The Development and Piloting of the Ambulatory Electronic Health Record Evaluation Tool: Lessons Learned.

BACKGROUND: Substantial research has been performed about the impact of computerized physician order entry on medication safety in the inpatient setting; however, relatively little has been done in ambulatory care, where most medications are prescribed. OBJECTIVE: To outline the development and piloting process of the Ambulatory Electronic Health Record (EHR) Evaluation Tool and to report the quantitative and qualitative results from the pilot. METHODS: The Ambulatory EHR Evaluation Tool closely mirrors the inpatient version of the tool, which is administered by The Leapfrog Group. The tool was piloted with seven clinics in the United States, each using a different EHR. The tool consists of a medication safety test and a medication reconciliation module. For the medication test, clinics entered test patients and associated test orders into their EHR and recorded any decision support they received. An overall percentage score of unsafe orders detected, and order category scores were provided to clinics. For the medication reconciliation module, clinics demonstrated how their EHR electronically detected discrepancies between two medication lists. RESULTS: For the medication safety test, the clinics correctly alerted on 54.6% of unsafe medication orders. Clinics scored highest in the drug allergy (100%) and drug-drug interaction (89.3%) categories. Lower scoring categories included drug age (39.3%) and therapeutic duplication (39.3%). None of the clinics alerted for the drug laboratory or drug monitoring orders. In the medication reconciliation module, three (42.8%) clinics had an EHR-based medication reconciliation function; however, only one of those clinics could demonstrate it during the pilot. CONCLUSION: Clinics struggled in areas of advanced decision support such as drug age, drug laboratory, and drub monitoring. Most clinics did not have an EHR-based medication reconciliation function and this process was dependent on accessing patients' medication lists. Wider use of this tool could improve outpatient medication safety and can inform vendors about areas of improvement.

Developing and Testing the Health Care Safety Hotline: A Prototype Consumer Reporting System for Patient Safety Events.

This article describes the design, development, and testing of the Health Care Safety Hotline, a prototype consumer reporting system for patient safety events. The prototype was designed and developed with ongoing review by a technical expert panel and feedback obtained during a public comment period. Two health care delivery organizations in one metropolitan area collaborated with the researchers to demonstrate and evaluate the system. The prototype was deployed and elicited information from patients, family members, and caregivers through a website or an 800 phone number. The reports were considered useful and had little overlap with information received by the health care organizations through their usual risk management, customer service, and patient safety monitoring systems. However, the frequency of reporting was lower than anticipated, suggesting that further refinements, including efforts to raise awareness by actively soliciting reports from subjects, might be necessary to substantially increase the volume of useful reports. It is possible that a single technology platform could be built to meet a variety of different patient safety objectives, but it may not be possible to achieve several objectives simultaneously through a single consumer reporting system while also establishing trust with patients, caregivers, and providers.

Implementation and evaluation of a prototype consumer reporting system for patient safety events.

OBJECTIVE: No methodologically robust system exists for capturing consumer-generated patient safety reports. To address this challenge, we developed and pilot-tested a prototype consumer reporting system for patient safety, the Health Care Safety Hotline. DESIGN: Mixed methods evaluation. SETTING: The Hotline was implemented in two US healthcare systems from 1 February 2014 through 30 June 2015. PARTICIPANTS: Patients, family members and caregivers associated with two US healthcare systems. INTERVENTION: A consumer-oriented incident reporting system for telephone or web-based administration was developed to elicit medical mistakes and care-related injuries. MAIN OUTCOMES MEASURES: Key informant interviews, measurement of website traffic and analysis of completed reports. RESULTS: Key informants indicated that Hotline participation was motivated by senior leaders' support and alignment with existing quality and safety initiatives. During the measurement period from 1 October 2014 through 30 June 2015, the home page had 1530 visitors with a unique IP address. During its 17 months of operation, the Hotline received 37 completed reports including 20 mistakes without harm and 15 mistakes with injury. The largest category of mistake concerned problems with diagnosis or advice from a health practitioner. Hotline reports prompted quality reviews, an education intervention, and patient follow-ups. CONCLUSION: While generating fewer reports than its capacity to manage, the Health Care Safety Hotline demonstrated the feasibility of consumer-oriented patient safety reporting. Further research is needed to understand how to increase consumers' use of these systems.

Characteristics of medication use during pediatric medical emergency team events and the role of a pharmacist-provided medication supply.

