bluuebunny/crossref_metadata_2025 huggingface dataset:
A Computable Definition of Sepsis Facilitates Screening and Performance Improvement Tracking
Authors: Alessi Lauren J. , Warmus Holly R. , Schaffner Erin K. , Kantawala Sajel , Carcillo Joseph , Rosen Johanna , Horvat Christopher M.
Published: June 2019

Background:

Sepsis kills almost 5,000 children annually, accounting for 16% of pediatric health care spending in the United States.

Objectives:

We sought to identify sepsis within the Electronic Health Record (EHR) of a quaternary children’s hospital to characterize disease incidence, improve recognition and response, and track performance metrics.

Methods:

Methods are organized in a plan-do-study-act cycle. During the “plan” phase, electronic definitions of sepsis (blood culture and antibiotic within 24 hours) and septic shock (sepsis plus vasoactive medication) were created to establish benchmark data and track progress with statistical process control. The performance of a screening tool was evaluated in the emergency department. During the “do” phase, a novel inpatient workflow is being piloted, which involves regular sepsis screening by nurses using the tool, and a regimented response to high risk patients.

Results:

Screening tool use in the emergency department reduced time to antibiotics (Fig. 1). Of the 6,159 admissions, EHR definitions identified 1,433 (23.3%) between July and December 2016 with sepsis, of which 159 (11.1%) had septic shock. Hospital mortality for all sepsis patients was 2.2% and 15.7% for septic shock (Table 1). These findings approximate epidemiologic studies of sepsis and severe sepsis, which report a prevalence range of 0.45–8.2% and mortality range of 8.2–25% (Table 2).
1–5

Conclusions/Implications:

Implementation of a sepsis screening tool is associated with improved performance. The prevalence of sepsis conditions identified with electronic definitions approximates the epidemiologic landscape characterized by other point-prevalence and administrative studies, providing face validity to this approach, and proving useful for tracking performance improvement.
Optimizing Performance: Emergency Department Sepsis Champions: Past, Present, and Future
Authors: Chavez Gabriela L. , Calhoun Celeste N. , Miller Ean C. , Espinosa Michelle T. , Hardee Terri L. , Myrick Cindy P.
Published: June 2019

Background:

Delays in recognition of sepsis and timely administration of fluids and antibiotics are significant barriers within pediatric emergency departments (ED).

Objectives:

To improve care for patients identified at risk for sepsis.

Methods:

In 2014, the ED at a large urban pediatric medical center created a unit-based sepsis committee. This multidisciplinary group meets monthly to discuss trends, barriers, metrics, education, and needs related to ED sepsis screening and alerts. The most successful educational committee activities provided were 3-hour sepsis classes for ED Registered Nurses and Paramedics during Spring 2015. Purpose was to increase ED awareness that sepsis kills without early recognition and intervention. Pathophysiology of sepsis, sepsis scoring tool, patient assessment, interventions, medications, case scenarios, and sepsis data were topics presented in these sessions. This education has now been integrated into orientation curriculum for all new staff.

Results:

One sepsis committee outcome was increased open communication channels between ED staff and physicians. Sepsis committee members give staff personalized feedback, ensuring staff understand urgency to act when patients are identified as sepsis alerts. Improved patient outcomes were evidenced by decreased: (1) median time to first fluid bolus administration from 65 minutes in 2014 to 32 minutes in July of 2017 and (2) median time to antibiotic administration from 137 minutes to 68 minutes (Fig. 1).

Conclusions/Implications:

Standardization of care using a sepsis scoring tool improves patient outcomes. The monthly sepsis meetings empower staff with knowledge, engage staff, and create accountability. Committee members are resources on the unit and help identify and recognize drifts from set benchmarks.
The Effect of Operating Room Temperature on the Performance of Clinical and Cognitive Tasks
Authors: Hakim Mumin , Walia Hina , Dellinger Heather L. , Balaban Onur , Saadat Haleh , Kirschner Richard E. , Tobias Joseph D. , Raman Vidya T.
Published: June 2019

Introduction:

Operating room (OR) temperature may impact the performance of health care providers. This study assesses whether hot or cold room temperature diminishes the performance of OR personnel measured by psychomotor vigilance testing (PVT) and self-report scales.

Methods:

This prospective observational study enrolled surgical/anesthesia trainees, student registered nurse anesthetists, and certified registered nurse anesthetists. Each provider participated in a test of psychomotor function and a questionnaire using a self-report scale of personal comfort and well-being. The PVT and questionnaires were completed after 30 minutes of exposure to 3 different conditions (temperature of 21°C, 23°C, and 26°C).

Results:

The cohort of 22 personnel included 9 certified registered nurse anesthetists, 7 anesthesia/surgical trainees, and 6 student registered nurse anesthetists. Mean reaction time on the PVT was comparable among baseline (280 ± 47 ms), hot (286 ± 55 ms; P = 0.171), and cold (303 ± 114 ms; P = 0.378) conditions. On the self-report score (range, 1–21), there was no difference in the self-rated subjective performance between baseline and cold conditions. However, the self-rated subjective performance scale was lower (12 ± 6, P = 0.003) during hot conditions.

