Mechanical ventilation for COVID-19: Outcomes following discharge from inpatient treatment.

Though mechanical ventilation (MV) is used to treat patients with severe coronavirus disease 2019 (COVID-19), little is known about the long-term health implications of this treatment. Our objective was to determine the association between MV for treatment of COVID-19 and likelihood of hospital readmission, all-cause mortality, and reason for readmission. This study was a longitudinal observational design with electronic health record (EHR) data collected between 3/1/2020 and 1/31/2021. Participants included 17,652 patients hospitalized for COVID-19 during this period who were followed through 6/30/2021. The primary outcome was readmission to inpatient care following discharge. Secondary outcomes included all-cause mortality and reason for readmission. Rates of readmission and mortality were compared between ventilated and non-ventilated patients using Cox proportional hazards regression models. Differences in reasons for readmission by MV status were compared using multinomial logistic regression. Patient characteristics and measures of illness severity were balanced between those who were mechanically ventilated and those who were not utilizing 1-to-1 propensity score matching. The sample had a median age of 63 and was 47.1% female. There were 1,131 (6.4%) patients who required MV during their initial hospitalization. Rates (32.1% versus 9.9%) and hazard of readmission were greater for patients requiring MV in the propensity score-matched samples [hazard ratio (95% confidence interval) = 3.34 (2.72-4.10)]. Rates (15.3% versus 3.4%) and hazard [hazard ratio (95% confidence interval) = 3.12 (2.32-4.20)] of all-cause mortality were also associated with MV status. Ventilated patients were more likely to be readmitted for reasons which were classified as COVID-19, infectious diseases, and respiratory diagnoses compared to non-ventilated patients. Mechanical ventilation is a necessary treatment for severely ill patients. However, it may be associated with adverse outcomes including hospital readmission and death. More intense post-discharge monitoring may be warranted to decrease this associational finding.

A randomized controlled trial of a community health worker delivered home-based asthma intervention to improve pediatric asthma outcomes.

OBJECTIVE: The objective of this study was to evaluate the effects of using Community Health Workers (CHWs) to deliver the home-based Wee Wheezers asthma education program on asthma symptoms among children with persistent asthma. METHODS: In this randomized controlled trial of 151 children aged 2-9 years with persistent asthma, we assigned 75 to the intervention and 76 to the control. The primary outcome was caregiver-reported asthma symptom days. Secondary outcomes included asthma-related healthcare utilization, caregivers' asthma knowledge, illness perception and management behaviors, MDI-spacer administration technique, and home environmental triggers. Outcomes were collected at baseline, 3, 6, 9 and 12 months. A repeated measurements analytic approach with generalized estimating equations was used. To account for missing data, multiple imputation methods were employed. RESULTS: At 3 and 6 months, improvement in symptom days was not significantly different between groups. However, at 9 and 12 months, the reduction in asthma symptom days was 2.15 and 2.31 days more respectively for those in the intervention group compared to the control. Improvements in MDI-spacer technique, knowledge and attitudes were significant throughout follow-up. Improvement in habits regarding MDI use was significant at 3 and 6 months, and asthma routines were improved at 3 months. However, there was no change in asthma-related healthcare utilization or home environmental triggers. CONCLUSION: Using CHWs to deliver a home-based asthma education program to caregivers of children with persistent asthma led to improvements in symptom days and several secondary outcomes. Expanding the use of CHWs to provide home-based interventions can help reduce disparities in children's health outcomes.

Diagnosis and Acute Management of COVID-19 and Multisystem Inflammatory Syndrome in Children.

ABSTRACT: Most children with coronavirus disease 2019 (COVID-19) infection are asymptomatic or have mild disease. About 5% of infected children will develop severe or critical disease. Rapid identification and treatment are essential for children who are critically ill with signs and symptoms of respiratory failure, septic shock, and multisystem inflammatory syndrome in children. This article is intended for pediatricians, pediatric emergency physicians, and individuals involved in the emergency care of children. It reviews the current epidemiology of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in children, summarizes key aspects of clinical assessment including identification of high-risk patients and manifestations of severe disease, and provides an overview of COVID-19 management in the emergency department based on clinical severity.

