"Good Catch, Kiddo"-Enhancing Patient Safety in the Pediatric Emergency Department Through Simulation.

OBJECTIVES: Adverse events that affect patient safety are a significant concern in pediatrics. Increasing situational awareness, identifying errors and near misses, and reporting them using organizational incident reporting systems enables mitigation of harm. METHODS: We designed and tested a brief, interactive, and easily replicable simulation activity for medical students, and emergency medicine interns and pediatric interns to strengthen their skills and enhance their self-efficacy in identifying and reporting patient safety hazards. Hazards fell into the categories of situational safety, patient identification and privacy, infection prevention, treatment errors, and issues with electronic health records (EHRs). RESULTS: The simulation training significantly increased the self-efficacy of medical students and interns in identifying and reporting patient safety hazards. Learners were very satisfied with the simulation training, successfully recognized key patient safety hazards, provided feedback to improve the training, and improved their ability to report hazards through organizational incident reporting systems. Patient safety hazards associated with patient misidentification were recognized most frequently, whereas safety hazards associated with EHRs were missed with the greatest frequency. CONCLUSIONS: The simulation training enabled learners to identify hazards and near misses and enhanced their ability to report hazards through organizational incident reporting systems. Learners at all levels of training identified safety hazards at comparable rates, which demonstrates the role that trainees play in critically observing clinical settings with fresh eyes and identifying and reporting patient safety hazards. Interventions to promote patient safety need to prioritize building situational awareness of potential hazards associated with EHR use.

Improving Pediatric Resident Safety Event Reporting Using Quality Improvement Methods.

BACKGROUND AND OBJECTIVES: Safety event reporting systems facilitate identification of system-level targets to improve patient safety. Resident physicians report few safety events despite their role as frontline providers and the frequent occurrence of events. The objective of this study is to increase the number of pediatric resident safety event submissions from <1 to 4 submissions per 14-day period within 12 months. METHODS: We conducted an iterative quality improvement process with 39 pediatric residents at a children's hospital. Interventions focused on 4 key drivers: user-friendly event submission process, resident buy-in, nonpunitive safety culture, and data transparency. The primary outcome measure of number of pediatric resident event submissions was analyzed by using statistical process control. Balancing measures included time from submission to feedback, duplicate submissions, and nonevent submissions. As a control, the primary outcome measure was monitored for nonpediatric residents during the same period. RESULTS: The mean number of pediatric resident event submissions increased from 0.9 to 5.7 submissions per 14 days. Impactful interventions included a designated space in the resident workroom to list safety events to submit, monthly project updates, and an interresident competition. There were no duplicate submissions or nonevent submissions in the postintervention period. Time to feedback in the postintervention period had both upward and downward shifts, with >8 consecutive points above and below the baseline period's centerline. The control group showed no sustained change in event submissions. CONCLUSIONS: Our improvement process was associated with significant increase in pediatric resident safety event submissions without an increase in the number of submissions categorized as duplicates or nonevents.

Testing Pediatric Emergency Telemedicine Implementation Strategies Using Quality Improvement Methods.

Background: Despite the recognized benefits of telemedicine use for pediatric emergency consultations, there are barriers to the widespread uptake of this technology. Quality improvement methods can be used to rapidly test implementation strategies. Our objective was to test telemedicine implementation strategies in real-world application using quality improvement methods. Our quality improvement aim was to achieve high rates of telemedicine use for pediatric transfer consultations. Methods: A multidisciplinary multisite improvement team identified that key drivers of increasing telemedicine use included telemedicine resource awareness, streamlined telemedicine workflow, provider buy-in, and data transparency. Interventions focused on telemedicine trainings, disseminating telemedicine uptake data, telemedicine reminders, telemedicine test calls, and preparing for telemedicine use for every transfer consultation. The outcome measure was percentage of pediatric emergency transfer consultations that used telemedicine. The balancing measure was time (minutes) from the initial transfer center call to completion of the consultation. Results: Multiple plan-do-study-act cycles were associated with special cause variation, with an upward shift in mean percentage of telemedicine use from 5% to 22%. Time from initial call to consultation completion remained unchanged. Conclusion: Our study supports the use of quality improvement methods to test telemedicine implementation strategies for pediatric telemedicine emergency consultations.

