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Using Quality Improvement Science to Promote Reliable Communication During Family-Centered Rounds

Glick, Alexander F; Foster, Lauren Z; Goonan, Michael; Hart, Louis H; Alam, Sadia; Rosenberg, Rebecca E
BACKGROUND AND OBJECTIVES/OBJECTIVE:Family-centered rounds (FCR) can lead to improved communication, satisfaction, and care delivery. However, FCR are variable in practice. Our primary goal was to implement and sustain consistent communication practices during FCR (a subset of all rounds in which parents were present) for patients on a pediatric hospital medicine service. We aimed to achieve 80% reliability for the following FCR practices: (1) discussion of risk factors and prevention strategies for hospital-acquired conditions (HACs), (2) discussion of discharge planning, and (3) asking families for questions. METHODS:Research assistants observed FCR on a pediatric acute care unit at an academic medical center and recorded if the rounding team discussed HAC risk factors, discussed discharge, or asked families for questions. Using the Model for Improvement, we performed multiple plan-do-study-act cycles to test and implement interventions, including (1) standardized note templates, (2) education via peer-led group discussions and team e-mails, and (3) routine provider feedback about performance. Data were analyzed by using statistical process control charts. RESULTS:From October 2017 to April 2019, reliability increased to >80% and sustained for (1) discussion of HAC risk factors (increased from 11% to 89%), (2) discussion of discharge planning (from 60% to 92%), and (3) asking families for questions (from 61% to 87%). Peer-led physician education, reminder e-mails, and physician engagement were the most impactful interventions corresponding to centerline shifts. CONCLUSIONS:Using multiple interventions, we achieved and sustained improvements in key communication-related elements of FCR. Future work will focus on determining if improved practices impact clinical outcomes.
PMID: 35362064
ISSN: 1098-4275
CID: 5201402

Meds to Beds: A Quality Improvement Approach to Optimizing the Discharge Medication Process for Pediatric Patients

Foster, Lauren; Choxi, Shivali; Rosenberg, Rebecca E; Tracy, Joanna; Toscano, Dante; Betancur Paez, Juan; Glick, Alexander F
BACKGROUND:Using an on-site pharmacy or medication to bedside (MTB) program allows patients to obtain prescriptions and education before discharge, potentially improving adherence and preventing harm. The aim of this project was to improve discharge processes for pediatric acute care patients by increasing the proportion of oral antibiotics (1) prescribed to the on-site pharmacy from 15% to 70% and (2) delivered to bedside from 0% to 50%. METHODS:The Model for Improvement was used to iteratively implement interventions: increased on-site pharmacy capabilities, MTB program creation and streamlined enrollment, and secure electronic health record (EHR) messaging between clinicians and pharmacy staff regarding prescriptions. Process measures were proportion of antibiotics prescribed to the on-site pharmacy and delivered to bedside. Outcomes included surveys of family satisfaction with discharge medication education and discharge medication-related safety reports. Discharge before noon (DBN) was the balancing measure. Aims were analyzed using statistical process control charts and chi-square tests. RESULTS:A total of 1,908 antibiotics were prescribed over 28-months. On-site pharmacy prescriptions increased from 15% to 46% after pharmacy capabilities increased, then to 86% after MTB program launch, optimized workflow, and initiation of EHR messaging. Bedside medication delivery increased from 0% to 58% with these interventions. Family satisfaction with discharge medication education and frequency of discharge medication-related safety reports was not significantly different pre- and postintervention. DBN varied throughout the study. CONCLUSION/CONCLUSIONS:Through clinician and pharmacy staff partnership, this initiative increased on-site pharmacy use and discharge antibiotics delivered to bedside. Key interventions included increased pharmacy capabilities, MTB program with streamlined workflow, and EHR-based communication.
PMID: 34740550
ISSN: 1938-131x
CID: 5184842

Central Venous Catheter Salvage in Ambulatory Central Line-Associated Bloodstream Infections

