The Rounds Efficiency Index: A Novel Physics-Based Construct for Patient- and Family-Centered Rounds.

BACKGROUND AND OBJECTIVES: Efficiently conducting patient- and family-centered rounds (PFCR) is challenging, particularly without a measure of efficiency. In physics, efficiency is the ratio of work output to work input. We sought to evaluate PFCR efficiency via a novel construct rooted in physics. Our objectives were to (1) Establish baseline work output for clinical work (CW), educational effectiveness (EE), and family experience (FE); (2) establish baseline work input for rounds length (RL); and (3) begin preliminary construction of a rounds efficiency index (REI) as a measure of PFCR efficiency. METHODS: Four components of rounds efficiency were collected on 5 inpatient acute care teams during a baseline period. CW consisted of the percentage of daily orders placed on rounds. EE was assessed via survey for trainees and FE by families. RL was recorded in minutes per patient. During an 8-week intensive period, the REI (reported as %) was calculated as a ratio of work output/work input using aggregate mean/median ratings for CW, EE, FE, and RL. RESULTS: Baseline data included 809 orders, 28 EE ratings, 21 FE ratings, and RL mean of 11.4 minutes per patient. During the intensive period, the median team-specific weekly REI for the end versus beginning of the academic year was 58% and 52.5% (P = .17), respectively. The median REI during the start and end of the block was 49% and 57% (P = .15), respectively. CONCLUSIONS: The study assessed 4 components of efficiency (CW, EE, FE, RL) and calculated REI allowing for a preliminary tool to measure rounding efficiency. With this, targeted interventions can improve PFCR efficiency.

Using Electronic Health Record Modifications to Increase Use of Adolescent Sensitive Notes.

OBJECTIVES: Confidentiality is imperative when caring for adolescents, yet the 21st Century Cures Act ensures guardian access to some of their child's documentation. Pediatric Hospital Medicine (PHM) history and physical (H&P) notes are visible to guardians, whereas adolescent sensitive notes (ASN) are not. Our aim was to decrease sexual history and substance use (SHSU) documentation in H&P notes. METHODS: This quality improvement study included adolescents ages 13 to 17 from August 1, 2020 to May 31, 2021. Interventions included disappearing help text added to PHM H&P template prompting placement of positive SHSU in the ASN, editing of disappearing help text to encourage copy and paste of all SHSU into ASN, and communication to providers. The primary outcome measure was documentation of SHSU in H&P notes. The process measure was presence of ASNs. The balancing measures were documentation of unapproved social history domains in the ASN and encounters with no SHSU documentation. Statistical process control was used for analysis. RESULTS: Four hundred fifty patients were included in this analysis. There was decreased documentation of SHSU within H&P notes from means of 58.4% and 50.4% to 8.4% and 11.4%, respectively. There was increased utilization of ASN from 22.8% to 72.3%. Special cause variation occurred. Other unapproved domains in the ASN decreased. Encounters with no SHSU were unchanged. CONCLUSIONS: The quality improvement intervention of disappearing help text in PHM H&Ps was associated with decreased documentation of SHSU within H&P notes and increased utilization of ASN. This simple intervention helps maintain confidentiality. Further interventions may include utilization of disappearing help text in other specialties.

Overweight Infants Hospitalized for Bronchiolitis Associated With Severe Disease.

OBJECTIVES: Overweight negatively affects pediatric respiratory function. In this study, we evaluate if overweight is associated with more severe bronchiolitis in hospitalized infants. METHODS: This retrospective cohort study analyzed infants aged 30 to 365 days hospitalized for bronchiolitis from September 2019 to April 2020. Exclusion criteria included known risk factors for severe bronchiolitis, asthma treatment, or bacterial pneumonia. Weight-for-length z-score was categorized per the World Health Organization's growth assessments as overweight (z-score >2), underweight (z-score <-2), and standard weight (between -2 and ≤2). Primary outcomes included respiratory support, ICU stay, and local bronchiolitis score. Secondary outcomes included supplemental interventions. RESULTS: After exclusion criteria, 385 of 644 infants were categorized as overweight (n = 24), standard (n = 335), or underweight (n = 26). There were differences in need for respiratory support (overweight, 100%; standard weight, 81.8%; underweight, 76.9%; P = .03), highest support of high-flow nasal cannula (overweight, 75%; standard weight, 48%; underweight, 42%; P = .03), admission to ICU (overweight, 54.2%; standard weight, 21.5%; underweight, 34.7%; P < .001), and median bronchiolitis score (overweight, 8 [interquartile range 5-10]; standard weight, 4 [3-7]; underweight, 4 [3-7]; P = .01). Findings remained significant after age adjustments. Additionally, overweight experienced higher frequency of certain treatments. CONCLUSIONS: This study suggests overweight is associated with more severe bronchiolitis in hospitalized infants supported by increased respiratory support level, bronchiolitis scores, and interventions. Higher need for ICU admission may be related to high-flow nasal cannula limitations on the acute care floor.