Regional Variation in Standardized Costs of Care at Children's Hospitals.

OBJECTIVE: (1) To evaluate regional variation in costs of care for 3 inpatient pediatric conditions, (2) assess potential drivers of variation, and (3) estimate cost savings from reducing variation. DESIGN/SETTING: Retrospective cohort study of hospitalizations for asthma, diabetic ketoacidosis (DKA), and acute gastroenteritis (AGE) at 46 children

Developing the Capacity for Rapid-Cycle Improvement at a Large Freestanding Children's Hospital.

BACKGROUND: To develop the capacity for rapid-cycle improvement at the unit level, a large freestanding children's hospital designated 2 inpatient units with normal patient loads and workforce as pilot "Innovation Units" where frontline staff was trained to lead rigorous improvement portfolios. METHODS: Frontline staff received improvement training, and interdisciplinary teams brainstormed ideas for tests of change. Ideas were prioritized using an impact-effort evaluation and an assessment of how they aligned with high-level goals. A template for each test summarized the following: the opportunity for improvement, the test being conducted, dates for the tests, driver diagrams, metrics to measure effects, baseline data, results, findings, and next steps. Successful interventions were implemented and disseminated to other units. RESULTS: Multidisciplinary staff generated 150 improvement ideas and Innovation Units collectively ran >40 plan-do-study-act cycles. Of the 10 distinct improvement projects, elements of all 10 were deemed "successful" and fully implemented on the unit, and elements from 8 were spread to other units. More than 3 years later, elements of all of the successful improvements are still in practice in some form on the units, and each unit has tested >20 additional improvement ideas, using multiple plan-do-study-act cycles to refine them. CONCLUSIONS: The Innovation Unit model successfully engaged frontline staff in improvement work and established a sustainable system and framework for managing rigorous improvement portfolios at the unit level. Other hospitals and health care delivery settings may find our quality improvement approach helpful, especially because it is rooted in the microsystem of care delivery.

Determining preventability of pediatric readmissions using fault tree analysis.

BACKGROUND: Previous studies attempting to distinguish preventable from nonpreventable readmissions reported challenges in completing reviews efficiently and consistently. OBJECTIVES: (1) Examine the efficiency and reliability of a Web-based fault tree tool designed to guide physicians through chart reviews to a determination about preventability. (2) Investigate root causes of general pediatrics readmissions and identify the percent that are preventable. DESIGN/SETTING/PATIENTS: General pediatricians from The Children's Hospital of Philadelphia used a Web-based fault tree tool to classify root causes of all general pediatrics 15-day readmissions in 2014. INTERVENTION/MEASUREMENTS: The tool guided reviewers through a logical progression of questions, which resulted in 1 of 18 root causes of readmission, 8 of which were considered potentially preventable. Twenty percent of cases were cross-checked to measure inter-rater reliability. RESULTS: Of the 7252 discharges, 248 were readmitted, for an all-cause general pediatrics 15-day readmission rate of 3.4%. Of those readmissions, 15 (6.0%) were deemed potentially preventable, corresponding to 0.2% of total discharges. The most common cause of potentially preventable readmissions was premature discharge. For the 50 cross-checked cases, both reviews resulted in the same root cause for 44 (86%) of files (κ = 0.79; 95% confidence interval: 0.60-0.98). Completing 1 review using the tool took approximately 20 minutes. CONCLUSION: The Web-based fault tree tool helped physicians to identify root causes of hospital readmissions and classify them as either preventable or not preventable in an efficient and consistent way. It also confirmed that only a small percentage of general pediatrics 15-day readmissions are potentially preventable. Journal of Hospital Medicine 2016;11:329-335. © 2016 Society of Hospital Medicine.