Discussion:

No difference was noted in reaction time depending on the temperature; however, excessive heat in the OR environment was associated with worse self-rated subjective performance among health care providers. Particularly, self-rated subjective physical demand and frustration were greater under hot condition.
Recognition of Sepsis Triggers in a Mixed EMR Community Hospital
Authors: Salt Michael D. , Beaton Adam , Schreiber Krista , Gamallo Bernardita
Published: June 2019

Background:

Early recognition of sepsis and rapid intervention has been proven to decrease both morbidity and mortality. However, early recognition continues to be a problem across all pediatric settings including our hospital.

Objectives:

Having no capable EMR system, our institution has implemented a manual trigger tool (Fig. 1) to help earlier identify those at risk and prevent progression to severe sepsis.

Methods:

All patients admitted to the pediatric floor at Goryeb Children’s Hospital, a community hospital, with 1,900 inpatient admissions annually, were monitored for abnormal vitals meeting criteria as defined by our trigger tool. With our key driver being prevention, we instituted a manual trigger tool as the secondary driver to help us achieve our goal. We retrospectively collected data on the number of patients who were identified and documented versus those who met criteria that were not documented. After the first month of data collection, further sepsis education was provided to the resident house staff and nursing staff. Additionally, vital sign criteria for our trigger were placed on all monitors (Fig. 2).

Results:

Over the first 4 months, from July to October, after instituting our manual trigger tool, 55%, 45%, 50%, and 43% of vital signs were appropriately identified and documented (Table 1).

Conclusions:

Our ability to recognize abnormal vitals in a potentially septic patient continues to be below our goal of 80% at 6 months with a manual trigger process. Areas for possible improvement include further education to the staff and integration of EMR with automated trigger tools.
Implementation of the CHA IPSO Collaborative at a Pediatric Academic Center
Authors: Mathur Himi , Zapata Lesly , Zhan Xin , Kahlon Prerna S.
Published: June 2019

Introduction:

Boston Children’s Hospital joined a national quality improvement collaborative to reduce the incidence of severe sepsis (SS) and associated mortality through early identification and treatment. We developed a scalable data infrastructure to retrospectively identify SS and non-severe sepsis (NSS) patients from the data warehouse (EDW) to identify opportunities for quality improvement by April 2017.

Methods:

Developed a 3-stage scalable process based on techniques involved in retrospective identification of SS patients by using RedCapTM, as the tool of choice (see Figure 1, Supplemental Digital Content 1, available at http://links.lww.com/PQ9/A22).

1. Retrospective Data Mining: SS and NSS patients are extracted from the EDW by SQL query based on the treatment criteria specified by IPSO (Fig. 1)

2. Data Verification: Data from the EDW is automatically extracted into a patient specific RedCapTM screening form for all patients filtered through the query logic into automated and manual fields, for data coordinator and clinical verification

3. Data submission: RedCapTM submission form is a completely automated extension of the RedcapTM screening form to extract data sepsis quality variables for all patients. An MS Excel version of this form is submitted to IPSO data portal

Results:

The data mining accuracy improved by 46% and time spent per manual review decreased from 20 minutes to 6 minutes after implementing the 3-stage process.

Conclusions:

Continuously optimize data collection through an iterative process by minimizing manual review to improve the identification of pediatric sepsis patients. Lessons learned from our process are definitely transferable and can be customized to other IPSO participants.
Impact of a Daily PICU Rounding Checklist on Urinary Catheter Utilization and Infection
Authors: Siegel Benjamin I. , Figueroa Janet , Stockwell Jana A.
Published: June 2019

Introduction:

In critically ill children, inappropriate urinary catheter (UC) utilization is associated with increased morbidity, including catheter-associated urinary tract infections (CAUTIs). Checklists are effective for reducing medical errors, but there is little data on their impact on device utilization in pediatric critical care. In this study, we evaluated UC utilization trends and CAUTI rate after implementing a daily rounding checklist.

Methods:

A retrospective review of our checklist database from 2006 through 2016 was performed. The study setting was a 36-bed pediatric intensive care unit in a quaternary-care pediatric hospital. Interventions included the “Daily QI Checklist” in 2006, ongoing education regarding device necessity, and a CAUTI prevention bundle in 2013. UC utilization and duration were assessed via auto-correlated time series models and Cochran-Armitage tests for trend. Changes in CAUTI rate were assessed via Poisson regression.

Results:

UC utilization decreased from 30% of patient-days in 2006 to 18% in 2016 (P < 0.0001, Cochran-Armitage trend test), while duration of UC use (median, 2.0 days; interquartile range, 1–4) did not change over time (P = 0.18). CAUTI rate declined from 9.49/1,000 UC-days in 2009 to 1.04 in 2016 (P = 0.0047).

Conclusions:

Implementation of the checklist coincided with a sustained 40% reduction in UC utilization. The trend may be explained by a combination of more appropriate selection of patients for catheterization and improved timeliness of UC discontinuation. We also observed an 89% decline in CAUTI rate that occurred after stabilization of UC utilization. These findings underscore the potential impact of a checklist on incorporating best practices into daily care of critically ill children.
Shortened Taper Duration after Implementation of a Standardized Protocol for Iatrogenic Benzodiazepine and Opioid Withdrawal in Pediatric Patients: Results of a Cohort Study
Authors: Vipond Jane M. , Heiberger Amy L. , Thompson Paul A. , Huber Jody N.
Published: June 2019

Introduction:

Methadone and lorazepam prescribing discrepancies for the use of iatrogenic withdrawal were observed among providers. A standardized pharmacist-managed methadone and lorazepam taper protocol was implemented at a pediatric tertiary care facility with the aim to reduce the length of taper for patients with iatrogenic withdrawal.