OBJECTIVES: To determine the type and frequency of and indications for medications used during pediatric medical emergency team (PMET) events and to describe a PMET pharmacist training model, creation of a standardized "pharmacist PMET supply," and the pharmacist's role in implementation and ongoing improvement of a PMET. METHODS: This is a retrospective observational cohort study of 210 PMET events in 172 patients in a tertiary care, academic pediatric hospital, from September 15, 2005, to September 15, 2007. We focused on the types and sources of medications used during PMET events. RESULTS: The medications most commonly used were lorazepam (11%), neuromuscular blockers (10.5%), atropine (9.5%), epinephrine bolus (9%), and albuterol or levalbuterol (9%). However, 49 distinct medications were used in 53.8% of all PMET events. Of all medications requested during a PMET event, only 40% originated from an institutionally standardized emergency medication box, while an additional 35% were readily available at the patient's bedside as part of the "pharmacist PMET supply." CONCLUSIONS: A wide variety of medications are required to care for children who suffer acute in-hospital deterioration. The pharmacist's medication supply and expertise ensured immediate availability of therapies for clinical entities ranging from seizures and anaphylaxis to rapid sequence intubation, regardless of the PMET event location.

Continuity-structured clinical observations: assessing the multiple-observer evaluation in a pediatric resident continuity clinic.

OBJECTIVES: The continuity-structured clinical observation tool was developed and used to conduct a multiple-observer evaluation to assess residents in the core competency areas of patient care, interpersonal and communication skills, and professionalism. The objectives were to assess pediatric resident performance in a continuity clinic by using direct observation and to compare evaluations among preceptors, residents, and parents. METHODS: Pediatric residents in a large continuity clinic participated between August and December 2005. The continuity-structured clinical tool included items in the following domains: opening the interview, history taking, relationship skills, personal manner, negotiation or management, and physical examination. Each resident was directly observed during 1 entire patient encounter. Parents, preceptors, and residents completed evaluations by selecting 1 of 4 possible responses for performance of each item. We dichotomized responses as "yes" versus "no/partial" and analyzed aggregate scores for individual items and domains among the 3 evaluators by McNemar test, percentage agreement, and interoberserver agreement (kappa). RESULTS: Fifty-four of 57 eligible residents had all 3 evaluations completed. Parents rated residents the highest and showed least variability (only 2 items for which parents indicated the task was completed in <90% of the encounters). Residents rated themselves the lowest (35 items with <90%). In comparing the residents and preceptors, the domains that had the lowest percentage of agreement were history taking (range: 61%-91%) and negotiation or management (range: 51%-88%). All of the evaluators scored residents the lowest in the domain of negotiation or management, with the following lowest-score items: probe for decision-makers, assess willingness and barriers, and use of visual aids. CONCLUSIONS: Compared with parents, residents and preceptors demonstrated greater variability in resident performance evaluations. All of the evaluators scored residents lowest in the domain of negotiation or management during continuity-clinic visits. Residency programs should strongly consider emphasizing skill development in this area.

Transition from a traditional code team to a medical emergency team and categorization of cardiopulmonary arrests in a children's center.

OBJECTIVES: To study the effect of an intervention on prevention of respiratory arrest and cardiopulmonary arrest (CPA) and to characterize ward CPAs by preceding signs and symptoms and initial cardiac rhythm. DESIGN: A before-and-after interventional trial (12 months preintervention and 12 months postintervention). SETTING: A tertiary care, academic children's hospital. PARTICIPANTS: Admitted patients who subsequently had either the code team or pediatric medical emergency team (PMET) called or who had a respiratory arrest or CPA on the wards. Intervention Transition from a traditional code team to a PMET that responds to clinically deteriorating children in noncritical care areas. OUTCOME MEASURES: Combined rate of respiratory arrests and CPAs, rate of CPAs, and rate of respiratory arrests on the wards and agreement between independent reviewers on categorization of CPAs. RESULTS: There was no change in the rate of CPAs on the wards. However, there was a 73% decrease in the incidence of respiratory arrests (0.23 respiratory arrests/1000 patient-days pre-PMET vs 0.06 post-PMET, P = .03). There was 100% agreement between reviewers on categorization of CPAs. CONCLUSIONS: Transition to a PMET was not associated with a change in CPAs but was associated with a significant decrease in the incidence of ward respiratory arrests. We also describe children who may have benefited from the PMET but whose data were not captured by current outcome measures. Finally, we present a new method for categorization of ward CPAs based on preceding signs and symptoms and initial cardiac rhythm.

Patient safety rounds in a pediatric tertiary care center.