Ford, William J H; Bundy, David G; Oyeku, Suzette; Heo, Moonseong; Saiman, Lisa; Rosenberg, Rebecca E; DeLaMora, Patricia; Rabin, Barbara; Zachariah, Philip; Mirhaji, Parsa; Klein, Elizabeth; Obaro-Best, Oghale; Drasher, Michael; Peshansky, Alexandre; Rinke, Michael L
BACKGROUND:Guidelines for treatment of central line-associated bloodstream infection (CLABSI) recommend removing central venous catheters (CVCs) in many cases. Clinicians must balance these recommendations with the difficulty of obtaining alternate access and subjecting patients to additional procedures. In this study, we evaluated CVC salvage in pediatric patients with ambulatory CLABSI and associated risk factors for treatment failure. METHODS:This study was a secondary analysis of 466 ambulatory CLABSIs in patients <22 years old who presented to 5 pediatric medical centers from 2010 to 2015. We defined attempted CVC salvage as a CVC left in place ≥3 days after a positive blood culture result. Salvage failure was removal of the CVC ≥3 days after CLABSI. Successful salvage was treatment of CLABSI without removal of the CVC. Bivariate and multivariable logistic regression analyses were used to test associations between risk factors and attempted and successful salvage. RESULTS:A total of 460 ambulatory CLABSIs were included in our analysis. CVC salvage was attempted in 379 (82.3%) cases. Underlying diagnosis, CVC type, number of lumens, and absence of candidemia were associated with attempted salvage. Salvage was successful in 287 (75.7%) attempted cases. Underlying diagnosis, CVC type, number of lumens, and absence of candidemia were associated with successful salvage. In patients with malignancy, neutropenia within 30 days before CLABSI was significantly associated with both attempted salvage and successful salvage. CONCLUSIONS:CVC salvage was often attempted and was frequently successful in ambulatory pediatric patients presenting with CLABSI.
PMID: 34814175
ISSN: 1098-4275
CID: 5147162

Pediatric surgical site infection (SSI) following ambulatory surgery: Incidence, risk factors and patient outcomes

Rinke, Michael L; Bundy, David G; Heo, Moonseong; Saiman, Lisa; Rabin, Barbara; Zachariah, Philip; Rosenberg, Rebecca E; DeLaMora, Patricia; Mirhaji, Parsa; Drasher, Michael; Klein, Elizabeth; Obaro-Best, Oghale; Ford, William J H; Zarowin, Diana; Peshansky, Alexandre; Oyeku, Suzette O
BACKGROUND:Inpatient surgical site infections (SSIs) cause morbidity in children. The SSI rate among pediatric ambulatory surgery patients is less clear. To fill this gap, we conducted a multiple-institution, retrospective epidemiologic study to identify incidence, risk factors, and outcomes. METHODS:We identified patients aged <22 years with ambulatory visits between October 2010 and September 2015 via electronic queries at 3 medical centers. We performed sample chart reviews to confirm ambulatory surgery and adjudicate SSIs. Weighted Poisson incidence rates were calculated. Separately, we used case-control methodology using multivariate backward logistical regression to assess risk-factor association with SSI. RESULTS:In total, 65,056 patients were identified by queries, and we performed complete chart reviews for 13,795 patients; we identified 45 SSIs following ambulatory surgery. The weighted SSI incidence following pediatric ambulatory surgery was 2.00 SSI per 1,000 ambulatory surgeries (95% confidence interval [CI], 1.37-3.00). Integumentary surgeries had the highest weighted SSI incidence, 3.24 per 1,000 ambulatory surgeries (95% CI, 0.32-12). The following variables carried significantly increased odds of infection: clean contaminated or contaminated wound class compared to clean (odds ratio [OR], 9.8; 95% CI, 2.0-48), other insurance type compared to private (OR, 4.0; 95% CI, 1.6-9.8), and surgery on weekend day compared to weekday (OR, 30; 95% CI, 2.9-315). Of the 45 instances of SSI following pediatric ambulatory surgery, 40% of patients were admitted to the hospital and 36% required a new operative procedure or bedside incision and drainage. CONCLUSIONS:Our findings suggest that morbidity is associated with SSI following ambulatory surgery in children, and we also identified possible targets for intervention.
PMID: 34376267
ISSN: 1559-6834
CID: 4972622

