Promoting Effective Communication with Limited English Proficient Families: Implementation of Video Remote Interpreting as Part of a Comprehensive Language Services Program in a Children's Hospital.

The aim of this study was to evaluate the process of implementing video remote interpreting (VRI) in a hospital already using in-person and over-the-phone interpreting (OPI), including the impact on utilization of language services, efficiency, and costs, as well as implementation challenges. METHODS: A prospective program-evaluation design was used. From 2012 to 2017, 165 VRI carts and iPads were rolled out in clinics, inpatient wards, and the emergency department. Each area was supported for six weeks with training and problem-solving issues. Additional VRI rollouts occurred in groups, every two to four months. Outcomes were assessed using utilization and observation/interview data. RESULTS: Postimplementation, 50,611 VRI encounters occurred for a total of 556,938 interpretation minutes. OPI decreased by 37.5%. Mean wait time for language services fell from 60 to 5 minutes. Rapid VRI uptake (> 10,000 VRI minutes in Year 1) occurred in clinics previously lacking access to in-person interpreters. VRI was associated with in-person interpreters having more time for professional development activities and with five promotions. Implementation challenges included initial resistance to VRI use, device connectivity problems, and six months' lead-in time to establish proper VRI use. Challenges were overcome through ongoing education, dialogue, and implementation rounds. CONCLUSION: After overcoming initial challenges, VRI implementation, as part of provision of comprehensive language services, can potentially yield several benefits, including immediate extensive use, decreased OPI, reduced wait times for language services, rapid uptake in clinics previously lacking in-person interpreter access, and increased average minutes per encounter by in-person interpreters.

Preoperative Educational Intervention Decreases Unplanned Gastrostomy-Related Health Care Utilization.

Apprehension in taking independent care of children with medical devices may lead to unnecessary visits to the ED and/or acute clinic (AC). To address these concerns, our institution implemented a gastrostomy tube (GT) class in 2011 for caretakers. We hypothesized that inappropriate GT-related ED/AC visits would be lower in preoperatively educated caregivers. We performed a retrospective cohort study of all patients aged 0 to 18 who received GT (surgical or percutaneous) at our institution between 2006 and 2015 (n = 1340). Class attendance (trained vs untrained) and unscheduled GT-related ED/AC visits one year after GT placement were reviewed. Gastrostomy-related ED/AC visits were classified as appropriate (hospital-based intervention) or inappropriate (site care and education/reassurance). Occurrence of ED/AC visits was compared between trained and untrained cohorts. We found that 59 per cent of patients had an unscheduled GT-related ED/AC visit within one year of placement. The trained cohort had 27 per cent less unplanned ED/AC visits within one year (mean 1.21 (SD 1.82) vs untrained 1.65 (2.24), P < 0.001). On multivariate analysis, GT education independently decreased one-year GT-related health care utilization (Odds Ratio 0.75, 95% Confidence Interval 0.59-0.95). Formal education seems to decrease GT-related health care utilization within one year of placement and should be integrated into a comprehensive care plan to improve caregiver self-efficacy.

Creating a Professional Ladder for Interpreters for Improvement of Care.

BACKGROUND: Children's Hospital Los Angeles (CHLA), a metropolitan academic medical center, recognized limitations in how the professional interpreters from the Diversity Services Department were used to support effective patient-provider communication across the organization. Given the importance of mitigating language and communication barriers, CHLA sought to minimize clinical and structural barriers to health care for limited English proficiency populations through a comprehensive restructuring of the Diversity Services Department. This approach entailed a new delivery model for hospital language assistance and cultural consultancy resources. METHODS: The intervention focused on restructuring the Diversity Services Department, redefining priorities, reallocating resources, and redefining the roles of the language staff positions in the department. The language staff role was redesigned to fit a four-level professional career ladder modeled after the professional career ladders commonly used in hospitals for the RN role and other professional disciplines. The approach involved creating new levels of language specialist, each with progressive requirements for performance, leadership, and accountability for patient care outcomes. Language staff in the inpatient, clinic, and emergency department settings worked alongside nurses, physicians, and other disciplines to care for a specific set of patients. RESULTS: The result of this work was a positive culture change resulting in service efficiencies, care improvements, and improved access to language services. CONCLUSIONS: A professional career ladder for language staff contributed to improving the quality and access of language services and advancing the interpreting profession by incorporating care coordination support, vital document translation, and cultural consultancy.