Methods:

A multidisciplinary team of nurses, pharmacists, and physicians reviewed the current literature, then developed and implemented a standardized withdrawal taper protocol. Outcomes were compared with a retrospective control group using past prescribing practices. The primary endpoint was the length of methadone and/or lorazepam taper. Secondary endpoints included evaluation for significant differences between the control and standardized protocol groups regarding additional breakthrough withdrawal medications, pediatric intensive care unit (PICU) and hospital length of stay. We also evaluated provider satisfaction with the protocol.

Results:

The standardized protocol group included 25 patients who received methadone and/or lorazepam taper. A retrospective control group contained 24 patients. Median methadone taper length before protocol implementation was 9.5 days with an interquartile range (IQR) of 5.5–14.5 days; after protocol implementation, it was 6.0 (IQR, 3.0–9.0) days (P = 0.0145). Median lorazepam taper length before protocol implementation was 13.0 (IQR, 8.0–18.0) days; after protocol implementation, it was 6.0 (4.0–7.0) days (P = 0.0006). A statistical difference between PICU length of stay, hospital length of stay, or the number of additional medications for breakthrough withdrawal was not found.

Conclusions:

The use of a standardized withdrawal protocol resulted in shorter taper duration for both the methadone and lorazepam groups. There was no difference in PICU or hospital length of stay.
Evaluating the Impact of a Feeding Protocol in Neonates before and after Biventricular Cardiac Surgery
Authors: Furlong-Dillard Jamie , Neary Alaina , Marietta Jennifer , Jones Courtney , Jeffers Grace , Gakenheimer Lindsey , Puchalski Michael , Eckauser Aaron , Delgado-Corcoran Claudia
Published: June 2019

Introduction:

Feeding difficulties and malnutrition are important challenges when caring for newborns with critical congenital heart disease (CCHD) without clear available guidelines for providers. This study describes the utilization of a feeding protocol with the focus on standardization, feeding modality, and total parenteral nutrition (TPN) utilization postoperatively.

Methods:

Patients included neonates with CCHD undergoing complex biventricular repair using cardiopulmonary bypass. Data were collected in 2013 preintervention and from 2015 to 2017 postintervention. The feeding protocol outlined guidelines for and postoperative use of TPN. Adverse outcomes data included rates of central line–associated bloodstream infections, necrotizing enterocolitis, chylothorax, and vocal cord dysfunction. Balance outcomes measured were weight for age Z-score at discharge, number of abdominal radiographs obtained, readmission within 90 days, and central venous line utilization.

Results:

We included a total of 121 neonates: 49 in the preintervention group and 72 in the postintervention group. The protocol standardized feeding practices in CCHD neonates undergoing surgery with improved compliance from 70% early in the study period to 90% at the end of the study. Infants were fed enterally more preoperatively (86% versus 67%;P = 0.023), reached a fluid goal sooner (63 hours versus 72 hours;P = 0.035), and postoperative duration of TPN usage was significantly shorter in the postintervention period (48 hours versus 62 hours;P= 0.041) with no increase in adverse outcome events or unintended consequences.

Conclusions:

By implementing a feeding protocol, we reduced practice variation among providers, increased the number of patients fed enterally preoperatively and reduced postoperative use of TPN without increased complications.
Using a Pediatric Trigger Tool to Estimate Total Harm Burden Hospital-acquired Conditions Represent
Authors: Stockwell David C. , Landrigan Christopher P. , Schuster Mark A. , Klugman Darren , Bisarya Hema , Classen David C. , Dizon Zoelle B. , Hall Matt , Wood Matthew , Sharek Paul J.
Published: June 2019

Introduction:

To improve patient safety, the Centers for Medicare & Medicaid Services (CMS) has promoted systematically measuring and reporting harm due to patient care. The CMS’s Partnership for Patients program identified 9 hospital-acquired conditions (HACs) for reduction, to make care safer, more reliable, and less costly. However, the proportion of inpatient pediatric harm represented by these HACs is unknown.

Methods:

We conducted a retrospective review of 240 harms previously identified using the Pediatric All-Cause Harm Measurement Tool, a trigger tool that is applied to medical records to comprehensively identify harms. The original sample included 600 randomly selected patients from 6 children’s hospitals in February 2012. Patients with rehabilitation, obstetric, newborn nursery, and psychiatric admissions were excluded. The 240 identified harms were classified as a HAC if the event description potentially met the definition of 1 of the 9 CMS-defined HACs. HAC assessment was performed independently by 2 coauthors and compared using Cohen’s Kappa.

Results:

Two hundred forty harms across 6 children’s hospitals were identified in February 2012 using a pediatric global trigger tool. Agreement between the coauthors on HAC classification was high (Kappa = 0.77). After reconciling differences, of the 240 identified harms, 58 (24.2%; 95% confidence interval: 9.1–31.7%) were classified as a CMS-defined HAC.

