Improving food insecurity screening across a health system throughout the COVID-19 pandemic.

BACKGROUND: Food insecurity has direct and indirect negative outcomes on the physical and mental health of children, with impacts throughout adult life. Rates of food insecurity have increased dramatically since the start of the COVID-19 pandemic. The American Academy of Pediatrics recommends paediatricians screen and intervene to address food insecurity. We aimed to increase the percentage of patient encounters with food insecurity screening completion at the paediatric medical home from 0% to 85% by July 2020 with extension to the paediatric emergency department (ED) and paediatric specialty clinic in the following year. METHODS: This multicentre project occurred in three sites within our health system: a teaching safety-net, paediatric medical home; a paediatric ED; and five divisions within paediatric specialty medical clinics. A screening tool was created using the validated Hunger Vital Sign Questionnaire. A standard screening, documentation and referral process was developed. The Model for Improvement was used testing changes via Plan-Do-Study-Act cycles. RESULTS: The percentage of households screened for food insecurity increased from a median of 0% to 30% for all sites combined. There was significant variability in screening with the ED screening a median of 24% and the medical home screening 80% by the end of the study period. A total of 9842 households (20.9%) screened were food insecure. During the study period, 895 families with 3925 household members received 69 791 pounds of food from our primary community resource using our clinic's food prescription. Of these families, 44% (398) also qualified for the US Department of Agriculture programme ensuring ongoing food distribution up to twice a month. DISCUSSION: Using quality improvement methodology to address a critical community need, we implemented food insecurity screening across a hospital system including multiple sites and specialties and provided critical resources to households in need.

Safely Shifting MRIs for Seizure Evaluation to the Outpatient Setting.

BACKGROUND AND OBJECTIVES: When a patient is admitted for seizure-like activity, in addition to obtaining a thorough history and physical exam, the evaluation may include a neurology consultation, EEG, and brain MRI. The cost of an inpatient MRI is significant and only 2% of MRIs yield clinically significant findings. At our institution, there was a 20% increase in patients undergoing inpatient MRI from 2018 to 2020. Our aim: Decrease the percentage of patient encounters receiving inpatient brain MRIs for seizure evaluation from 50% to 40% in 6 months by safely shifting MRIs to the outpatient setting. METHODS: Initially, provider variability in ordering practices of MRIs was analyzed. Stakeholders were gathered and a local guideline was developed to standardize MRI utilization. A process map was created and highlighted barriers to obtaining an outpatient MRI. A new standard process was developed that streamlined and automated processes, and reduced delays and reliance on patients' families. RESULTS: Since implementation of the new clinical guideline, the percentage of inpatient MRIs ordered for patient encounters presenting with seizures and seizure-like episodes decreased from a mean of 50% to 26%. Significant reductions occurred for patients with complex febrile seizures, provoked but afebrile seizures, and unprovoked seizures. The MRI guideline recommendations were followed in 93% of encounters in the final 12 months. None of the patients who underwent outpatient MRI required readmission for acute findings. CONCLUSIONS: In this project, the percentage of inpatient MRIs was safely decreased with the implementation of a clinical guideline and standardized process.

Reducing Overutilization of High-flow Nasal Cannula in Children with Bronchiolitis.

Background: Bronchiolitis is a leading cause of pediatric hospitalizations. A high-flow nasal cannula (HFNC) does not significantly improve clinical outcomes and is associated with increased costs and intensive care unit (ICU) utilization. Despite this, hospitals continue to overuse HFNC in children with bronchiolitis. We aimed to reduce HFNC initiation in children hospitalized with bronchiolitis by 20 percentage points within 6 months. Methods: This study included patients aged 1 month to 2 years diagnosed with bronchiolitis, excluding patients with prematurity less than 32 weeks or preexisting cardiopulmonary, genetic, congenital, or neuromuscular abnormalities. Measures included HFNC utilization, length of stay, length of oxygen supplementation (LOOS), ICU transfers, and emergency department (ED) revisits and readmissions. For our primary intervention, we implemented a HFNC initiation protocol incorporating a respiratory scoring system, a multidisciplinary care-team huddle, and an emphasis on supportive care. Staff education, electronic health record integration, and audit and feedback were used to support implementation. Statistical process control charts were used to track metrics. Results: We analyzed 325 hospitalizations (126 baseline and 199 postintervention). The proportion of children hospitalized with bronchiolitis who received HFNC decreased from a mean of 82% to 60% within 1 month of implementation. Length of stay decreased from a median of 54 to 42 hours, and length of oxygen supplementation decreased from 50 to 38 hours. There were no significant changes in ICU transfers, 7-day ED revisits, or readmissions. Conclusions: Implementing a HFNC initiation protocol can safely reduce the overutilization of HFNC in children hospitalized with bronchiolitis.