Improving Documentation of Postdischarge Issue Mitigation during Postdischarge Phone Calls.

Postdischarge phone calls (PDPCs) are recommended to identify and mitigate postdischarge issues such as missed follow-up appointments, medication errors, and failure to activate contingency plans. A current state assessment showed variability in documenting PDPC content and postdischarge issue mitigation. Therefore, the primary aim was to improve the postdischarge issue mitigation documentation rate from 65% to 100% over 16 months. Methods: An interdisciplinary quality improvement team used the Model for Improvement to perform planned sequential interventions over 16 months. The outcome measure was documentation of postdischarge issue mitigation. Process measures included PDPC template use and completion and postdischarge issue identification. Balancing measures included call attempts and caller perceptions of ease of documentation. Interventions included creating a flowsheet note template, creating caller template training sessions, and sharing team data and feedback. We gathered data via reports generated from the electronic medical record, chart review, and survey. Data were analyzed using statistical process control charts and established rules for detecting special cause variation. Results: The postdischarge issue mitigation documentation increased from 65% to 91% over 16 months. Template use and completion increased from 0% to 100% and 98%, respectively. The number of postdischarge issues identified remained unchanged. Call attempts increased from 40% to 59%. Caller perceptions remained unchanged. Conclusions: Documentation of postdischarge issues and issue mitigation promotes adequate communication with the patient's care providers, improving the quality and safety of care. Data sharing to promote team engagement was the key factor in improving documentation of postdischarge issue mitigation.

Pediatric Respiratory Illness Hospitalizations Prior to COVID-19 and During the First Year of the COVID-19 Pandemic in Southeast Wisconsin.

BACKGROUND: Public health measures combatting the COVID-19 pandemic also led to a decrease in other pediatric respiratory illnesses. We describe the local pattern of pediatric respiratory hospitalizations in southeast Wisconsin prior to COVID-19 and during the first year of the pandemic. METHODS: We performed a cross-sectional examination of hospitalizations for asthma, bronchiolitis, and bacterial pneumonia at a single tertiary children's hospital prior to COVID-19 through the first year of the COVID-19 pandemic. RESULTS: We found a significant decrease in the average monthly hospitalization rates prior to and during COVID-19 for asthma, bronchiolitis, and bacterial pneumonia (P < 0.001), with average percent decrease of hospitalizations per month of 48%, 78%, and 47.7%, respectively. CONCLUSIONS: The decrease in hospitalizations is likely multifactorial and related to public health measures, behavior changes, and other epidemiological factors.

An Opportunity in Cancer Prevention: Human Papillomavirus Vaccine Delivery in the Hospital.

OBJECTIVE: Pediatric hospitalizations are a missed opportunity for delivery of the human papilloma virus (HPV) vaccination. In this study, the authors' aim was to increase HPV vaccination rates among adolescents cared for by the pediatric hospital medicine (PHM) service at our academic children's hospital. METHODS: This quality improvement (QI) study included adolescents ≥13 years who were discharged from PHM. Interventions included: modification of discharge order sets to include vaccination status and provider training seminars regarding the delivery of the HPV vaccine. Follow-up materials were distributed to providers by e-mail. The primary outcome measure was adolescent HPV vaccination rates. Secondary outcome measures were adolescent meningococcal vaccination rates and accuracy of immunization status documentation. The balancing measure was length of stay (LOS). Data were collected via chart review. Statistical process control charts were used to analyze for special cause variation. RESULTS: From May 2019 through February 2020, 440 patients were included in this analysis. Throughout the study, HPV and meningococcal vaccination rates increased from a baseline median of 4.6% to 21.2% and 8.3% to 26.6%, respectively. HPV vaccination was not significantly associated with sex, HPV dose due, or admitting service. Accuracy of immunization status documentation and LOS remained unchanged. CONCLUSIONS: Using QI methodology we were successful in increasing HPV and meningococcal vaccination rates among hospitalized adolescents. Considering the relationship of these 2 vaccines is a potential topic of future work. Discerning the correct immunization status at time of admission may be a potential opportunity for improvement in future work.