Conclusions:

One-fourth of all harms detected by a pediatric-specific trigger tool are represented by HACs. Although substantial effort is focused on identifying and minimizing HACs, to better understand and ultimately mitigate harm, more comprehensive harm identification and quantification may be needed to address events unidentified using this approach.
I-PASS Handoff Program: Use of a Campaign to Effect Transformational Change
Authors: Rosenbluth Glenn , Destino Lauren A. , Starmer Amy J. , Landrigan Christopher P. , Spector Nancy D. , Sectish Theodore C.
Published: June 2019

Background:

Behavior change is notoriously difficult to achieve within health care systems. Successful implementation of the I-PASS handoff bundle with subsequent decreases in medical errors and preventable adverse events represents an example of successful transformational change within academic medical centers.

Objective:

We designed a campaign to support and enhance uptake of the I-PASS handoff bundle at 9 study sites from 2011 to 2013.

Methods:

Following Kotter’s model of transformational change, we established urgency using local data and institutional mandates, and site leaders built local guiding coalitions with institutional leaders, key faculty, and Chief Residents. We created and communicated our vision using a branded campaign and empowered others to act by soliciting and acting on feedback and supporting systems changes. Site leaders planned for and created short-term wins by recognizing residents who engaged with I-PASS, consolidated improvements, and institutionalized new approaches.

Results:

Implementation of I-PASS was successful, with achievement of substantial improvements in rates of medical errors and preventable adverse events. Data from the initial I-PASS study have continued to drive a national campaign that has included national recognition by leaders in the field of patient safety and pediatrics. Momentum has increased significantly to support mentored implementation of the I-PASS handoff program at over 35 academic medical centers across North America.

Conclusions:

I-PASS provides an example of transformational change achieved through a combination of educational interventions and change management to address resistance/barriers, supported by a robust campaign. We encourage others in academic medicine to consider using change models, including campaigns, to support health care improvement programs.
Decreasing Radiograph Errors in Pediatric Sports Medicine Clinic
Authors: Valasek Amy E. , Gallup James , Wheeler T. Arthur , Valleru Jahnavi
Published: June 2019

Background:

Radiographs are frequently ordered for general musculoskeletal complaints in the outpatient setting. However, incorrect laterality, incorrect location, or unnecessary radiographs have been reported as errors in our clinics. This quality improvement (QI) project aimed to reduce incorrect duplicate radiographs in outpatient pediatric sports medicine clinic. The overall global goal was to stop unnecessary radiation exposure in our pediatric patients.

Methods:

Using QI methodology, we evaluated the current clinic flow, the process of ordering radiographs, and the completion of radiographs at the main sports medicine outpatient clinic. Staff communication, staff education, and patient participation were identified as the prominent gaps in our clinic process. We implemented interventions using progressive biweekly Plan-Do-Study-Act (PDSA) cycles to promote change and to reduce our radiographic errors.

Results:

Retrospective baseline data demonstrated baseline errors of 9% (10/106) in the main outpatient clinic. After 6 months of PDSA cycles, we found no duplicate errors. Highly successful interventions included radiograph screening survey for families, staff education, and improved staff communication. The project was expanded to a second outpatient clinic with baseline errors of 6% (4/64). After 2 months of PDSA cycles, no duplicate errors were found.

Conclusion:

Our goal was to reduce incorrect duplicate radiographs in outpatient sports medicine clinic and limit unnecessary radiation exposure in our pediatric patients. A reduction in duplicate errors at 2 clinics occurred using the Institute for Healthcare Improvement model to facilitate change. Effective communication between physicians, clinical athletic trainers, radiology technologists, patients, and families drove the success of this quality improvement initiative.
Improving Follow-up Skeletal Survey Compliance in Suspected Nonaccidental Trauma Patients: What’s the FUSS About?
Authors: Gan Tong , Draus John M.
Published: June 2019

Introduction:

Nonaccidental trauma (NAT) victims account for a significant percentage of our pediatric trauma population. The skeletal survey (SS) and follow-up skeletal survey (FUSS) are essential in the evaluation of selected NAT patients. We identified that our clinically indicated FUSS completion rate was suboptimal. We hypothesized that implementing an intervention of postdischarge follow-up in our pediatric surgery clinic would improve FUSS completion rates.

Methods:

A follow-up clinic for NAT patients was established in July 2013. A retrospective review was performed of all suspected NAT cases younger than 2 years old seen at Kentucky Children’s Hospital between November 2012 and February 2014. The study population was divided into pre (Group 1) and postintervention (Group 2). Bivariate analysis was performed.

Results:

Group 1 consisted of 50 patients (58% male; median age, 9 months). Forty-7 (94%) had an SS; fractures were identified in 37 (74%) patients. Only 20 patients (40%) had FUSS; of those, 4 had newly identified fractures. Group 2 consisted of 52 patients (54% male; median age, 7 months). All 52 children (100%) had an SS; fractures were identified in 35 (67%) patients. Forty-seven patients (90%) had FUSS. Of those, 6 had new radiographic findings. Thirty-five patients (67%) were seen in our clinic. This improvement in FUSS (40% versus 90%) was statistically significant, P < 0.001.