Association of Race and Ethnicity with Sedation Management in Pediatric Intensive Care.

Rationale: Racial disparities in pain management have been previously reported for children receiving emergency care.Objectives: To determine whether patient race or ethnicity is associated with the broader goal of pain management and sedation among pediatric patients mechanically ventilated for acute respiratory failure.Methods: Planned secondary analysis of RESTORE (Randomized Evaluation of Sedation Titration for Respiratory Failure). RESTORE, a cluster-randomized clinical trial conducted in 31 U.S. pediatric intensive care units, compared protocolized sedation management (intervention arm) with usual care (control arm). Participants included 2,271 children identified as non-Hispanic white (white, n = 1,233), non-Hispanic Black (Black, n = 502), or Hispanic of any race (Hispanic, n = 536).Results: Within each treatment arm, neither opioid nor benzodiazepine selection, nor cumulative dosing, differed significantly among race and ethnicity groups. Black patients experienced fewer days with an episode of pain (compared with white patients in the control arm and with Hispanic patients in the intervention arm) and experienced less iatrogenic withdrawal syndrome (compared with white patients in either arm or with Hispanic patients in the intervention arm). The percentage of days awake and calm while intubated was not significantly different in pairwise comparisons by race and ethnicity groups in either the control arm (median: white, 75%; Black, 71%; Hispanic, 75%) or the intervention arm (white, 86%; Black, 88%; Hispanic, 85%).Conclusions: Across multiple measures, our study found scattered differences in sedation management among critically ill Black, Hispanic, and white children that did not consistently favor any group. However, racial disparities related to implicit bias cannot be completely ruled out.Clinical trial registered with clinicaltrials.gov (NCT00814099).

Interprofessional/interdisciplinary teamwork during the early COVID-19 pandemic: experience from a children's hospital within an academic health center.

The COVID-19 pandemic has created multiple, complex and intense demands on hospitals, including the need for surge planning in the many locations outside epicenters such as northern Italy or New York City. We here describe such surge planning in an Academic Health Center that encompasses a children's hospital. Interprofessional teams from every aspect of inpatient care and hospital operations worked to prepare for a COVID-19 surge. In so doing, they successfully innovated ways to integrate pediatric and adult care and maximize bed capacity. The success of this intense collaborative effort offers an opportunity for ongoing teamwork to enhance efficient, effective, and high-quality patient care.

Developing an Interfacility Transfer Handoff Intervention: Applying the Person-Based Approach Method.

OBJECTIVE: To develop an interfacility transfer handoff intervention by applying the person-based approach method. METHODS: We conducted a qualitative study that used nominal group technique (NGT) and focus groups to apply the person-based approach for intervention development. NGT methods were used to determine prioritized pediatric transfer handoff elements to design the initial intervention prototype. Five focus group sessions were then held to solicit feedback on the intervention, perceptions on implementing the intervention, and outcomes for evaluating the intervention. Data were analyzed by using content analysis. Iterative improvements were made to the intervention prototype as data emerged. RESULTS: Forty-two clinical providers in total participated in NGT and focus group sessions, including physicians, advanced practitioners, nurses, and a respiratory therapist. The initial intervention prototype was a handoff mnemonic tool, "SHARING" (short introduction, how the patient appeared, action taken, responses and results, interpretation, next steps, gather documents). Perceived benefits of the intervention included clarifying handoff expectations, reducing handoff deficits, supporting less experienced clinical providers, and setting the stage for ongoing effective communication. Outcomes perceived to be meaningful were related to triage appropriateness, workflow and use, and communication and information sharing. The final version of the intervention consisted of a SHARING reference card and a SHARING electronic medical record note template. CONCLUSIONS: Using qualitative methods to apply the person-based approach to intervention development, we developed a transfer handoff intervention. Future research is needed to examine impacts of this tool; outcomes can include those identified as meaningful by participants in our present study.

Interprofessional Approach to the Sustained Reduction in Ventilator-Associated Pneumonia in a Pediatric Intensive Care Unit.