Pediatric Early Warning Score and unplanned readmission to the pediatric intensive care unit.

BACKGROUND AND OBJECTIVES: Early unplanned Pediatric Intensive Care Unit (PICU) readmission is associated with greater length of stay and mortality. No tools exist to identify children at risk for PICU readmission. The Pediatric Early Warning Score (PEWS) currently identify children at risk for deterioration on the ward. Our primary objective was to evaluate the ability of PEWS to identify children at risk for unplanned PICU readmission. METHODS: A single-center case-control study of 189 children (38 cases and 151 age-matched controls) 18years or younger transferred from the PICU to the pediatric ward from January 1, 2010-March 30, 2013, at an urban tertiary care children's hospital was conducted. RESULTS: Thirty-eight cases had unplanned PICU readmission within 48hours of transfer to pediatric ward, whereas 151 controls were not readmitted. The PEWS assigned prior to PICU discharge and first PEWS assigned on the ward were collected for cases and controls. Each 1-point increase in the PEWS score significantly increased risk of PICU readmission (odds ratios [95% confidence intervals], 1.6 [1.12-2.27; P = .009] and 1.89 [1.33-2.69; P < .001], respectively). Discrimination ability of PEWS for PICU readmission improved when chronic diagnoses were included. CONCLUSIONS: Higher PEWS scores were associated with increased risk of unplanned PICU readmission. However, cutoff scores are not sensitive or specific enough to be clinically useful. Adding chronic disease variables may improve the clinical utility of cutoff PEWS scores.

Substance use trends among younger vs. older homeless parolees.

This cross-sectional study of 540 homeless ex-offenders exiting prisons and jails assessed sociodemographic, childhood, and drug-related differences. Older ex-offenders from prison were more likely to have been married, come from a two-parent family, and used crack, whereas younger ex-offenders from prison were more likely to have used methamphetamine. Older ex-offenders from jail were more likely to be African American, have children, and report a history of crack and injection drug use, whereas younger ex-offenders from jail were more likely to have engaged in binge drinking and be in a gang. Our findings showcase the need to understand unique correlates of younger and older incarcerated populations.

Improving home management plan of care compliance rates through an electronic asthma action plan.

BACKGROUND: In 2007, the Joint Commission mandated reporting of three children's asthma care (CAC) measures for hospitalized patients with asthma. The third children's asthma care measure (CAC-3) focuses on hospital discharge with a comprehensive home management plan of care (HMPC) based on the clinical severity. OBJECTIVE: To improve CAC-3 compliance and identify what interventions would have the most impact. METHODS: This was a retrospective observational study, conducted at the Children's Hospital Los Angeles (CHLA) between October 2008 and January 2012. A total of 470 patients admitted with a primary diagnosis of asthma were included. Four Plan-Do-Study-Act cycles testing separate interventions were used throughout the study period: clinical care coordinators (CCCs), red clipboard for paper HMPC, electronic HMPC, and hard-stop HMPC. Chi-square and binomial tests compared CHLA's CAC-3 compliance rates within intervention windows as well as to the national average. RESULTS: Between October 2008 and May 2009, CHLA had a compliance rate of 39%, well below the national average (p = .001). Involvement of CCCs increased the overall compliance to 74% (χ(2)(1) = 11.59, p < .001). Implementation of an electronic HMPC in October 2010 led to the largest increase in overall compliance (93%) when compared to the previous intervention window (χ(2)(1) = 4.38, p < .036), as well as the national average (p = .016). Compliance rates remained above 90% for four out of the following five quarters. CONCLUSIONS: Involvement of CCCs led to a significant increase in the overall CAC-3 compliance. An electronic HMPC improved rates well above the national average. This provides a framework for other institutions that may or may not utilize an electronic medical record.