Quality Initiative to Increase Delivery of Adolescent Hospital-Based Reproductive Health Care.

OBJECTIVES: Hospitals are an important nontraditional setting in which to address adolescent reproductive health. However, opportunities for intervention are frequently missed, especially for boys and patients hospitalized for noningestion complaints. Our global aim was to increase delivery of reproductive health care to adolescents hospitalized through our children's hospital Pediatric Hospital Medicine service. METHODS: We performed 2 quality improvement intervention cycles: (1) provider education and monthly reminder e-mails and (2) an automated electronic health record (EHR) adolescent history and physical note template with social history prompts while discontinuing reminder e-mails. The primary outcome measure was sexual history documentation (SHD). Secondary measures were sexually transmitted infection (STI) testing and contraception provision. Statistical process control charts were used to analyze effectiveness of interventions. RESULTS: From July 2018 through June 2019, 528 Primary Hospital Medicine encounters were included in this study and compared with published baseline data on 150 encounters. Control charts revealed a special cause increase in SHD from 60% to 82% overall, along with 37% to 73% for boys and 57% to 80% for noningestion hospitalizations. Increased SHD correlated with cycle 1 and was maintained through cycle 2. Percent STI testing significantly increased but did not shift or trend toward special cause variation. Contraception provision, length of stay, and patient relations consultations were not affected. CONCLUSIONS: The interventions were successful in increasing SHD, including among boys and noningestion hospitalizations. The EHR enhancement maintained these increases after reminder emails were discontinued. Future interventions should specifically address STI testing and provision of contraception.

Use of Peer- and Self-Evaluation to Improve Conversations with Interfacility Referring Clinicians.

INTRODUCTION: Pediatric hospital medicine physicians receive little formal training in communicating with interfacility referring clinicians. We sought to improve pediatric hospital medicine physician confidence and communication scores by 10% during patient triage calls from interfacility referring providers via a continuing professional development initiative. METHODS: We conducted a single-center 10-month quality improvement project. Confidence was assessed via survey before and after the initiative. A novel self- and peer-evaluation tool was used to assess accepting pediatric hospital medicine physician communication on recorded calls. Call assessment scores were measured at baseline, cycle 1, and cycle 2. Interventions included group discussion and development of a scripting flowsheet. RESULTS: Twenty pediatric hospital medicine physicians participated and completed a total of 203 call assessments. From baseline to post-initiative, general confidence communicating with referring clinicians increased by 13% (mean ranks 11.8, 16.8, respectively), and specific confidence communicating when there is a difference of opinion increased significantly by 37% (mean ranks 9.8, 19.2, P < 0.001). Interfacility transfer conversation evaluation scores increased by 11%. DISCUSSION: Our initiative improved accepting physician's confidence and communication evaluation scores using self- and peer-evaluation, group reflection, and a scripting flowsheet. Self- and peer-evaluation of recorded calls can be an effective intervention for building physician confidence in communicating with referring clinicians.

Using Electronic Health Record Tools to Decrease Antibiotic Exposure in Infant Sepsis Evaluation.

BACKGROUND: Our internal infant sepsis evaluation clinical practice guideline recommends infants with negative culture results who are undergoing sepsis evaluation receive antibiotics until culture results are negative for a maximum of 36 hours. The aims of our project were to decrease the percentage of patients who received >30 hours of administered antibiotic doses (recognizing effective concentrations last until hour 36) and increase 36-hour phrase documentation by using clinical decision support tools. METHODS: We used quality improvement methodology to study infants aged ≤60 days with negative culture results. The outcome measures were the percentage of patients who received >30 hours of administered antibiotic doses, the percentage of history and physical (H&P) notes that included a statement of the anticipated 36-hour antibiotic discontinuation time (36-hour phrase), and length of stay. The process measure was the use of an illness-specific H&P template or an influencer smartphrase. Balancing measures were readmissions for positive culture results. Interventions included education, an illness-specific H&P template, a criteria-based rule to default to this H&P template, and editing influencer smartphrases. RESULTS: Over 33 months, 311 patients were included. Percentage of patients who received >30 hours of administered antibiotic doses decreased from 75.6% to 62%. Percentage of H&P notes documenting the 36-hour phrase increased from 4.9% to 75.6%. Illness-specific H&P template and influencer smartphrase usage increased to a mean of 51.5%; length of stay did not change. No readmissions for positive culture results were reported. CONCLUSIONS: Clinical decision support techniques and educational interventions popularized the "36-hour phrase" and were associated with a reduction in the antibiotic exposure in infants with negative culture results hospitalized for sepsis evaluation.

