Improving Accuracy of Handoff by Implementing an Electronic Health Record-generated Tool: An Improvement Project in an Academic Neonatal Intensive Care Unit.

BACKGROUND: Written patient handoffs are susceptible to errors or incompleteness. The accuracy is dependent on the person inputting the information. Thus, handoff printouts generated by electronic health records (EHR) with automation reduces the risk of transcription errors and improves consistency in format. This single-center quality improvement project aims to increase the accuracy of handoff printouts with an EHR-generated handoff tool. METHODS: This project used a plan-do-study-act methodology. Participants included registered nurses, neonatal nurse practitioners, neonatal hospitalists, pediatric residents, neonatal fellows, and neonatologists. The goals were to (1) increase accuracy of information to 80%, (2) reduce verbal handoff time by 20%, (3) reduce the frequency of incorrectly listed medications below 20%, and (4) improve user satisfaction by 1 point (on a 5-point Likert scale) over 6 months. Baseline assessment included a survey and a review of handoff reports 4 months before transitioning to the new handoff tool. We created a new handoff tool using EHR autogenerated phrases (Epic SmartPhrases) and autopopulated fields for pertinent Neonatal Intensive Care Unit patient data. RESULTS: After the unit-wide implementation of the new tool, the accuracy of 16 patient data points increased from 51% to 97%, while the frequency of patients with incorrectly listed medications decreased from 51% to 0%. Handoff time remained unchanged, while a 5-question user satisfaction survey showed an increase on the Likert scale. CONCLUSIONS: We demonstrated that handoff printouts generated by EHR have fewer inaccuracies than manually scripted versions and do not add to the time required to give verbal handoff.

Clinical decision support tool for phototherapy initiation in preterm infants.

OBJECTIVE: Adherence to guidelines for phototherapy initiation in preterm infants was 39% in our academic NICU (61% of phototherapy was initiated at total bilirubin (TB) levels below recommended thresholds). We hypothesized that adoption of an electronic health record integrated clinical decision support (CDS) tool would improve adherence to phototherapy guidelines. STUDY DESIGN: We developed and implemented Premie BiliRecs (PBR), a novel CDS tool for phototherapy initiation in preterm infants from 27 through 34 weeks postmenstrual age. The primary outcome measure was the proportion of phototherapy initiation events consistent with recommended TB thresholds. RESULT: Following the implementation of PBR, adherence to guidelines for phototherapy initiation in preterm infants increased to 69.8% (p < 0.001), an improvement of 77%. There was no increase in the incidence of severe hyperbilirubinemia nor exchange transfusions. CONCLUSION: The adoption of PBR was associated with improved adherence to phototherapy guidelines in preterm infants without increased adverse events.

Development of a Web-Based Decision Support Tool to Operationalize and Optimize Management of Hyperbilirubinemia in Preterm Infants.

Premie BiliRecs is a novel electronic clinical decision support tool for the management of hyperbilirubinemia in moderately preterm infants less than 35 weeks gestational age. It serves to operationalize and automate current expert consensus-based guidelines, and to aid in the generation of new practice-based evidence to inform future guidelines.

Early Childhood Screen Time and Parental Attitudes Toward Child Television Viewing in a Low-Income Latino Population Attending the Special Supplemental Nutrition Program for Women, Infants, and Children.

BACKGROUND: Early childhood media exposure is associated with obesity and multiple adverse health conditions. The aims of this study were to assess parental attitudes toward childhood television (TV) viewing in a low-income population and examine the extent to which child BMI, child/parent demographics, and household media environment are associated with adherence to American Academy of Pediatrics (AAP) guidelines for screen time. METHODS: This was a cross-sectional survey study of 314 parents of children ages 0-5 years surveyed in English or Spanish by self-administered questionnaire at a Special Supplemental Nutrition Program for Women, Infants and Children (WIC) clinic in Oregon. RESULTS: In this majority Latino sample (73%), half (53%) of the children met AAP guidelines on screen time limits, 56% met AAP guidelines for no TV in the child's bedroom, and 29% met both. Children were more likely to meet AAP guidelines when there were <2 TVs in the home, there was no TV during dinner, or their parents spent less time viewing electronic media. Parents who spent less time viewing electronic media were more likely to report believing that TV provides little value or usefulness. CONCLUSIONS: In this low-income, predominantly Latino population attending WIC, parent media-viewing and household media environment are strongly associated with child screen time. Programs aimed at reducing child screen time may benefit from interventions that address parental viewing habits.

Red blood cell transfusion is not associated with necrotizing enterocolitis: a review of consecutive transfusions in a tertiary neonatal intensive care unit.

OBJECTIVE: To explore the association between red blood cell transfusion and necrotizing enterocolitis (NEC) in a neonatal intensive care unit with liberal transfusion practices. STUDY DESIGN: A retrospective cohort study was conducted for all infants weighing <1500 g who received at least 1 packed red blood cell transfusion between January 2008 and June 2013 in a tertiary neonatal intensive care unit. The primary outcome was NEC, defined as Bell stage II or greater. The temporal association of NEC and transfusion was assessed using multivariate Poisson regression. RESULTS: The study sample included 414 very low birth weight infants who received 2889 consecutive red blood cell transfusions. Twenty-four infants (5.8%) developed NEC. Four cases of NEC occurred within 48 hours of a previous transfusion event. Using multivariate Poisson regression, we did not find evidence of a temporal association between NEC and transfusion (P = .32). CONCLUSION: There was no association between NEC and red blood cell transfusion. Our results differ from previous studies and suggest that the association between NEC and transfusion may be contextual.

Prevention of Kernicterus in South Asia: role of neonatal G6PD deficiency and its identification.

Extreme hyperbilirubinemia (EHB) caused by neonatal glucose-6-phosphate dehydrogenase (G6PD) deficiency is strongly associated with mortality and long-term neurodevelopmental impairment, yet there are limited national strategies to reduce this burden in South Asia. Current known and predicted prevalence of G6PD deficiency in Afghanistan, Bangladesh, Bhutan, India, Nepal, and Pakistan ranges from 3.8 to 15 %, with regional "hot spots" exceeding 22 %. Annually, 3.14 million infants are born at risk for this condition. In 2010, South Asian countries reported 37 million (27 %) of world-wide livebirths ≥ 32 wk gestational-age and G6PD deficiency accounted for > 33 % of the global EHB burden, in contrast to 2.2 % for those born in high-income nations. Traditional national approach includes universal newborn screening in malaria-endemic countries or those with prevalence >3.5 %. However, screening implementation should be best optimized using timely quantitative enzyme assay and identification of at-risk female newborns. Furthermore, economic and social constraints, in context of sub-regional variances, call for flexible problem-solving methods in anticipation of changing community demographics. Thus, incremental and need-based newborn screening programs could be the most optimal approach. A human-centered design (HCD) approach, as an alternate pathway, could build the evidence to translate the complex biology of G6PD deficiency and the biodesign of affordable technologies, allowing facilitation of access to knowledge and services, in order to deliver on a long-term public health mandate. Key steps would encompass the initiation of local inquiry of both quantitative and qualitative data to identify at-risk communities and to prospectively design for local innovative solutions.