BACKGROUND: Ventilator-associated pneumonia (VAP) increases morbidity, mortality, and health care costs. OBJECTIVE: To reduce the VAP rate in the pediatric/cardiac intensive care unit to fewer than 2 events per 1000 ventilator days within 2 years and to sustain a rate near 0 for the next 5 years. METHODS: An evidence-based VAP prevention bundle was developed and implemented by an interprofessional team using the Six Sigma Define, Measure, Analyze, Improve, Control methodology. The mixed unit's 5-element VAP prevention bundle consisted of age-appropriate oral care, proper airway suction technique, maintenance of safe endotracheal-tube cuff pressures, aspiration precautions, and head-of-bed elevation. Knowledge and practice were reinforced through multidisciplinary education and one-on-one teaching. Practice compliance was monitored through regular, unannounced bedside audits linked to just-in-time teaching. RESULTS: Within 2 years, the annual VAP rate fell from 7.86 to 1.16 events per 1000 ventilator days; VAP bundle-element compliance ranged from 86% to 99%. There were no VAP events during a 10-quarter period in 2012 through 2014. CONCLUSIONS: Development, implementation, and revision of a VAP prevention strategy using the Define, Measure, Analyze, Improve, Control methodology was associated with marked, sustained reduction in VAP rates, notably during the unit's expansion from 16 to 24 beds, the opening of a pediatric cardiothoracic unit, and the hiring of more than 80 new nurses. After 7 years, the VAP rate continues to be low at 0.86 for 2016 and 0 through June 2017.

Illness Severity of Children Admitted to the PICU From Referring Emergency Departments.

OBJECTIVES: To compare patient factors and outcomes among children admitted to PICUs from referring versus children's hospital emergency departments (EDs). METHODS: Pediatric patients (<19 years old) admitted to PICUs from referring and children's hospital EDs from July 1, 2011 to June 30, 2013. We compared demographic and clinical factors, including severity of illness as measured by a recalibrated Pediatric Index of Mortality, version 2 score. RESULTS: Of 80 045 children from 109 PICUs, 35.6% were admitted from referring EDs and 64.4% were admitted from children's hospital EDs. Children from referring EDs had higher illness severity (Pediatric Index of Mortality, version 2-predicted risk of mortality, 3.1% vs 2.2%, P < .001), were more likely to be mechanically ventilated within their first hour in the PICU (28.4% vs 23.4%, P < .001), and had higher observed mortality (3.3% vs 2.1%, P < .001). Once adjusted for illness severity and other confounders in a multivariable logistic regression model, there was no difference in the odds of mortality between children from referring and children's hospital EDs (odds ratio: 0.90; 95% confidence interval: 0.79 to 1.02, P = .09) CONCLUSIONS: Children transferred to PICUs from referring EDs had higher illness severity on arrival compared with children admitted from children's hospital EDs. Variations in patient selection for transfer or pretransfer treatment at referring EDs may contribute to the greater illness severity of transferred children. Referring hospitals may benefit from leveraging existing resources to improve patient stabilization before transfer.

Racial and Ethnic Disparities in Parental Refusal of Consent in a Large, Multisite Pediatric Critical Care Clinical Trial.

OBJECTIVE: To evaluate whether race or ethnicity was independently associated with parental refusal of consent for their child's participation in a multisite pediatric critical care clinical trial. STUDY DESIGN: We performed a secondary analyses of data from Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE), a 31-center cluster randomized trial of sedation management in critically ill children with acute respiratory failure supported on mechanical ventilation. Multivariable logistic regression modeling estimated associations between patient race and ethnicity and parental refusal of study consent. RESULT: Among the 3438 children meeting enrollment criteria and approached for consent, 2954 had documented race/ethnicity of non-Hispanic White (White), non-Hispanic Black (Black), or Hispanic of any race. Inability to approach for consent was more common for parents of Black (19.5%) compared with White (11.7%) or Hispanic children (13.2%). Among those offered consent, parents of Black (29.5%) and Hispanic children (25.9%) more frequently refused consent than parents of White children (18.2%, P < .0167 for each). Compared with parents of White children, parents of Black (OR 2.15, 95% CI 1.56-2.95, P < .001) and Hispanic (OR 1.44, 95% CI 1.10-1.88, P = .01) children were more likely to refuse consent. Parents of children offered participation in the intervention arm were more likely to refuse consent than parents in the control arm (OR 2.15, 95% CI 1.37-3.36, P < .001). CONCLUSIONS: Parents of Black and Hispanic children were less likely to be approached for, and more frequently declined consent for, their child's participation in a multisite critical care clinical trial. Ameliorating this racial disparity may improve the validity and generalizability of study findings. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00814099.