Conclusion:

The decision to follow NAT patients in our clinic had significantly increased our rates of FUSS completion. This additional clinic follow-up also provided more evidence for NAT evaluation.
Reducing Unplanned Extubations Across a Children’s Hospital Using Quality Improvement Methods
Authors: Kandil Sarah B. , Emerson Beth L. , Hooper Michael , Ciaburri Rebecca , Bruno Christie J. , Cummins Nancy , DeFilippo Virginia , Blazevich Beth , Loth Adrienne , Grossman Matthew
Published: June 2019

Introduction:

Children who require an endotracheal (ET) tube for care during critical illness are at risk of unplanned extubations (UE), or the unintended dislodgement or removal of an ET tube that can lead to significant patient harm. A proposed national benchmark is 1 UE per 100 ventilator days. We aimed to reduce the rate of UEs in our intensive care units (ICUs) from 1.20 per 100 ventilator days to below the national benchmark within 2 years.

Methods:

We identified several key drivers including ET securement standardization, safety culture, and strategies for high-risk situations. We employed quality improvement methodologies including apparent cause analysis and plan-do-study-act cycles to improve our processes and outcomes.

Results:

Over 2 years, we reduced the rate of UEs hospital-wide by 75% from 1.2 to 0.3 per 100 ventilator days. We eliminated UEs in the pediatric ICU during the study period, while the UE rate in the neonatal ICU also decreased from 1.2 to 0.3 per 100 ventilator days.

Conclusion:

We demonstrated that by using quality improvement methodology, we successfully reduced our rate of UE by 75% to a level well below the proposed national benchmark.
A Learning Collaborative Approach to Improve Mental Health Service Delivery in Pediatric Primary Care
Authors: Baum Rebecca A. , Manda Divya , Brown Courtney M. , Anzeljc Samantha A. , King Melissa A. , Duby John
Published: June 2019

Background:

Pediatric primary care practitioners (PPCPs) report inadequate training in the care of children with common mental health conditions. Although additional training is needed, system changes are also necessary to support improvements in care.

Methods:

We developed the Building Mental Wellness Learning Collaborative to assist PPCPs in delivering better mental health services in primary care by targeting 5 focus areas: mental health promotion; early identification and screening; practitioner skills; collaboration and community linkages; and medication management. Aims were developed for each area.

Results:

Twenty-one practices and 50 practitioners completed the collaborative in 2 seven-month waves. For mental health promotion, ≥85% of charts showed documentation in 3 of 4 preselected areas. For early identification/screening, screening increased, but the ≥85% goal was not met. For practitioner skills, a ≥20% increase in the proportion of children/youth ≥1 visits for anxiety or depression was achieved, from 0.70% of children/youth in the 12 months preintervention to 1.09% children/youth in the 12 months after. For collaboration/linkages, mental health referral completion was unchanged and below the 60% goal. For medication use, a ≥15% increase in selective serotonin reuptake inhibitor prescribing by Building Mental Wellness (BMW) practitioners was achieved from 0.72% children/youth with office visits pre-BMW to 0.92% post. Prescribing did not decrease for atypical antipsychotic medication use or for psychotropic medication use in children younger than 6 years, although there was a trend toward more appropriate prescribing.

Conclusions:

The BMW Learning Collaborative was effective in helping PPCPs implement certain aspects of a comprehensive approach to the delivery of mental health services in primary care.
Improved Teamwork and Implementation of Clinical Pathways in a Congenital Heart Surgery Program
Authors: Willis Tina Schade , Yip Theodore , Brown Karla , Buck Scott , Mill Michael
Published: June 2019

Introduction:

Complex surgical populations are at increased risk of morbidity, especially when experiencing variations in care and poor teamwork. The goal of this project was to improve teamwork and decrease variations in care in a pediatric congenital heart surgery population by implementing Integrated Clinical Pathways (ICPs) on a foundation of teamwork training.

Methods:

A core team used project management for completion of the project and measurement of success. The leadership team created a new operations infrastructure for the program to effectively implement and sustain improvement. Master trainers targeting teams caring for the patient population completed teamwork training and coaching. ICPs were designed and implemented using iterative tests of change with the assistance of an expert panel.

Results:

Three of the 4 units experienced a significant improvement in teamwork after training and coaching. The area without a significant change was one with high-level teamwork training already in place. ICPs were implemented in 2 patient subpopulations. We detected a decrease in total hours intubated using statistical process control charts in both of the ICP patient populations. Despite a decrease in intubation hours, we did not detect a reduction in length of stay in days. The infrastructure for the program was successfully implemented and remains in place 6 years later.

Conclusions:

Teamwork can be improved with an efficiently delivered training and coaching program. On a foundation of teamwork, ICPs can be implemented and sustained if a supporting infrastructure is in place including program leadership, buy-in from all teams, project management, and ongoing measurement.
Necrotizing Enterocolitis and Spontaneous Intestinal Perforation: A Spatiotemporal Case Cluster Analysis
Authors: Murphy Thomas , Yang Samuel , Tucker Richard , Collyer Hillary , Kurkchubasche Arlet G. , Bender Jesse
Published: June 2019

Objective:

To expand existing statistical methods to identify clusters of necrotizing enterocolitis (NEC) and spontaneous intestinal perforation (SIP) cases in the neonatal intensive care unit.