Pediatric COVID-19 Delirium: Case Report of 2 Adolescents.

INTRODUCTION: Neurological complications of COVID-19, including delirium, are emerging in the adult population but have not been well described in pediatrics. CASE PRESENTATION: We report the cases of 2 adolescent males, ages 16 and 17, who presented with delirium secondary to an acute COVID-19 infection in the fall of 2020 at Children's Wisconsin in Milwaukee, Wisconsin. The foundation of our treatment strategy was the triad of alpha-2 agonists (clonidine, dexmedetomidine, guanfacine), antipsychotic agents (quetiapine, haloperidol, olanzapine), and melatonin. Discharge planning required involvement from inpatient psychiatry, case management, social work, and the family. Both patients showed improvement after several weeks. DISCUSSION: We believe these are the first reported cases of COVID-19-associated delirium in children outside of multisystem inflammatory syndrome in children (MIS-C). CONCLUSION: Pediatric COVID-19 delirium is a new manifestation of the COVID-19 disease. Treatment guidelines are emerging and lessons regarding therapies and discharge considerations are described in these 2 unique cases.

One Call Away: Addressing a Safety Gap for Urgent Issues Post Discharge.

OBJECTIVES: The transition period from hospitalization to outpatient care can be high risk for pediatric patients. Our aim was to profile the use of a "safety net" for families through provision of specific inpatient provider contact information for urgent issues post discharge. METHODS: In this prospective study, we implemented an updated after-visit summary that directed families to call the hospital operator and specifically ask for the pediatric hospital medicine attending on call if they were unable to reach their primary care provider (PCP) with an urgent postdischarge concern. Education for nursing staff, operators, and pediatric hospital medicine providers was completed, and contact information was automatically populated into the after-visit summary. Information collected included the number of calls, the topic, time spent, whether the family contacted the PCP first, and the time of day. Descriptive statistics and Fisher's exact test were used to summarize findings. RESULTS: Over a 13-month period, of 5145 discharges, there were 47 postdischarge phone calls, which averaged to 3.6 calls per month. The average length of time spent on a call was 21 minutes. For 30% of calls, families had tried contacting their PCPs first, and 55% of calls occurred at night. Topics of calls included requesting advice about symptoms, time line for reevaluation, and assistance with medications. CONCLUSIONS: This safety net provided families with real-time problem-solving for an urgent need post discharge, which included triaging patient symptoms at home, counseling on medication questions, information about the time line of illness recovery, and provision of additional resources.

Letting Residents Lead: Implementing Resident Admission Triage Call Curriculum and Practice.

BACKGROUND AND OBJECTIVES: Graduating residents are expected to be competent in triaging patients to appropriate resources. Before 2017, pediatric residents were not involved in admission triage decisions. In 2017, after implementing an admission triage curriculum (ATC), residents had opportunities to be involved in overnight admission calls with the emergency department (ED), which were initially supervised (joint calls), and as skills progressed, residents conducted calls and admitted patients independently. We implemented and evaluated the impact of a graduated ATC intervention bundle on pediatric resident opportunities to participate in admission triage, while monitoring resident confidence, the ED experience, and patient safety. METHODS: We evaluated the impact of our ATC using quality improvement methodology. The primary outcome was the frequency of resident participation in joint and independent triage calls. Other measures included resident confidence, the ED clinician experience, and patient safety. Resident confidence and the ED clinician experience were rated via surveys. Safety was monitored with daytime hospitalist morning assessments and postadmission complications documented in the medical record. RESULTS: The percent of joint calls with the hospitalist increased from 7% to 88%, and 125 patients were admitted independently. Residents reported significant increases in adequacy of triage training and confidence in 3 triage skills (P < .001) after ATC. There were no complications or safety concerns on patients admitted by residents. ED clinicians reported increased admitting process efficiency and satisfaction. CONCLUSIONS: Our ATC intervention bundle increased the number of admission decision opportunities for pediatric residents, while increasing resident triage confidence, maintaining safety, and improving ED clinician experience.