The Association Between Insurance and Transfer of Noninjured Children From Emergency Departments.

STUDY OBJECTIVE: Among children requiring hospital admission or transfer, we seek to determine whether insurance is associated with the decision to either admit locally or transfer to another hospital. METHODS: This cross-sectional study used Healthcare Cost and Utilization Project 2012 Nationwide Emergency Department Sample. Pediatric patients receiving care in emergency departments (EDs) who were either admitted or transferred were included. Clinical Classifications Software was used to categorize patients into noninjury diagnostic cohorts. Multivariable logistic regression models adjusting for potential confounders, including severity of illness and comorbidities, and incorporating nationally representative weights were used to determine the association between insurance and the odds of transfer relative to admission. RESULTS: A total of 240,620 noninjury pediatric ED events met inclusion criteria. Patient and hospital characteristics, including older age and nonteaching hospitals, were associated with greater odds of transfer relative to admission. Patients who were uninsured or had self-pay had higher odds of transfer (odds ratio [OR] 3.84; 95% confidence interval [CI] 2.08 to 7.09) relative to admission compared with those with private insurance. Uninsured and self-pay patients also had higher odds of transfer across all 13 diagnostic categories, with ORs ranging from 2.96 to 12.00. Patients with Medicaid (OR 1.05; 95% CI 0.90 to 1.22) and other insurances (OR 1.14; 95% CI 0.87 to 1.48) had similar odds of transfer compared with patients with private insurance. CONCLUSION: Children without insurance and those considered as having self-pay are more likely to be transferred to another hospital than to be admitted for inpatient care within the same receiving hospital compared with children with private insurance. This study reinforces ongoing concerns about disparities in the provision of pediatric ED and inpatient care.

Impact of Telemedicine on Severity of Illness and Outcomes Among Children Transferred From Referring Emergency Departments to a Children's Hospital PICU.

OBJECTIVES: To compare the severity of illness and outcomes among children admitted to a children's hospital PICU from referring emergency departments with and without access to a pediatric critical care telemedicine program. DESIGN: Retrospective cohort study. SETTING: Tertiary academic children's hospital PICU. PATIENTS: Pediatric patients admitted directly to the PICU from referring emergency departments between 2010 and 2014. INTERVENTIONS: None. MEASUREMENTS: Demographic factors, severity of illness, and clinical outcomes among children receiving care in emergency departments with and without access to pediatric telemedicine, as well as a subcohort of children admitted from emergency departments before and after the implementation of telemedicine. MAIN RESULTS: Five hundred eighty-two patients from 15 emergency departments with telemedicine and 524 patients from 60 emergency departments without telemedicine were transferred and admitted to the PICU. Children admitted from emergency departments using telemedicine were younger (5.6 vs 6.9 yr; p< 0.001) and less sick (Pediatric Risk of Mortality III score, 3.2 vs 4.0; p < 0.05) at admission to the PICU compared with children admitted from emergency departments without telemedicine. Among transfers from emergency departments that established telemedicine programs during the study period, children arrived significantly less sick (mean Pediatric Risk of Mortality III scores, 1.2 units lower; p = 0.03) after the implementation of telemedicine (n = 43) than before the implementation of telemedicine (n = 95). The observed-to-expected mortality ratios of posttelemedicine, pretelemedicine, and no-telemedicine cohorts were 0.81 (95% CI, 0.53-1.09), 1.07 (95% CI, 0.53-1.60), and 1.02 (95% CI, 0.71-1.33), respectively. CONCLUSIONS: The implementation of a telemedicine program designed to assist in the care of seriously ill children receiving care in referring emergency departments was associated with lower illness severity at admission to the PICU. This study contributes to the body of evidence that pediatric critical care telemedicine programs assist referring emergency departments in the care of critically ill children and could result in improved clinical outcomes.