Methods:

In an academic, tertiary referral center, possible NEC or SIP clusters were identified using a binomial distribution scan test. The incidence-density rate (IDR) was calculated as the number of cases per 1,000 patient-days during each possible cluster and compared with the baseline IDR. A structured chart review compared cluster and noncluster cases. Spatial clustering analyzed the physical distribution of cases using the Grimson Test. Repeat analysis included only SIP cases.

Result:

The initial scan identified 3 suspected temporal clusters. IDR comparison confirmed only 1 cluster. Analysis of SIP only cases revealed similar results. Physical proximity was not a significant factor. Chart review of the SIP and NEC cases revealed significant increases during the confirmed cluster of small for gestational age infant births and indomethacin treatment. Chart review of the SIP only cases in the confirmed cluster revealed no significant differences.

Conclusion:

Statistical methods distinguish whether suspected case clusters represent a significant increase in baseline incidence. True clusters warrant detailed investigation including spatial analysis and chart review. This approach may have application in other disease processes and populations.
Improving Access to Lactation Consultation and Early Breast Milk Use in an Outborn NICU
Authors: Leeman Kristen T. , Barbas Kimberly , Strauss Julia , Adams Shannon , Sussman-Karten Karen , Kelly Alyssa , Parker Margaret G. K. , Hansen Anne
Published: June 2019

Introduction:

Increasing the use of breast milk in critically ill neonates is an important priority to improve neonatal care. Lactation consultants (LCs) educate mothers about evidence-based benefits of breast milk and provide technical support. LC support can lead to increased breastfeeding initiation. The project aim was to improve access to lactation services for mothers of patients admitted at <48 hours after birth to an exclusively outborn level III/IV neonatal intensive care unit (NICU).

Methods:

The interventions included (1) implementation of an automatic electronic admission order for a lactation consult, (2) initiation of a daily lactation team notification, (3) assignment of a consistent NICU LC, and (4) targeted education. The percent of mothers who received lactation consults, the time to the first consultation, and the percent of patients receiving breast milk at 7 days of age were measured over 32 months and analyzed using statistical process control charts.

Results:

The lactation consultation rate increased significantly from 74% to 88% with a shift in the mean by statistical process control chart analysis that was sustained over time. Concurrently, the time to first lactation consultation significantly decreased from hospital days 5 to 3.3, and variation decreased. Rates of breast milk use at 7 days of age also significantly increased from 75.6% to 89.6%.

Conclusions:

Targeted quality improvement interventions led to an increased rate of lactation consultations, decreased time to first lactation consult, and increased rate of breast milk use at 7 days of age. These interventions could feasibly be implemented in similar referral NICU settings.
Implementing Outcome-based Care in Pediatric Psychiatry: Early Results and Overcoming Barriers
Authors: Krishna Rajeev , Valleru Jahnavi , Smith Whitney
Published: June 2019

Background:

Poor utilization of standardized outcome measures for monitoring patient care and progress in mental health services is evident. The objective of this work was to implement computerized diagnostic and history assessments for outpatient mental health visits in the ambulatory psychiatric clinic of a large pediatric health system.

Methods:

A computerized assessment system was created for the iPad to administer and score a series of validated diagnostics before new patient and follow-up appointments with a psychiatry provider. Outcome measures were a percentage of completed assessments, provider satisfaction, and patient satisfaction.

Results:

Across all outpatient psychiatry clinics, screener completion rate for new patients increased from 0% to 90% within 1 year of implementation and sustained within 3σ process control limits for 2 years. Return visit assessment completion increased from 0% to 80%. The most substantial completion rate increase was related to scheduling assessment time as part of the visit. Assessment of provider and patient satisfaction through surveys before and after the implementation showed 94% of providers felt that visit efficiency had improved, and overall opinion of the system was highly positive. Patients also reported high satisfaction with the assessment process (4.1 on Likert scale 0–5, 5 = very positive).

Conclusions:

This quality improvement program demonstrates strategies for overcoming barriers to the use of standardized assessments in outpatient psychiatry. We show that a large pediatric mental health system can achieve systematic outcome data collection with minimal disruption to routine clinical care.
Improving Efficiency and Communication around Sedated Fracture Reductions in a Pediatric Emergency Department
Authors: Paydar-Darian Niloufar , Goldman Michael P. , Michelson Kenneth A. , Button Katharine C. , Hewett Elizabeth K. , Macnow Theodore E. , Miller Andrew F. , Musisca Megan A. , Hudgins Joel D. , Eisenberg Matthew A.
Published: June 2019

Introduction:

Procedural sedation for fracture reduction in the pediatric emergency department (ED) is a time-consuming process requiring multidisciplinary coordination. We implemented a quality improvement initiative aimed at (1) decreasing mean ED length of stay (LOS) for children with sedated long bone fracture reductions by 15% over 12 months and (2) improving interdisciplinary communication around procedural sedation.

Methods:

Pediatric emergency medicine fellows at a children’s hospital designed and implemented an initiative targeting the efficiency of the sedation process. Interventions included a centralized sedation tracking board, a team member responsibility checklist, family handouts, early discharge initiatives, and postsedation review forms. We tracked progress via statistical process control charts and interdisciplinary communication by intermittent surveys.