Arriving Safely: Decreasing Rapid Escalations in Care for Incoming Transported Pediatric Patients.

Accurate inpatient placement at the level of care needed for incoming transported patients can present challenges that may result in a rapid escalation in care following admission to the general inpatient unit. The Pediatric Early Warning System (PEWS) score is useful for early recognition of clinical deterioration. Therefore, we aimed to reduce rapid escalations in care for incoming transported patients via the implementation of an escalation algorithm with a goal of 80% PEWS score completion rate during transport within 6 months. Methods: We created an escalation algorithm utilizing PEWS scores and direct lines of communication between emergency medical technicians and receiving physicians. Audit and feedback increased the adoption of the process. We defined rapid escalations as transfer to a higher level of care within 6 hours of admission. Results: PEWS score completion increased from a mean of 48% to 70%. This result varied by emergency medical technician crew level of care. Eleven percent (n = 114) of PEWS scores required physician notification, 20% (n = 23) of which resulted in interventions en route. There were no differences in rapid escalation rates over time, but it remained low at <2% of all incoming transported patients. Some crew members report improved communication with hospital providers and feel more empowered to speak up when a patient's assessment is not as expected following algorithm implementation. Conclusions: This project improved PEWS score completion and maintained a low rate of rapid escalations of care among incoming transfers.

Using QI Methodology to Improve a Program's QI Curriculum: An Educational Improvement Project.

Quality improvement (QI) as a method of obtaining meaningful change is increasingly valued. A few comprehensive, longitudinal curricula demonstrate efficacy, patient impact, and behavior change over time. This educational improvement study aimed to create a curriculum that increased resident proficiency in practicing QI principles, score on the QI Knowledge Application Tool-Revised, and QI projects completing at least 2 plan-do-study-act (PDSA) cycles in 5 years. Methods: We utilized The Model for Improvement and sequential PDSA cycles, testing curricular components for improvement. Measures were analyzed annually (2014-2020). The curriculum includes modules and didactic workshops for foundational knowledge, rapid personal improvement projects for putting knowledge into practice, and experiential learning through developing and leading QI projects. Results: Graduating residents reporting proficiency in practicing QI principles increased from 4 (44%) to 11 (100%). The average QI Knowledge Application Tool-Revised score increased from 50% to 94% (95% CI, 37-51). Resident QI projects completing at least 2 PDSA cycles increased from 30% (n = 3) to 100% (n = 4), P = 0.0005, while projects achieving improvement increased from 40% (n = 4) to 100% (n = 3), P = 0.002. Patients were also positively impacted, with 63% (n = 3) of clinical QI projects that measured patient-centered outcomes achieving improvement and 69% (n = 11) of clinical QI projects improving clinical processes. Conclusions: This study developed a curriculum that successfully prepares residents to practice QI principles and lead multidisciplinary QI projects while demonstrating patient impact and behavior change. It offers an example of curriculum development and evaluation aided by QI science.

Optimizing Resident Education during Family-centered Rounds: An Educational Improvement Initiative.

Family-centered rounding (FCR) allows the medical team to partner with patients in medical decision-making, improving communication, and enhancing safety. However, FCR may compromise aspects of the resident education experience. In a survey of pediatric residents at our children's hospital, only 20% felt FCR provided the best educational experience. We designed this project to increase the percentage of residents with a positive perception of the educational experience on FCR from 20% to 80% in 6 months. Methods: This project utilized The Model for Improvement and sequential plan-do-study-act cycles. A needs assessment identified educational activities negatively impacted by FCR. We then designed a hybrid FCR process with formal presentations outside patient rooms followed by traditional bedside FCR. Our primary measure was the percentage of residents positively perceiving the FCR educational experience. Our balancing measures included rounding duration and family satisfaction and comprehension. Results: Residents who perceive FCR to be the best educational experience improved from a baseline of 21% to 76%, with a calculated response rate of 79%. Patients receiving FCR remained above 80%. All surveyed families understood their care plans and remained satisfied with the information provided, although 21% were concerned about the number of people present on rounds during the COVID-19 pandemic. Forty-three percent of hospitalist rounds exceeded the allotted time. Conclusions: The hybridization of FCR to include formal presentations may improve the resident learning experience while preserving family satisfaction and comprehension.