Relationship of Physician-identified Patient Race and Ethnicity to Use of Computed Tomography in Pediatric Blunt Torso Trauma.

OBJECTIVES: The objective was to determine whether a child's race or ethnicity as determined by the treating physician is independently associated with receiving abdominal computed tomography (CT) after blunt torso trauma. METHODS: We performed a planned secondary analysis of a prospective observational cohort of children < 18 years old presenting within 24 hours of blunt torso trauma to 20 North American emergency departments (EDs) participating in a pediatric research network, 2007-2010. Treating physicians documented race/ethnicity as white non-Hispanic, black non-Hispanic, or Hispanic. Using a previously derived clinical prediction rule, we classified each child's risk for having an intra-abdominal injury undergoing acute intervention to define injury severity. We performed multivariable analyses using generalized estimating equations to control for confounding and for clustering of children within hospitals. RESULTS: Among 12,044 enrolled patients, treating physicians documented race/ethnicity as white non-Hispanic (n = 5,847, 54.0%), black non-Hispanic (n = 3,687, 34.1%), or Hispanic of any race (n = 1,291, 11.9%). Overall, 51.8% of white non-Hispanic, 32.7% of black non-Hispanic, and 44.2% of Hispanic children underwent abdominal CT imaging. After age, sex, abdominal ultrasound use, risk for intra-abdominal injury undergoing acute intervention, and hospital clustering were adjusted for, the likelihood of receiving an abdominal CT was lower (odds ratio [OR] = 0.8, 95% confidence interval [CI] = 0.7 to 0.9) for black non-Hispanic than for white non-Hispanic children. For Hispanic children, the likelihood of receiving an abdominal CT did not differ from that observed in white non-Hispanic children (OR = 0.9, 95% CI = 0.8 to 1.1). CONCLUSIONS: After blunt torso trauma, pediatric patients identified by the treating physicians as black non-Hispanic were less likely to receive abdominal CT imaging than those identified as white non-Hispanic. This suggests that nonclinical factors influence clinician decision-making regarding use of abdominal CT in children. Further studies should focus on explaining how patient race can affect provider choices regarding ED radiographic imaging.

Pediatric super-refractory status epilepticus treated with allopregnanolone.

Super-refractory status epilepticus is a life-threatening condition. Resistance to benzodiazepine and barbiturate treatment for this disorder is thought to be due to internalization of synaptic γ-aminobutyric acid (GABA)A receptors, and withdrawal of benzodiazepines and barbiturates during treatment often triggers seizure recurrence. The neurosteroid allopregnanolone acts as a positive allosteric modulator of synaptic and extrasynaptic GABAA receptors. Here we describe the use of allopregnanolone in 2 pediatric patients with super-refractory status epilepticus. This treatment allowed the general anesthetic infusions to be weaned with resolution of status epilepticus. This is the first report of allopregnanolone use to treat status epilepticus in children.

Improving pediatric health care delivery by engaging residents in team-based quality improvement projects.

The goal was to implement and evaluate an experimental and longitudinal team-based curriculum in quality improvement (QI) for pediatric residents that would increase their ability to apply QI methodology while improving clinical processes and outcomes. The curriculum evolved over 3 years based on resident feedback. Working in teams, residents and faculty apply QI principles to systematically design and implement QI projects. Residents increased their level of comfort with key QI concepts. They showed an increase in QI skills by meaningful integration of the following QI concepts into their projects: establishing the magnitude of the problem, developing focused aims for improvement, identifying areas to change, using QI tools, collecting data, and assessing if changes were successful. The 10 resident-led projects conducted over the past 3 years also resulted in improvements in measures of multiple clinical processes and outcomes. This curriculum was effective and feasible within the constraints of residency work hours.

Cranial computed tomography use among children with minor blunt head trauma: association with race/ethnicity.

