Implementing Inpatient Social Needs Screening in an Urban Tertiary Care Children's Hospital.

BACKGROUND AND OBJECTIVES: The American Academy of Pediatrics recommends screening for unmet social needs, and the literature on inpatient screening implementation is growing. Our aim was to use quality improvement methods to implement standardized social needs screening in hospitalized pediatric patients. METHODS: We implemented inpatient social needs screening using the Model for Improvement. An interprofessional team trialed interventions in a cyclical manner using plan-do-study-act cycles. Interventions included a structured screening questionnaire, standardized screening and referrals workflows, electronic health record (EHR) modifications, and house staff education, deliberate practice, and feedback. The primary outcome measure was the percentage of discharged patients screened for social needs. Screening for social needs was defined as a completed EHR screening questionnaire or a full social work evaluation. Process and balancing measures were collected to capture data on screening questionnaire completion and social work consultations. Data were plotted on statistical process control charts and analyzed for special cause variation. RESULTS: The mean monthly percentage of patients screened for social needs improved from 20% at baseline to 51% during the intervention period. Special cause variation was observed for the percentage of patients with completed social needs screening, EHR-documented screening questionnaires, and social work consults. CONCLUSIONS: Social needs screening during pediatric hospitalization can be implemented by using quality improvement methods. The next steps should be focused on sustainability and the spread of screening. Interventions with greater involvement of interdisciplinary health care team members will foster process sustainability and allow for the spread of screening interventions to the wider hospitalized pediatric population.

Decreasing Prescribing Errors in Antimicrobial Stewardship Program-Restricted Medications.

OBJECTIVES: Antimicrobial stewardship programs (ASPs) restrict prescribing practices to regulate antimicrobial use, increasing the risk of prescribing errors. This quality improvement project aimed to decrease the proportion of prescribing errors in ASP-restricted medications by standardizing workflow. METHODS: The study took place on all inpatient units at a tertiary care children's hospital between January 2020 and February 2022. Patients <22 years old with an order for an ASP-restricted medication course were included. An interprofessional team used the Model for Improvement to design interventions targeted at reducing ASP-restricted medication prescribing errors. Plan-Do-Study-Act cycles included standardizing communication and medication review, implementing protocols, and developing electronic health record safety nets. The primary outcome was the proportion of ASP-restricted medication orders with a prescribing error. The secondary outcome was time between prescribing errors. Outcomes were plotted on control charts and analyzed for special cause variation. Outcomes were monitored for a 3-month sustainability period. RESULTS: Nine-hundred ASP-restricted medication orders were included in the baseline period (January 2020-December 2020) and 1035 orders were included in the intervention period (January 2021-February 2022). The proportion of prescribing errors decreased from 10.9% to 4.6%, and special cause variation was observed in Feb 2021. Mean time between prescribing errors increased from 2.9 days to 8.5 days. These outcomes were sustained. CONCLUSIONS: Quality improvement methods can be used to achieve a sustained reduction in the proportion of ASP-restricted medication orders with a prescribing error throughout an entire children's hospital.

Feeding Pathway for Children on High Flow Nasal Cannula Decreases Time to Enteral Nutrition.

High Flow Nasal Cannula (HFNC) is commonly used for children with respiratory failure, yet no standardized guidelines exist on how to initiate, escalate, and maintain enteral nutrition (EN) for these patients. EN in critically ill children is associated with decreased hospital length of stay, decreased ventilator days, and fewer acquired infections. We aimed to decrease the mean time to EN initiation by 50% after the start of HFNC in 6 months. Methods: This quality improvement project used the Model for Improvement to inform interventions. A multidisciplinary team created an EN pathway for critically ill patients on HFNC. We conducted Plan-Do-Study-Act cycles related to implementing a standardized pathway for EN on HFNC. The primary outcome was time to EN initiation once on HFNC. Secondary outcomes were time to goal caloric EN, duration of HFNC, and adverse events. Outcomes were plotted on statistical process control charts and analyzed for special cause variation between baseline and intervention periods. Results: We included 112 patients in the study. Special cause variation occurred for both primary and secondary outcomes. The mean time to EN initiation decreased from 24.6 hours to 11.7 hours (47.5%). Mean time to goal feeds decreased from 25.8 hours to 15.1 hours (58.5%). Mean HFNC duration did not show any special cause variation. There were no episodes of aspiration. Conclusion: Implementation of a standardized pathway for EN on patients receiving HFNC resulted in decreased time to initiation of EN and time to goal caloric EN with no significant increase in adverse events.

Epidemiology of Organ Failure Before and During COVID-19 Pandemic Surge Conditions.