Pediatric Ambulatory Central Line-Associated Bloodstream Infections

Rinke, Michael L.; Heo, Moonseong; Saiman, Lisa; Bundy, David G.; Rosenberg, Rebecca E.; DeLaMora, Patricia; Rabin, Barbara; Zachariah, Philip; Mirhaji, Parsa; Ford, William J. H.; Obaro-Best, Oghale; Drasher, Michael; Klein, Elizabeth; Peshansky, Alexandre; Oyeku, Suzette O.
ISSN: 0031-4005
CID: 4773602

Costs of ambulatory pediatric healthcare-associated infections: Central-line-associated bloodstream infection (CLABSIs), catheter-associated urinary tract infection (CAUTIs), and surgical site infections (SSIs)

Rinke, Michael L; Oyeku, Suzette O; Ford, William J H; Heo, Moonseong; Saiman, Lisa; DeLaMora, Patricia; Rabin, Barbara; Zachariah, Philip; Rosenberg, Rebecca E; Mirhaji, Parsa; Obaro-Best, Oghale; Drasher, Michael; Klein, Elizabeth; Peshansky, Alexandre; Bundy, David G
OBJECTIVE:Ambulatory healthcare-associated infections (HAIs) occur frequently in children and are associated with morbidity. Less is known about ambulatory HAI costs. This study estimated additional costs associated with pediatric ambulatory central-line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTI), and surgical site infections (SSIs) following ambulatory surgery. DESIGN/METHODS:Retrospective case-control study. SETTING/METHODS:Four academic medical centers. PATIENTS/METHODS:Children aged 0-22 years seen between 2010 and 2015 and at risk for HAI as identified by electronic queries. METHODS:Chart review adjudicated HAIs. Charges were obtained for patients with HAIs and matched controls 30 days before HAI, on the day of, and 30 days after HAI. Charges were converted to costs and 2015 USD. Mixed-effects linear regression was used to estimate the difference-in-differences of HAI case versus control costs in 2 models: unrecorded charge values considered missing and a sensitivity analysis with unrecorded charge considered $0. RESULTS:Our search identified 177 patients with ambulatory CLABSIs, 53 with ambulatory CAUTIs, and 26 with SSIs following ambulatory surgery who were matched with 382, 110, and 75 controls, respectively. Additional cost associated with an ambulatory CLABSI was $5,684 (95% confidence interval [CI], $1,005-$10,362) and $6,502 (95% CI, $2,261-$10,744) in the 2 models; cost associated with a CAUTI was $6,660 (95% CI, $1,055, $12,145) and $2,661 (95% CI, -$431 to $5,753); cost associated with an SSI following ambulatory surgery at 1 institution only was $6,370 (95% CI, $4,022-$8,719). CONCLUSIONS:Ambulatory HAI in pediatric patients are associated with significant additional costs. Further work is needed to reduce ambulatory HAIs.
PMID: 32880250
ISSN: 1559-6834
CID: 4614632

Pediatric ambulatory catheter-associated urinary tract infections (CAUTIs): Incidence, risk factors, and patient outcomes