OBJECTIVE: To determine if patient race/ethnicity is independently associated with cranial computed tomography (CT) use among children with minor blunt head trauma. DESIGN: Secondary analysis of a prospective cohort study. SETTING: Pediatric research network of 25 North American emergency departments. PATIENTS: In total, 42 412 children younger than 18 years were seen within 24 hours of minor blunt head trauma. Of these, 39 717 were of documented white non-Hispanic, black non-Hispanic, or Hispanic race/ethnicity. Using a previously validated clinical prediction rule, we classified each child's risk for clinically important traumatic brain injury to describe injury severity. Because no meaningful differences in cranial CT rates were observed between children of black non-Hispanic race/ethnicity vs Hispanic race/ethnicity, we combined these 2 groups. MAIN OUTCOME MEASURE: Cranial CT use in the emergency department, stratified by race/ethnicity. RESULTS: In total, 13 793 children (34.7%) underwent cranial CT. The odds of undergoing cranial CT among children with minor blunt head trauma who were at higher risk for clinically important traumatic brain injury did not differ by race/ethnicity. In adjusted analyses, children of black non-Hispanic or Hispanic race/ethnicity had lower odds of undergoing cranial CT among those who were at intermediate risk (odds ratio, 0.86; 95% CI, 0.78-0.96) or lowest risk (odds ratio, 0.72; 95% CI, 0.65-0.80) for clinically important traumatic brain injury. Regardless of risk for clinically important traumatic brain injury, parental anxiety and request was commonly cited by physicians as an important influence for ordering cranial CT in children of white non-Hispanic race/ethnicity. CONCLUSIONS: Disparities may arise from the overuse of cranial CT among patients of nonminority races/ethnicities. Further studies should focus on explaining how medically irrelevant factors, such as patient race/ethnicity, can affect physician decision making, resulting in exposure of children to unnecessary health care risks.

Benchmarking, public reporting, and pay-for-performance: a mixed-methods survey of California pediatric intensive care unit medical directors.

OBJECTIVES: We sought to assess the attitudes of pediatric intensive care unit medical directors in California regarding the need for, the validity of, and the potential impact of benchmarking, public reporting, and pay-for-performance on pediatric critical care. DESIGN: Cross-sectional survey. SETTING: Pediatric intensive care units in California. SUBJECTS: Medical directors of pediatric intensive care units. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Self-administered questionnaire and a semi-structured phone interview from 16 pediatric intensive care unit medical directors. All data were anonymized before review. Standard methods for identifying and agreeing on themes in transcribed interviews were applied. Seventy-three percent of California pediatric intensive care unit medical directors agree that benchmarking improves patient outcomes but are undecided whether public reporting and pay-for-performance improve healthcare quality. They are wary of the validity of data used to generate these performance measures and are discouraged by the time and costs required to collect data for standard performance outcomes (severity-adjusted pediatric intensive care unit mortality). Leadership opinions appear potentially "dynamic" in multiple domains and across each of the measures assessed. CONCLUSIONS: Pediatric intensive care unit medical directors sometimes express contradictory opinions about the merits of shared benchmarking efforts and express concerns across a range of logistic, methodological, and policy issues. These findings raise fundamental questions about how to create clinical performance standards that facilitate quality improvement in the face of a seriously divided constituency. Further, we propose that pediatric intensive care unit medical directors play more active roles in the development, implementation, and communication of shared state-wide data collection.

Intervention to reduce parental bypass of community pediatric primary health facilities in asmara, eritrea.

OBJECTIVE: To reduce direct parental referral of low acuity ill pediatric patients to the outpatient facilities of a nation's only pediatric referral hospital. PATIENTS AND METHODS: Longitudinal monitoring of outpatient visits at Orotta Children's Hospital (OCH) and primary health facilities (PHFs) following implementation of an intervention designed in response to information provided by parents and health-care providers. Parental surveys were undertaken before and after exposure to the intervention to assess effects on knowledge, attitudes, and behavioral intentions. RESULTS: We analyzed 5,639 visits between baseline and follow-up, documenting a decline in parental referral among OCH outpatients from 95% to approximately 80%. Educational intervention increased the proportion of parents intending to use PHF for future outpatient care from 28% to 82%. Staff of the PHFs responded enthusiastically to this intervention program and requested further activities. CONCLUSIONS: Self-referral to tertiary care hospital was reduced following a modest program of parental education designed and implemented by residents in training.