BACKGROUND: Patient safety rounds were implemented in a pediatric tertiary care setting. Completed patient safety issues from three years of pediatric patient safety rounds and nine months of pediatric surgical safety rounds were analyzed. Completed issues were categorized into both Modified Vincent and University HealthSystem Consortium (UHC) categorization schemes to compare and contrast their attributes. FINDINGS: From January 2003 through January 2006, there were 159 completed patient safety issues, 148 (93%) from general pediatric safety rounds and 11 (7%) from pediatric surgical safety rounds. Using the UHC classification scheme, 35.8% of the issues were classified as care coordination/records, 27.0% as equipment safety situation/preventive maintenance, 21.4% as equipment/supplies/devices, 3.8% as error related to procedure/ treatment/test, and 3.8% as medication error. In the Modified Vincent classification scheme, 63.5% of the issues were classified as environmental factors, 23.3% as team factors, 6.9% as individual factors, 3.1% as task factors, and 1.9% as patient characteristics. Pediatric safety rounds were well received by both frontline staff and senior executives. DISCUSSION: The use of pediatric safety rounds is a low-cost intervention that helps to partner senior leaders and frontline staff on patient safety and is an effective tool for improving patient safety in a pediatric setting.

Maternal and child factors affecting high-volume pediatric emergency department use.

OBJECTIVE: To describe maternal and child characteristics associated with high-volume nonurgent pediatric emergency department (ED) use. METHODS: We surveyed female caregivers of children aged 1 to 14 years who were brought to the ED at an urban medical center for nonurgent conditions. We analyzed characteristics associated with low-volume (1 ED visit) or high-volume (> or = 2 ED visits) use within the past year. Independent factors included predisposing, reinforcing, and enabling factors. Logistic regression was used to model high-volume ED use. RESULTS: Of the 300 participants (84% response rate), 99 were low-volume users and 201 were high-volume users. Most participants were mothers (94%). In adjusted analyses, high-volume use was associated with caregivers being single [odds ratio (OR), 2.57; 95% confidence interval (CI), 1.13-5.80], having high-volume ED use for themselves (OR, 2.02; 95% CI, 1.08-3.80), seeking care primarily in the pediatric ED for "sick visits" (OR, 2.47; 95% CI, 1.12-5.49), and lack of weekend hours at their child's usual source of care (OR, 2.58; CI, 1.24-5.37). CONCLUSIONS: Marital status, high maternal use of the ED, perception of the ED as the place to seek care for a sick child, and lack of weekend hours for usual source of care are associated with high-volume ED use among children. Given similarities in patterns of ED use among mothers and children, further attention is needed to address clinical practice and system issues that contribute to familial use of EDs.

Epidemiology of pediatric emergency department use at an urban medical center.

OBJECTIVES: Dramatic increases in emergency department (ED) use contribute to rising healthcare costs and decrease continuity of care in the United States. Yet little is known about the acuity, frequency of visits, and demographic characteristics of children using the ED. This study examines general demographic trends over a 3-year period and examines whether there are factors associated with varying acuity at an urban academic pediatric ED. METHODS: Analysis of administrative ED records from fiscal years (FY) 1999 to 2001 for children 0 to 18 years was performed to assess demographic characteristics, periodicity of ED use, and acuity level. RESULTS: Patient demographic characteristics, periodicity, and acuity were comparable for ED visits across each study year with approximately 25,000 annual visits. Among ED users in FY 2001, 42% sought urgent care exclusively, 12% received both urgent and nonurgent care, and 46% used the ED solely for nonurgent care. Of those with only nonurgent visits, 80% had 1 visit. In FY 2001, ED use was predominantly among patients who were black (77.3%) and were 1 to 4 years of age (35.4%). Relative to all patients, a greater percentage of those who used the ED exclusively for nonurgent care were black (87.2% vs. 76.0%, P < 0.05) and lived within 2 miles of the hospital (45.2% vs. 37.4%, P < 0.05). CONCLUSIONS: Nearly half of pediatric emergency visits are for nonurgent care. Racial disparities in use of the ED for nonurgent care may be related to patient's proximity to the hospital. Patterns of use are stable across the 3 years. Further study is needed to identify mutable factors in emergency care use.

Maternal depression: an old problem that merits increased recognition by child healthcare practitioners.

PURPOSE OF REVIEW: Maternal depression is an old problem that has received heightened public attention in recent years. Although the prevalence of maternal depression remains considerable, healthcare providers continue to underrecognize and undertreat women with this condition. Currently there is increasing political as well as international support for further study to understand depression and its impact on those directly and indirectly involved. This article will review the magnitude, impact, and suggested screening interventions for maternal depression. RECENT FINDINGS: Various studies and reviews have documented the prevalence of maternal depression as well as the underrecognition and undertreatment of the problem. The barriers that contribute to this can be related to the individual, the provider, as well as the healthcare delivery system. Depression and even depressive symptoms have been well documented to have deleterious impacts in several domains. These include maternal-child relationships, parenting practices, family functioning, and even children's general development and well-being. SUMMARY: The care of the mother has not been in the conventional scope of practice for pediatricians. However, child healthcare practitioners play a crucial rule in delivering family-oriented care, including the identification and referral of parents for emotional health problems that adversely affect children and family well-being.