Results:

Pediatric emergency medicine fellows performed 2,246 sedations during the study period. Mean LOS decreased from 361 to 340 minutes (5.8%) after implementation and demonstrated sustainability over the postintervention period. One hundred eight providers completed the preimplementation communication survey, with 58 and 64 completing surveys at 4 and 9 months postimplementation, respectively. The proportion reporting somewhat or strong satisfaction with communication increased from 68% at baseline to 86% at 4 months (P = 0.02) and 92% at 9 months (P < 0.001 versus baseline).

Conclusions:

A quality improvement initiative created a sustainable process to reduce ED LOS for sedated reductions while improving satisfaction with interdisciplinary communication.
Quality Improvement Interventions across a Network of Pediatric Hematology–Oncology Clinics
Authors: Morgan Jennifer , Deyo Jeffrey , Cox Jennifer , Fasipe Francisca , Mohamed Ashraf , Russo Carolyn
Published: June 2019

Introduction:

Achieving improvement in quality among different institutions is challenging. Immunocompromised children with febrile neutropenia are at high risk of severe infection. Pediatric hematology–oncology patients frequently experience central line–associated bloodstream infections (CLABSIs) associated with implanted catheters. A network of 8 pediatric hematology–oncology clinics affiliated with St. Jude Children’s Research Hospital launched 2 initiatives designed to reduce the incidence of infections and improve infection treatment.

Methods:

We reviewed the timing of antibiotic administration for immunocompromised patients with a fever before and after a quality improvement intervention tailored to each affiliate clinic. We also reviewed the frequency of CLABSIs before and after implementing a central line care bundle for implanted catheters in ambulatory patients.

Results:

Across the affiliate clinic network, the timing of antibiotic administration improved from the preintervention period (23% of patients received antibiotics within 60 min of registration) to 53% and 73%, in successive postintervention periods. Implementing a central line bundle for implanted catheters was associated with increased compliance and a trend toward increased time between CLABSIs.

Conclusion:

We describe an approach to quality improvement utilizing a system of monitoring with annual clinical audits, development of joint quality improvement initiatives, ongoing education, and focused training of staff for effecting change that improves patient healthcare across multiple institutions.
Encouraging Resident Adverse Event Reporting: A Qualitative Study of Suggestions from the Front Lines
Authors: Szymusiak John , Walk Thomas J. , Benson Maggie , Hamm Megan , Zickmund Susan , Gonzaga Alda Maria , Bump Gregory M.
Published: June 2019

Introduction:

Little is known about what motivates residents to report adverse events. The goals of the qualitative study were to: (1) better understand facilitators to residents’ event reporting and (2) identify effective interventions that encourage residents to report.

Methods:

The authors conducted focus groups of upper-level residents from 4 training programs (2 internal medicine, a pediatric, and a combined medicine-pediatric) who rotated at 3 institutions within a large healthcare system in 2016. Quantitative data on reporting experience were gathered. Focus groups were audio recorded and transcribed. Two coders reviewed transcripts using the editing approach and organized codes into themes.

Results:

Sixty-four residents participated in 8 focus groups. Residents were universally exposed to reportable events and knew how to report. Residents’ reporting behavior varied by site according to local culture, with residents filing more reports at the pediatric hospital compared to other sites, but all groups expressed similar general views about facilitators to reporting. Facilitators included familiarity with the investigation process, reporting via telephone, and routine safety educational sessions with safety administrators. Residents identified specific interventions that encouraged reporting at the pediatric hospital, including incorporating an attending physician review of events into sign-out and training on error disclosure.

Conclusions:

This study provides insight into what motivates resident event reporting and describes concrete interventions to increase reporting. Our findings are consistent with the Theoretical Domains Framework of behavioral change. These strategies could prove successful at other pediatric hospitals to build a culture that values reporting and prepares residents as patient safety champions.
Quality Initiative to Reduce Cardiac CT Angiography Radiation Exposure in Patients with Congenital Heart Disease
Authors: Ali Fatima , Rizvi Arjumand , Ahmad Huzaifa , McGonagill Phillip , Khan Muneeb , Krishnamurthy Rajesh , Jamil Zafar , Nadeem Naila , Yousuf Mohammad , Hasan Babar
Published: June 2019

Background:

The use of cardiac computed tomography angiography (CCTA) as a complementary diagnostic modality to echocardiography in patients with congenital heart diseases (CHDs) is expanding in low- and middle-income countries. The adoption of As Low As Reasonably Achievable techniques is not widespread, resulting in significant unintended radiation exposure, especially in children. Simple quality improvement measures geared toward reducing radiation dose can have a impact on patient safety in resource-limited centers in low- and middle-income countries.

Objectives:

To determine how a quality improvement initiative can reduce radiation exposure during CCTA in patients with CHD.

Methods:

We designed a key driver -based quality initiative to reduce radiation dose during CCTA for CHD using protocol optimization, communication, and training and implementation as the drivers for intervention. Preintervention variables (radiation exposure, scanning protocols, and image quality) were collected from September 2012 to July 2016 and compared with variables in the postimplementation phase (February 2017 to July 2017). We compared quantitative and categorical variables using the chi-square test. Linear regression analysis was used to evaluate the effect of various factors on radiation dose.

Results:

We documented a reduction in the effective dose in the postintervention versus preintervention phase (mean, 2.0 versus 21 mSv, P < 0.0001, respectively). Linear regression showed that the optimal organizational levels are associated with the same reduction in radiation. This finding shows that the time factor translates a combination of organizational and technical factors that contributed to the reduction in radiations.

