Disseminating child abuse clinical decision support among commercial electronic health records: Effects on clinical practice.

Objectives: The use of electronic health record (EHR)-embedded child abuse clinical decision support (CA-CDS) may help decrease morbidity from child maltreatment. We previously reported on the development of CA-CDS in Epic and Allscripts. The objective of this study was to implement CA-CDS into Epic and Allscripts and determine its effects on identification, evaluation, and reporting of suspected child maltreatment. Materials and Methods: After a preimplementation period, CA-CDS was implemented at University of Wisconsin (Epic) and Northwell Health (Allscripts). Providers were surveyed before the go-live and 4 months later. Outcomes included the proportion of children who triggered the CA-CDS system, had a positive Child Abuse Screen (CAS) and/or were reported to Child Protective Services (CPS). Results: At University of Wisconsin (UW), 3.5% of children in the implementation period triggered the system. The CAS was positive in 1.8% of children. The proportion of children reported to CPS increased from 0.6% to 0.9%. There was rapid uptake of the abuse order set.At Northwell Health (NW), 1.9% of children in the implementation period triggered the system. The CAS was positive in 1% of children. The child abuse order set was rarely used. Preimplementation, providers at both sites were similar in desire to have CA-CDS system and perception of CDS in general. After implementation, UW providers had a positive perception of the CA-CDS system, while NW providers had a negative perception. Discussion: CA-CDS was able to be implemented in 2 different EHRs with differing effects on clinical care and provider feedback. At UW, the site with higher uptake of the CA-CDS system, the proportion of children who triggered the system and the rate of positive CAS was similar to previous studies and there was an increase in the proportion of cases of suspected abuse identified as measured by reports to CPS. Our data demonstrate how local environment, end-users' opinions, and limitations in the EHR platform can impact the success of implementation. Conclusions: When disseminating CA-CDS into different hospital systems and different EHRs, it is critical to recognize how limitations in the functionality of the EHR can impact the success of implementation. The importance of collecting, interpreting, and responding to provider feedback is of critical importance particularly with CDS related to child maltreatment.

Dissemination of child abuse clinical decision support: Moving beyond a single electronic health record.

BACKGROUND: Child maltreatment is a leading cause of pediatric morbidity and mortality. We previously reported on development and implementation of a child abuse clinical decision support system (CA-CDSS) in the Cerner electronic health record (EHR). Our objective was to develop a CA-CDSS in two different EHRs. METHODS: Using the CA-CDSS in Cerner as a template, CA-CDSSs were developed for use in four hospitals in the Northwell Health system who use Allscripts and two hospitals in the University of Wisconsin health system who use Epic. Each system had a combination of triggers, alerts and child abuse-specific order sets. Usability evaluation was done prior to launch of the CA-CDSS. RESULTS: Over an 18-month period, a CA-CDSS was embedded into Epic and Allscripts at two hospital systems. The CA-CDSSs vary significantly from each other in terms of the type of triggers which were able to be used, the type of alert, the ability of the alert to link directly to child abuse-specific order sets and the order sets themselves. CONCLUSIONS: Dissemination of CA-CDSS from one EHR into the EHR in other health care systems is possible but time-consuming and needs to be adapted to the strengths and limitations of the specific EHR. Site-specific usability evaluation, buy-in of multiple stakeholder groups and significant information technology support are needed. These barriers limit scalability and widespread dissemination of CA-CDSS.

Dead in the air- The need to adapt to CoVID adaptations.

During the recent CoVID-19 pandemic, airway management recommendations have been provided to decrease aerosolization and risk of viral spread to healthcare providers. High efficiency particulate air (HEPA) viral filters and adaptors are one way to decrease the risk of aerosolization during intubation. When placed proximal to the ventilator circuit, these viral filters and adaptors can create a significant amount of dead space, which in our smallest patients can significantly impact effective ventilation. We report a case of hypoventilation in a pediatric patient due to lack of provider team appreciation or ventilator sensing of additional dead space due to HEPA viral filter and adaptor.

Comprehensive Care Improvement for Oncologic Fever and Neutropenia from a Pediatric Emergency Department.