Description and Evaluation of an Educational Intervention on Health Care Costs and Value.

OBJECTIVE: There is growing consensus that to ensure that health care dollars are spent efficiently, physicians need more training in how to provide high-value, cost-conscious care. Thus, in fiscal year 2014, The Children's Hospital of Philadelphia piloted a 9-part curriculum on health care costs and value for faculty in the Division of General Pediatrics. This study uses baseline and postintervention surveys to gauge knowledge, perceptions, and views on these issues and to assess the efficacy of the pilot curriculum. METHODS: Faculty completed surveys about their knowledge and perceptions about health care costs and value and their views on the role physicians should play in containing costs and promoting value. Baseline and postintervention responses were compared and analyzed on the basis of how many of the sessions respondents attended. RESULTS: Sixty-two faculty members completed the baseline survey (71% response rate), and 45 faculty members completed the postintervention survey (63% response rate). Reported knowledge of health care costs and value increased significantly in the postintervention survey (P=.04 and P<.001). Odds of being knowledgeable about costs and value were 2.42 (confidence interval: 1.05-5.58) and 6.22 times greater (confidence interval: 2.29-16.90), respectively, postintervention. Reported knowledge of health care costs and value increased with number of sessions attended (P=.01 and P<.001). CONCLUSIONS: The pilot curriculum appeared to successfully introduce physicians to concepts around health care costs and value and initiated important discussions about the role physicians can play in containing costs and promoting value. Additional education, increased cost transparency, and more decision support tools are needed to help physicians translate knowledge into practice.

Freelisting on Costs and Value in Health Care by Pediatric Attending Physicians.

OBJECTIVE: In preparation for the development of a curriculum on health care costs and value for pediatricians, the goal of this study was to assess pediatricians' baseline perceptions about the concepts of "cost" and "value" in health care, and topics that should be included in a curriculum that teaches about costs and value in pediatrics. METHODS: Physicians in the Department of Pediatrics at The Children's Hospital of Philadelphia received an online freelisting survey asking them to generate lists of words that come to mind when thinking about "costs" in health care, "value" in health care, and topics to include in a curriculum on costs and value in pediatrics. AnthroPac software generated salience scores, indicating the relative importance of each term. RESULTS: A total of 207 surveys were completed for a 40% response rate. For the "cost" prompt, the most salient responses were "excessive," "waste," and "insurance." For the "value" prompt, the most salient responses were "outcomes" and "quality." For elements to include in a curriculum, the most salient responses were "insurance" and "costs." Analyzing responses based on years in practice, percentage clinical time, and division resulted in slightly different lists and salience scores. CONCLUSIONS: In this freelisting exercise, there was general agreement that health care costs are "excessive," that "outcomes" and "quality" are integral to value, and that there is a need for education in these areas, especially around "insurance." Differences based on years in practice, percentage clinical time, or division can inform the development of targeted curricula that consider the needs, knowledge, and interests of these groups.

Measuring patient flow in a children's hospital using a scorecard with composite measurement.

BACKGROUND: Although patient flow is a focus for improvement in hospitals, commonly used single or unaggregated measures fail to capture its complexity. Composite measures can account for multiple dimensions of performance but have not been reported for the assessment of patient flow. OBJECTIVES: To present and discuss the implementation of a composite measure system as a way to measure and monitor patient flow and improvement activities at an urban children's hospital. METHODS: A 5-domain patient flow scorecard with composite measurement was designed by an interdisciplinary workgroup using measures involved in multiple aspects of patient flow. RESULTS: The composite score measurement system provided improvement teams and administrators with a comprehensive overview of patient flow. It captured overall performance trends and identified operational domains and specific components of patient flow that required improvement. DISCUSSION: A patient flow scorecard with composite measurement holds advantages over a single or unaggregated measurement system, because it provides a holistic assessment of performance while also identifying specific areas in need of improvement.