BACKGROUND: Understanding the distribution of organ failure before and during the COVID-19 pandemic surge can provide a deeper understanding of how the pandemic strained health care systems and affected outcomes. OBJECTIVE: To assess the distribution of organ failure in 3 New York City hospitals during the COVID-19 pandemic. METHODS: A retrospective cohort study of adult admissions across hospitals from February 1, 2020, through May 31, 2020, was conducted. The cohort was stratified into those admitted before March 17, 2020 (prepandemic) and those admitted on or after that date (SARS-CoV-2-positive and non-SARS-CoV-2). Sequential Organ Failure Assessment scores were computed every 2 hours for each admission. RESULTS: A total of 1 794 975 scores were computed for 20 704 admissions. Before and during the pandemic, renal failure was the most common type of organ failure at admission and respiratory failure was the most common type of hospital-onset organ failure. The SARS-CoV-2-positive group showed a 231% increase in respiratory failure compared with the prepandemic group. More than 65% of hospital-onset organ failure in the prepandemic group and 83% of hospital-onset respiratory failure in the SARS-CoV-2-positive group occurred outside intensive care units. The SARS-CoV-2-positive group showed a 341% increase in multiorgan failure compared with the prepandemic group. Compared with the prepandemic and non-SARS-CoV-2 patients, SARS-CoV-2-positive patients had significantly higher mortality for the same admission and maximum organ failure score. CONCLUSION: Most hospital-onset organ failure began outside intensive care units, with a marked increase in multiorgan failure during pandemic surge conditions and greater hospital mortality for the severity of organ failure.

Improving the Pediatric Floor Discharge Process Following Tonsillectomy.

OBJECTIVES/HYPOTHESIS: Over 300,000 tonsillectomies are performed nationwide every year. In 2017, half of children undergoing tonsillectomy at our institution were admitted to the pediatric floor, with only 10.4% being discharged before 11 AM on postoperative day 1 (POD1). Our primary objective was to increase the percentage of patients discharged before 11 AM on POD1 to at least 50% within 1 year. STUDY DESIGN: Prospective observational (quality improvement). METHODS: A multidisciplinary quality improvement (QI) team was assembled. The primary outcome was "timely discharges," defined as percentage of patients discharged before 11 AM on POD1; secondary outcomes were percentage of patients discharged before 1 PM and mean length of stay (hours). Seven-day readmission rate served as our balancing measure. Prior year data served as baseline. A process map, Ishikawa diagram, and Pareto chart were utilized to identify specific target areas for improvement. Key interventions included announcement of our initiative, an electronic health record-based handoff text prompt, discharge checklist, automated discharge instructions, encouragement to place discharge orders by 9 AM and implementation of early POD1 rounds. Data were collected on a biweekly basis and the primary and secondary outcomes were plotted on control charts and analyzed using rules for special cause variation. RESULTS: Within 12 months, POD1 discharges before 11 AM and before 1 PM increased to 44.9% and 83.8%, respectively, with sustained improvement for the first 6 months of the subsequent year. Mean length of stay decreased, and 7-day readmission rates were unchanged. CONCLUSIONS: By understanding the factors influencing timely POD1 discharges after tonsillectomy, key interventions were implemented to achieve an increase in timely discharges. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:225-233, 2022.

Effect of Real-Time Feedback Devices on Primary Care Patient Experience Scores: A Cluster-Randomized Trial.

Patient experience is a critical measure for ambulatory primary care, although it is unclear how to best improve patient experience scores. This study aimed to determine whether use of a real-time feedback (RTF) device improved patient experience scores in a cluster-randomized trial. The primary outcomes were change from baseline in 9 Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) question and domain scores most closely related to the RTF questions asked in a linear mixed effects model. There were no observed statistically significant intervention-related differences in CG-CAHPS scores in any of the 9 CG-CAHPS questions or domains (P = .12-.99). In intervention clinics, there were no statistically significant correlation between CG-CAHPS top box scores and RTF device scores (P = .23-.98). Clinics in an urban primary care network randomized to receive RTF devices did not significantly improve related CG-CAHPS question or domain scores nor were those scores correlated with RTF device scores. More research is needed to identify effective interventions to improve ambulatory primary care patient experience.

"Increasing Warm Handoffs: Optimizing Community Based Referrals in Primary Care Using QI Methodology".

Social and environmental factors have an outsized effect on one's health. Children are particularly impacted by the adverse effects of poverty. While social determinants of health (SDH) screening in healthcare settings has proliferated there remain gaps in best practices for screening processes. As research has shown that patient navigation leads to an improvement in unmet social needs and family-reported child health, warm handoffs may be a key factor in assuring that the social needs of families are effectively addressed. Using quality improvement (QI) methods our pediatric clinic worked to increase the warm handoff rate between Community Health Workers (CHWs) and patients with unmet social needs. CHW warm handoff rates increased two-fold over the intervention period. Our results illustrate that QI methods can be used to optimize workflows to increase warm handoffs with CHWs. This is important as health centers work to improve their social needs screening and referral programs.