Introduction: Rapid time to antibiotics (TTA) for pediatric patients with fever and neutropenia in an emergency department decreases in-hospital mortality. Additionally, national guidelines recommend outpatient antibiotic management strategies for low-risk fever and neutropenia (LRFN). This study had two specific aims: (1) improve the percent of patients with suspected fever and neutropenia who receive antibiotics within 60 minutes of arrival from 55% to 90%, and (2) develop and operationalize a process for outpatient management of LRFN patients by October 2018. Methods: Using Lean methodologies, we implemented Plan-Do-Check-Act cycles focused on guideline development, electronic medical record reminders, order-set development, and a LRFN pathway as root causes for improvements. We used statistical process control charts to assess results. Results: The project conducted from July 2016 to October 2018 showed special cause improvement in December 2016 on a G-chart. Monthly Xbar-chart showed improvement in average TTA from 68.5 minutes to 42.5 minutes. A P-chart showed improvement in patients receiving antibiotics within 60 minutes, from 55% to 86.4%. A LRFN guideline and workflow was developed and implemented in October 2017. Conclusions: Implementation of guidelines, electronic medical record reminders, and order sets are useful tools to improve TTA for suspected fever and neutropenia. Utilizing more sensitive statistical process control charts early in projects with fewer patients can help recognize and guide process improvement. The development of workflows for outpatient management of LRFN may be possible, though it requires further study.

Electronic Health Record-Based Surveillance for Community Transmitted COVID-19 in the Emergency Department.

INTRODUCTION: SARS-CoV-2, a novel coronavirus, manifests as a respiratory syndrome (COVID-19) and is the cause of an ongoing pandemic. The response to COVID-19 in the United States has been hampered by an overall lack of diagnostic testing capacity. To address uncertainty about ongoing levels of SARS-CoV-2 community transmission early in the pandemic, we aimed to develop a surveillance tool using readily available emergency department (ED) operations data extracted from the electronic health record (EHR). This involved optimizing the identification of acute respiratory infection (ARI)-related encounters and then comparing metrics for these encounters before and after the confirmation of SARS-CoV-2 community transmission. METHODS: We performed an observational study using operational EHR data from two Midwest EDs with a combined annual census of over 80,000. Data were collected three weeks before and after the first confirmed case of local SARS-CoV-2 community transmission. To optimize capture of ARI cases, we compared various metrics including chief complaint, discharge diagnoses, and ARI-related orders. Operational metrics for ARI cases, including volume, pathogen identification, and illness severity, were compared between the preand post-community transmission timeframes using chi-square tests of independence. RESULTS: Compared to our combined definition of ARI, chief complaint, discharge diagnoses, and isolation orders individually identified less than half of the cases. Respiratory pathogen testing was the top performing individual ARI definition but still only identified 72.2% of cases. From the pre to post periods, we observed significant increases in ED volumes due to ARI and ARI cases without identified pathogen. CONCLUSION: Certain methods for identifying ARI cases in the ED may be inadequate and multiple criteria should be used to optimize capture. In the absence of widely available SARS-CoV-2 testing, operational metrics for ARI-related encounters, especially the proportion of cases involving negative pathogen testing, are useful indicators for active surveillance of potential COVID-19 related ED visits.

Rapid cycle testing drives improved communication and satisfaction using in-person survey.

Background: Good communication with families improves safety and drives patient/family satisfaction. Rapid cycle improvement for the communication is difficult in our emergency department as current mailed surveys provide little and delayed data. We had two aims in this quality improvement study: (1) to increase proportion of families responding 'always' when asked if they received consistent communication from nurses and providers from 52% to 80% and (2) increase families reporting their visit as excellent, reflecting higher family satisfaction. Methods: Key drivers of the consistent communication were determined using the model for improvement. Interventions focused on interprovider communication and parental knowledge of communication processes. Eight Plan-Do-Study-Act ramps were conducted focusing on each of the key drivers, with 1-10 cycles per ramp. A five-question in-person survey was conducted at the time of disposition by the research assistants. Process and outcome measures were tracked on the statistical process control charts. Results: Mean percentage of families who reported always receiving consistent communication increased from 52% to 70% over 12 months. Additionally, families reporting their visit as 'excellent' increased from 62.5% to 75%. Using in-person surveys, weekly responses increased from 3 to 22. Conclusions: Iterative processes to improve interprovider communication and inform families about their care led to improvement in families' perceived communication consistency. Improved communication can lead to higher family satisfaction, most affecting those previously feeling neutral about their visit. In-person surveys can inform the real-time improvement efforts.

Onychomadesis as a Late Complication of Hand-Foot-Mouth Disease: A Case Series Shedding Light on Nail Shedding.

Hand-foot-mouth disease is a viral illness frequently caused by enterovirus and coxsackievirus. Traditionally, this disease initially causes malaise, fever, and rash with vesicles in the mouth, as well as on the hands and feet. Occasionally, more severe presentations and late postinfectious sequelae occur, including onychomadesis, nail matrix arrest. We describe a series of 4 cases of onychomadesis and its evaluation following recent hand-foot-mouth disease during this current enteroviral season as a way to ensure appropriate clinician diagnosis and guidance.