bluuebunny/crossref_metadata_2025_split huggingface dataset:
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.