Risk Factors for Pediatric Asthma Readmissions: A Systematic Review.

OBJECTIVE: To systematically review the literature on pediatric asthma readmission risk factors. STUDY DESIGN: We searched PubMed/MEDLINE, CINAHL, Scopus, PsycINFO, and Cochrane Central Register of Controlled Trials for published articles (through November 2019) on pediatric asthma readmission risk factors. Two authors independently screened titles and abstracts and consensus was reached on disagreements. Full-text articles were reviewed and inclusion criteria applied. For articles meeting inclusion criteria, authors abstracted data on study design, patient characteristics, and outcomes, and 4 authors assessed bias risk. RESULTS: Of 5749 abstracts, 74 met inclusion criteria. Study designs, patient populations, and outcome measures were highly heterogeneous. Risk factors consistently associated with early readmissions (≤30 days) included prolonged length of stay (OR range, 1.1-1.6) and chronic comorbidities (1.7-3.2). Risk factors associated with late readmissions (>30 days) included female sex (1.1-1.6), chronic comorbidities (1.5-2), summer discharge (1.5-1.8), and prolonged length of stay (1.04-1.7). Across both readmission intervals, prior asthma admission was the most consistent readmission predictor (1.3-5.4). CONCLUSIONS: Pediatric asthma readmission risk factors depend on the readmission interval chosen. Prior hospitalization, length of stay, sex, and chronic comorbidities were consistently associated with both early and late readmissions. TRIAL REGISTRATION: CRD42018107601.

SAFER Care: Improving Caregiver Comprehension of Discharge Instructions.

BACKGROUND: One in five pediatric patients suffers from adverse events related to hospital discharge. Current literature lacks evidence on effective interventions to improve caregiver comprehension (CC) of discharge instructions. We examined if a standardized framework for written and verbal discharge counseling was associated with increased CC of key discharge instructions after discharge from a general pediatric inpatient unit. METHODS: An interprofessional team created the SAFER Care framework to encourage standard, comprehensive discharge counseling. Plan-do-study-act cycles included electronic health record smartphrases, educational initiatives, data feedback, visual aids, and family outreach. Caregivers were surveyed by phone within 4 days of discharge. Our primary outcome was the proportion of caregivers correctly responding to all questions related to discharge care, comparing pre- and postintervention periods. Data were plotted on a statistical process control chart to assess the effectiveness of interventions. RESULTS: A total of 171 surveys were analyzed in the preintervention period, and 262 surveys were analyzed in the postintervention period. A total of 37% of caregivers correctly responded to all questions in the preintervention period, compared with 62% of caregivers in the postintervention period, meeting rules for special cause variation. CONCLUSIONS: Development of the SAFER Care framework and its use in written and verbal discharge counseling was associated with significantly improved CC of discharge instructions in a general pediatric inpatient unit. Further studies should be focused on expanding this to other populations, particularly limited-English-proficiency families.

Implementation of a Standardized Approach to Improve the Pediatric Discharge Medication Process.

BACKGROUND AND OBJECTIVES: The pediatric inpatient discharge medication process is complicated, and caregivers have difficulty managing instructions. Authors of few studies evaluate systematic processes for ensuring quality in these care transitions. We aimed to improve caregiver medication management and understanding of discharge medications by standardizing the discharge medication process. METHODS: An interprofessional team at an urban, tertiary care children's hospital trialed interventions to improve caregiver medication management and understanding. These included mnemonics to aid in complete medication counseling, electronic medical record enhancements to standardize medication documentation and simplify dose rounding, and housestaff education. The primary outcome measure was the proportion of discharge medication-related failures in each 4-week period. Failure was defined as an incorrect response on ≥1 survey questions. Statistical process control was used to analyze improvement over time. Process measures related to medication documentation and dose rounding were compared by using the χ2 test and process control. RESULTS: Special cause variation occurred in the mean discharge medication-related failure rate, which decreased from 70.1% to 36.1% and was sustained. There were significantly more complete after-visit summaries (21.0% vs 85.1%; P < .001) and more patients with simplified dosing (75.2% vs 95.6%; P < .001) in the intervention period. Special cause variation also occurred for these measures. CONCLUSIONS: A systematic approach to standardizing the discharge medication process led to improved caregiver medication management and understanding after pediatric inpatient discharge. These changes could be adapted by other hospitals to enhance the quality of this care transition.

Rapid Implementation of an Adult Coronavirus Disease 2019 Unit in a Children's Hospital.