Conclusions:

Our project showed a reduction in CCTA-associated radiation exposure.
ICTV Virus Taxonomy Profile: Endornaviridae
Authors: Valverde Rodrigo A. , Khalifa Mahmoud E. , Okada Ryo , Fukuhara Toshiyuki , Sabanadzovic Sead ,   ICTV Report Consortium
Published: June 2019

The family Endornaviridae includes viruses with linear, single-stranded, positive-sense RNA genomes that range from 9.7 to 17.6 kb and have been reported infecting plants, fungi and oomycetes. The family consists of two genera, Alphaendornavirus and Betaendornavirus, into which viruses are classified based on their genome size, host and presence of unique domains. Alphaendornavirus includes species whose members infect plants, fungi and oomycetes, while the genus Betaendornavirus includes species whose members infect ascomycete fungi. This is a summary of the ICTV Report on the family Endornaviridae, which is available at www.ictv.global/report/endornaviridae.
Predicting the Prognosis of Non-Small Cell Lung Cancer by Integrating Microarray and Clinical Data with Deep Learning
Authors: Lai Yu-Heng , Chen Wei-Ning , Hsu Te-Cheng , Lin Che , Tsao Yu , Wu Semon
Published: June 2019

Abstract

Non-small cell lung cancer (NSCLC) is one of the most common lung cancers worldwide. Accurate prognostic stratification of NSCLC can become an important clinical reference when designing therapeutic strategies for cancer patients. With this clinical application in mind, we developed a deep neural network (DNN) combining heterogeneous data sources of gene expression and clinical data to accurately predict the prognosis of NSCLC patients. Based on microarray data from a cohort set (614 patients), seven well-known NSCLC markers were used to group patients into marker- and marker+ subgroups. Using a systems biology approach, prognosis relevance values (PRV) were then calculated to select eight additional novel prognostic gene markers. Gene markers along with clinical data were then used to develop an integrative DNN via bimodal learning to predict the 5-year survival rate of NSCLC patients with tremendously high accuracy (AUC: 0.8163, accuracy: 75.44%), which is superior to all other existing methods based on AUC. Using the capability of deep learning, we believe that our predicted cancer prognosis can be a promising index helping oncologists and physicians develop personalized therapy and build the foundation of precision medicine in the future.
Horizontal gene transfer rate is not the primary determinant of observed antibiotic resistance frequencies in Streptococcus pneumoniae
Authors: Lehtinen Sonja , Chewapreecha Claire , Lees John , Hanage William P. , Lipsitch Marc , Croucher Nicholas J. , Bentley Stephen D. , Turner Paul , Fraser Christophe , Mostowy Rafał J.
Published: June 2019

The extent to which evolution is constrained by the rate at which horizontal gene transfer (HGT) allows DNA to move between genetic lineages is an open question, which we address in the context of antibiotic resistance in Streptococcus pneumoniae. We analyze microbiological, genomic and epidemiological data from the largest-to-date sequenced pneumococcal carriage study in 955 infants from a refugee camp on the Thailand-Myanmar border. Using a unified framework, we simultaneously test prior hypotheses on rates of HGT and a key evolutionary covariate (duration of carriage) as determinants of resistance frequencies. We conclude that in this setting, there is only weak evidence for the rate of HGT playing a role in the evolutionary dynamics of resistance. Instead, observed resistance frequencies are best explained as the outcome of selection acting on a pool of variants, irrespective of the rate at which resistance determinants move between genetic lineages.
Fluoxetine-induced dematuration of hippocampal neurons and adult cortical neurogenesis in the common marmoset
Authors: Ohira Koji , Hagihara Hideo , Miwa Miki , Nakamura Katsuki , Miyakawa Tsuyoshi
Published: June 2019

The selective serotonin reuptake inhibitor fluoxetine (FLX) is widely used to treat depression and anxiety disorders. Chronic FLX treatment reportedly induces cellular responses in the brain, including increased adult hippocampal and cortical neurogenesis and reversal of neuron maturation in the hippocampus, amygdala, and cortex. However, because most previous studies have used rodent models, it remains unclear whether these FLX-induced changes occur in the primate brain. To evaluate the effects of FLX in the primate brain, we used immunohistological methods to assess neurogenesis and the expression of neuronal maturity markers following chronic FLX treatment (3 mg/kg/day for 4 weeks) in adult marmosets (n = 3 per group). We found increased expression of doublecortin and calretinin, markers of immature neurons, in the hippocampal dentate gyrus of FLX-treated marmosets. Further, FLX treatment reduced parvalbumin expression and the number of neurons with perineuronal nets, which indicate mature fast-spiking interneurons, in the hippocampus, but not in the amygdala or cerebral cortex. We also found that FLX treatment increased the generation of cortical interneurons; however, significant up-regulation of adult hippocampal neurogenesis was not observed in FLX-treated marmosets. These results suggest that dematuration of hippocampal neurons and increased cortical neurogenesis may play roles in FLX-induced effects and/or side effects. Our results are consistent with those of previous studies showing hippocampal dematuration and increased cortical neurogenesis in FLX-treated rodents. In contrast, FLX did not affect hippocampal neurogenesis or dematuration of interneurons in the amygdala and cerebral cortex.