Acceptability of Deimplementing High-Flow Nasal Cannula in Pediatric Bronchiolitis.

BACKGROUND AND OBJECTIVES: High-flow nasal cannula (HFNC) in children hospitalized with bronchiolitis does not significantly improve clinical outcomes but can increase costs and intensive care unit use. Given widespread HFNC use, it is imperative to reduce use. However, there is limited information on key factors that affect deimplementation. To explore acceptability of HFNC deimplementation, perceptions of HFNC benefits, and identify barriers and facilitators to deimplementation. METHODS: We conducted a study of health care providers that included quantitative survey data supplemented by semistructured interviews. Data were analyzed using univariate tests and thematic content analysis. RESULTS: A total of 152 (39%) providers completed the survey; 9 participated in interviews. Eighty-three (55%) providers reported feeling positively about deimplementing HFNC. Reports of feeling positively increased as perceived familiarity with evidence increased (P = .04). Physicians were more likely than nurses and respiratory therapists to report feeling positively (P = .003). Hospital setting and years of clinical experience were not associated with feeling positively (P = .98 and .55, respectively). One hundred (66%) providers attributed nonevidence-based clinical benefits to HFNC. Barriers to deimplementation included discomfort with not intervening, perception that HFNC helps, and variation in risk tolerance and clinical experience. Facilitators promoting deimplementation include staff education, a culture of safely doing less, and enhanced multidisciplinary communication. CONCLUSIONS: Deimplementation of HFNC in children with bronchiolitis is acceptable among providers. Hospital leaders should educate staff, create a culture for safely doing less, and enhance multidisciplinary communication to facilitate deimplementation.

Realizing Inclusion and Systemic Equity in Medicine: Upstanding in the Medical Workplace (RISE UP)-an Antibias Curriculum.

Introduction: Racism is a public health threat, and racist behaviors adversely affect clinicians in addition to patients. Medical trainees commonly experience racism and bias. More than half of pediatric residents at a single institution reported experiencing or witnessing discriminatory behavior at work; only 50% reported receiving training on implicit bias, delivering difficult feedback, or peer support. Our multispecialty team created Realizing Inclusion and Systemic Equity in Medicine: Upstanding in the Medical Workplace (RISE UP), an antibias, anti-racism communication curriculum composed of three hybrid (virtual and in-person) workshops. Methods: During the pediatric resident workshops, we introduced tools for addressing bias, presented video simulations, and led small-group debriefings with guided role-play. We also reviewed escalation pathways, reporting methods, and support systems. Residents completed an evaluation before and after each workshop to assess the curriculum's efficacy. Results: Thirty-nine residents participated in RISE UP, with 20 attending all three workshops. Ninety-six percent of participants indicated they would recommend the workshops to colleagues. After the third workshop, 92% reported having tools to respond to bias, and 85% reported knowing how to escalate concerns regarding discriminatory behavior. Chief residents were most frequently identified as sources of resident support when encountering discriminatory behavior. Discussion: This curriculum was successful in developing and strengthening residents' responses to discrimination, including upstander support. The curriculum is adaptable for virtual, in-person, and hybrid settings, allowing for flexibility. Establishing institutional support, promoting faculty development, and creating and disseminating escalation pathways are critical to addressing racism in health care.

Managing Patient Bias: Teaching Residents to Navigate Racism and Bias in the Workplace.

