare organizations. As a body, they have huge experience of system processes and how they differ from one organization to the other, moving, as they often do, from hospital to hospital. This group of doctors should be expected and supported to use these insights to identify areas where systems are under-performing, where risks might be reduced and safety enhanced, where processes are inefficient. Trainees are an untapped resource which could be directly involved in identifying solutions and effecting change. Trainees in paediatrics are no different, and one could argue its process driven nature make the specialty more receptive the quality improvement methodologies than others. Batalden and Davidoff1 define quality improvement as ‘the combined and unceasing efforts of everyone – healthcare professionals, patients and their families, researchers, payers, planners and educators – to make the changes that will lead to better patient outcomes (health), better system performance (care) and better professional development (learning)’. Paediatric trainees in the UK have minimal or no meaningful involvement in the processes of improving the quality of the systems which deliver patient care. They simply are not taught the methodologies as part of their training, nor are invited to participate in quality improvement initiatives. Although it is a requirement that trainees demonstrate involvement in audit, the findings of these time and labour-intensive exercises are often never presented, and very rarely lead to meaningful and sustainable change (personal communication with Emma Stanton, 2010). Data gathering should not be the sole aim of the process (as is often the case in current trainee audit projects), but should rather have the aim of analysing systems, critically appraising process, proposing solutions, and being supported in implementing changes to improve clinical outcomes. A quality improvement agenda, delivered within training programmes starting in medicals schools should not have to compete with the current curriculum and assessment burden that doctors in training in the UK currently face. It should be integral within it, as it will be vital for the future delivery of services. In the same way as evidence-based medicine now permeates throughout clinical practice (it is difficult to consider a clinical consultation in which the benefits of action or inaction are not considered) delivering high quality care should be regarded as an essential standard. In this context simply performing an audit would be considered an unacceptable training standard to promote. Although potentially a bitter pill to swallow for traditionalists, the benefits of this new approach are apparent for many stakeholders.

The right care, every time: improving adherence to evidence-based guidelines

Guidelines are integral to reducing variation in paediatric care by ensuring that children receive the right care, every time. However, for reasons discussed in this paper, clinicians do not always follow evidence-based guidelines. Strategies to improve guideline usage tend to focus on dissemination and education. These approaches, however, do not address some of the more complex factors that influence whether a guideline is used in clinical practice. In this article, part of the Equipped Quality Improvement series, we outline the literature on barriers to guideline adherence and present practical solutions to address these barriers. Examples outlined include the use of care bundles, integrated care pathways and quality improvement collaboratives. A sophisticated information technology system can improve the use of evidence-based guidelines and provide organisations with valuable data for learning and improvement. Key to success is the support of an organisation that places reliability of service delivery as the way business is done. To do this requires leadership from clinicians in multidisciplinary teams and a system of continual improvement. By learning from successful approaches, we believe that all healthcare organisations can ensure the right care for each patient, every time.