Rinke, Michael L; Oyeku, Suzette O; Heo, Moonseong; Saiman, Lisa; Zachariah, Philip; Rosenberg, Rebecca E; DeLaMora, Patricia; Rabin, Barbara; Mirhaji, Parsa; Klein, Elizabeth; Ford, William J H; Obaro-Best, Oghale; Drasher, Michael; Peshansky, Alexandre; Balem, Kelly Ann; Bundy, David G
OBJECTIVE:Catheter-associated urinary tract infections (CAUTIs) occur frequently in pediatric inpatients, and they are associated with increased morbidity and cost. Few studies have investigated ambulatory CAUTIs, despite at-risk children utilizing home urinary catheterization. This retrospective cohort and case-control study determined incidence, risk factors, and outcomes of pediatric patients with ambulatory CAUTI. DESIGN/METHODS:Broad electronic queries identified potential patients with ambulatory urinary catheters, and direct chart review confirmed catheters and adjudicated whether ambulatory CAUTI occurred. CAUTI definitions included clean intermittent catheterization (CIC). Our matched case-control analysis assessed risk factors. SETTING/METHODS:Five urban, academic medical centers, part of the New York City Clinical Data Research Network. PATIENTS/METHODS:Potential patients were age <22 years who were seen between October 2010 and September 2015. RESULTS:In total, 3,598 eligible patients were identified; 359 of these used ambulatory catheterization (representing186,616 ambulatory catheter days). Of these, 63 patients (18%) experienced 95 ambulatory CAUTIs. The overall ambulatory CAUTI incidence was 0.51 infections per 1,000 catheter days (1.35 for indwelling catheters and 0.47 for CIC; incidence rate ratio, 2.88). Patients with nonprivate medical insurance (odds ratio, 2.5; 95% confidence interval, 1.1-6.3) were significantly more likely to have ambulatory CAUTIs in bivariate models but not multivariable models. Also, 45% of ambulatory CAUTI resulted in hospitalization (median duration, 3 days); 5% resulted in intensive care admission; 47% underwent imaging; and 88% were treated with antibiotics. CONCLUSIONS:Pediatric ambulatory CAUTIs occur in 18% of patients with catheters; they are associated with morbidity and healthcare utilization. Ambulatory indwelling catheter CAUTI incidence exceeded national inpatient incidence. Future quality improvement research to reduce these harmful infections is warranted.
PMID: 32498724
ISSN: 1559-6834
CID: 4516452

Setting an Agenda for Hospital Medicine Research: Making Sure the Right People Are at the Table [Editorial]

Glick, Alexander F; Jacobs-Shaw, Ramon Ea; Rosenberg, Rebecca E
PMID: 32525793
ISSN: 1553-5606
CID: 4510472

Accuracy of Parent Perception of Comprehension of Discharge Instructions: Role of Plan Complexity and Health Literacy

Glick, Alexander F; Farkas, Jonathan S; Rosenberg, Rebecca E; Mendelsohn, Alan L; Tomopoulos, Suzy; Fierman, Arthur H; Dreyer, Benard P; Migotsky, Michael; Melgar, Jennifer; Yin, H Shonna
OBJECTIVE:Inpatient discharge education is often suboptimal. Measures of parents' perceived comprehension of discharge instructions are included in national metrics given linkage to morbidity; few studies compare parents' perceived and actual comprehension. We (1) compared parent perceived and actual comprehension of discharge instructions and (2) assessed associations between plan complexity and parent health literacy with overestimation of comprehension (perceive comprehension but lack actual comprehension). METHODS:Prospective cohort study of English/Spanish-speaking parents (n=192) of inpatients ≤12 years old and discharged on ≥1 daily medication from an urban public hospital. We used McNemar's tests to compare parent perceived (agree/strongly agree on 5-point Likert scale) and actual comprehension (concordance of parent report with medical record) of instructions (domains: medications, appointments, return precautions, and restrictions). Generalized estimating equations were performed to assess associations between low parent health literacy (Newest Vital Sign score ≤3) and plan complexity with overestimation of comprehension. RESULTS:Medication side effects were the domain with lowest perceived comprehension (80%), while >95% of parents perceived comprehension for other domains. Actual comprehension varied by domain (41-87%) and was lower than perceived comprehension. Most (84%) parents overestimated comprehension in ≥1 domain. Plan complexity (adjusted odds ratio [aOR] 3.6 [95% CI 2.9-4.7]) and low health literacy (aOR 1.9 [1.3-2.6]) were associated with overestimation of comprehension. CONCLUSIONS:Parental perceived comprehension of discharge instructions overestimated actual comprehension in most domains. Plan complexity and low health literacy were associated with overestimation of comprehension. Future interventions should incorporate assessment of actual comprehension and standardization of discharge instructions.
PMID: 31954854
ISSN: 1876-2867
CID: 4272542

Three-year-old girl with progressive leg pain, weakness and refusal to ambulate [Case Report]

Gallagher, Julie; Mangalick, Keshav; Bradshaw, Chanda; Rosenberg, Rebecca
PMID: 31621978
ISSN: 1440-1754
CID: 4140602