BACKGROUND: Racial inequities are infused within American society and healthcare systems; notable events in 2020 highlighted an urgent need for change. Many organizations were inspired to examine the impacts of systemic racism. The impact of physician bias on patient experiences and outcomes has been well documented; biased patient behavior is now becoming more openly discussed. In response to the current climate and painful effects of discrimination on healthcare and providers, we aimed to provide training for our surgical residents to more comfortably respond to bias in the workplace. METHODS: We designed and piloted a simulation-based communication module focused on managing bias with medical students. We incorporated feedback received from students, facilitators, faculty, and simulated patients (SPs) to create an anti-bias workshop for surgical residents. Additionally, we worked with the pediatric and emergency departments to develop training videos depicting bias incidents, standardize debriefing processes, and implement anti-bias workshops for their residencies. RESULTS: Twenty students participated in the medical student pilot session. Student confidence increased in target skills; many noted this was their first exposure to the topic in a medical school course, and first opportunity to practice these skills. Sixteen surgical residents participated in an in-person module; learners self-identifying as "completely confident" increased in number significantly for "determining whether to respond" (p = 0.023), "knowing how to ensure follow up" (p = 0.041), and "self-care following an event" (p = 0.023). CONCLUSION: Our low-cost, high-impact anti-bias module provided learners with tools and practice, suggesting that such an effort is feasible, affordable, and effective. Our interdepartmental trainings have inspired our institution to develop approved statements clinicians may use when responding to race-based discrimination; offering a uniform approach to race-based microaggression or abuse can create a shared mental model for all team members, especially for those vulnerable to biased comments.

To Be or Not to Be (Inpatient Versus Observation): Improving Admission-Status Assignment.

BACKGROUND: Observation care is frequently indistinguishable from inpatient care. However, the financial burden of inappropriate status assignment for hospitals and patients can be large. Increased awareness of the potential for financial hardships experienced by patients because of status designation spurred interest among physicians in this improvement project. The goal was to improve the percentage of appropriate inpatient-status assignments from 76% to 90% in 2 years and eliminate observation assignments for patients with hospitalizations >48 hours. METHODS: Our multidisciplinary team used the Model for Improvement. Interventions included securing a lead physician advisor to the use-review team, improving the process for status review and adjustment, and creating educational sessions and tools for physicians. Data collected included the percentage of appropriate inpatient assignments, percentage of observation assignments for patients with hospitalizations >48 hours, write-off dollar amount per year from denial of payment due to payer disagreement with inpatient status, and resident physician confidence in assigning status. RESULTS: Appropriate use of inpatient assignments increased from 76% to 84%. Status assignments remaining in observation >48 hours of hospital length of stay decreased by one-half, from 6% to 3%. The write-off dollar amount increased during the study period but decreased by 19% the following calendar year, 2018. Resident self-reported confidence in status designation increased after educational sessions. CONCLUSIONS: Careful selection of admission status by educated providers and a system to identify relevant cases for status changes can increase appropriate status assignment and, potentially, positively affect the economic burden placed on patients and hospitals.

Combined multichannel intraluminal impedance-pH (MII-pH): multicenter report of normal values from 117 children.

Although combined multichannel intraluminal impedance/esophageal pH monitoring (MII-pH) has replaced prolonged pH monitoring alone for assessing gastroesophageal reflux (GER) in the pediatric population, it does so in the absence of reference values for non-acid GER (NAGER). The purpose of this study was to identify a normal range of NAGER impedance values for infants and children. We evaluated EPM/MII tracings for patients referred for GER assessment to Nationwide Children's Hospital (Columbus, OH), Inova Children's Hospital, and Hospital Italiano (Buenos Aires, Argentina). We excluded tracings from patients who had AGER indices greater than 50 % of the upper end of normal (i.e., >3 % for children >12 months and >6 % for infants ≤ 12 months), had a positive temporal association of GER with symptoms, were on anti-reflux medications at the time of the study, and/or had a fundoplication prior to the study. We also excluded studies with durations shorter than 20 h. Values for NAGER percent time, NAGER episode frequency, frequency of proximal NAGER, and mean NAGER duration were calculated for upright position, recumbent, and total. Study population consisted of 46 infants (20 female [F]/26 male [M], median age 4.8 months [range 3 weeks-11.9 months]) with a median AGER index of 2.2 % (range 0.0-5.9 %) and 71 children (22 F/49 M, median age 7.2 years [range 1.3-17 years]) with a median AGER index of 1.1 % (range 0-3.0 %). Data are presented in tables in the text. The results of this study provide a range of values characteristic of infants and children with normal AGER indices and no positive temporal associations of GER with symptoms. These values may be used as references for comparison to identify infants and/or children who may be at risk of developing serious clinical manifestations due to abnormal patterns of GER.