OBJECTIVE: To describe the rapid implementation of an adult coronavirus disease 2019 (COVID-19) unit using pediatric physician and nurse providers in a children's hospital and to examine the characteristics and outcomes of the first 100 adult patients admitted. STUDY DESIGN: We describe our approach to surge-in-place at a children's hospital to meet the local demands of the COVID-19 pandemic. Instead of redeploying pediatric providers to work with internist-led teams throughout a medical center, pediatric physicians and nurses organized and staffed a 40-bed adult COVID-19 treatment unit within a children's hospital. We adapted internal medicine protocols, developed screening criteria to select appropriate patients for admission, and reorganized staffing and equipment to accommodate adult patients with COVID-19. We used patient counts and descriptive statistics to report sociodemographic, system, and clinical outcomes. RESULTS: The median patient age was 46 years; 69% were male. On admission, 78 (78%) required oxygen supplementation. During hospitalization, 13 (13%) eventually were intubated. Of the first 100 patients, 14 are still admitted to a medical unit, 6 are in the intensive care unit, 74 have been discharged, 4 died after transfer to the intensive care unit, and 2 died on the unit. The median length of stay for discharged or deceased patients was 4 days (IQR 2, 7). CONCLUSIONS: Our pediatric team screened, admitted, and cared for hospitalized adults by leveraging the familiarity of our system, adaptability of our staff, and high-quality infrastructure. This experience may be informative for other healthcare systems that will be redeploying pediatric providers and nurses to address a regional COVID-19 surge elsewhere.

Readmission and Ambulatory Health Care Use After Asthma Hospitalization Among Urban Minority Children.

OBJECTIVES: The role of ambulatory follow-up after pediatric asthma hospitalization in preventing long-term readmissions is not well studied among hospitalized minority children. We sought to examine the association of ambulatory visit attendance with long-term readmission as well as identify predictors of attendance at these visits among urban, minority children with asthma. METHODS: This 2-year retrospective cohort study analyzed data for urban, minority children 2 to 18 years old who were hospitalized for asthma at a tertiary-care center. Using bivariate and multivariable analyses, we examined the independent associations of attending a postdischarge visit (within 14 days), a routine visit (within 3 months of discharge or postdischarge visit), and both visits with likelihood of asthma readmission within 365 days. We also identified predictors of attending each of these visits. RESULTS: The study included 613 children with a median age of 5 years. Of the children, 57.4% were boys, 51.2% were Hispanic, and 36.9% were non-Hispanic African American. One-quarter of the children were readmitted within 365 days of the index hospitalization. Children who attended the postdischarge visit had lower odds of long-term readmission (odds ratio = 0.65; 95% confidence interval = 0.43-0.97). However, attending a routine or both a postdischarge and a routine visit was not significantly associated with long-term readmission. Children with previous sick visits, complicating comorbidities, or more severe exacerbation were more likely to attend visits. CONCLUSIONS: Attending a postdischarge visit within 14 days of hospitalization is associated with a lower likelihood of long-term readmission. Those with a previous sick visit, more severe disease, or exacerbation are more likely to attend ambulatory visits after hospital discharge. This knowledge is important in fostering quality care transitions for children with asthma.

Caregiver Medication Management and Understanding After Pediatric Hospital Discharge.

OBJECTIVES: Caregivers frequently make mistakes when following instructions on discharge medications, and these instructions often contain discrepancies. Minimal literature reflects inpatient discharges. Our objective was to describe failures in caregiver management and understanding of inpatient discharge medications and to test the association of documentation discrepancies and sociodemographic factors with medication-related failures after an inpatient hospitalization. METHODS: This study took place in an urban tertiary care children's hospital that serves a low-income, minority population. English-speaking caregivers of children discharged on an oral prescription medication were surveyed about discharge medication knowledge 48 to 96 hours after discharge. The primary outcome was the proportion of caregivers who failed questions on a 10-item questionnaire (analyzed as individual question responses and as a composite outcome of any discharge medication-related failure). Bivariate tests were used to compare documentation errors, complex dosing, and sociodemographic factors to having any discharge medication-related failure. RESULTS: Of 157 caregivers surveyed, 70% had a discharge medication-related failure, most commonly because of lack of knowledge about side effects (52%), wrong duration (17%), and wrong start time (16%). Additionally, 80% of discharge instructions provided to caregivers lacked integral medication information, such as duration or when the next dose after discharge was due. Twenty five percent of prescriptions contained numerically complex doses. In bivariate testing, only race and/or ethnicity was significantly associated with having any failure (P = .03). CONCLUSIONS: The majority of caregivers had a medication-related failure after discharge, and most discharge instructions lacked key medication information. Future work to optimize the discharge process to support caregiver management and understanding of medications is needed.