bluuebunny/crossref_metadata_2025_split huggingface dataset:
Deployment of a Second Victim Peer Support Program: A Replication Study
Authors: Merandi Jenna , Liao Nancy , Lewe Dorcas , Morvay Shelly , Stewart Barb , Catt Charline , Scott Susan D. 
Published: June 2019

Background:The second victim phenomenon occurs when health-care providers experience significant professional distress (compassion dissatisfaction, burnout, secondary traumatic stress) and psychological distress (shame, anxiety, and depression) as a result of medical errors or adverse patient outcomes. Few hospitals have institution-wide systems in place to assist employees through the recovery process.Methods:At Nationwide Children’s Hospital (NCH), a peer-based support program called “YOU Matter” was executed and spread hospital-wide. The program emulated the framework and execution strategy designed by University of Missouri Health Care’s (MUHC) “forYOU” Team. Strategic elements of the program’s structure were reviewed and adapted for NCH with system-wide deployment and enhancement to include electronic peer support reporting. This article summarizes program implementation, management, and sustainment over the past 2 years.Results:By following University of Missouri Health Care’s model, we successfully deployed an institution-wide second victim program. Since the November 2013 initiation, we have documented 232 peer and 21 group encounters. High-risk clinical areas for second victimization at NCH included the emergency department (ED), pediatric intensive care unit (PICU), cardiothoracic intensive care unit (CTICU), and pharmacy department. Registered nurses (RNs) and licensed practical nurses (LPNs) have had the highest number of encounters necessitating second victim support (32%). Supported staff reported improved emotional state and improved return-to-work metrics.Conclusions:An organization’s culture of patient safety can be enhanced by ensuring staff psychological safety. Programs like “YOU Matter” and the “forYOU” Team are essential building blocks to improve the overall safety culture and quality of care. Implementation of “YOU Matter” at NCH validates the MUHC program and demonstrates its generalizability to other health-care institutions.
Emergency Department Asthma Medication Delivery Program: An Initiative to Provide Discharge Prescriptions and Education
Authors: Durkin Kayla , Montgomery Tricia , Lamberjack Kristen , Hafer Cindy C. , Naprawa James , Yarosz Shannon 
Published: June 2019

Background:
Prescription fill rates for children being discharged from the emergency department (ED) after asthma exacerbations are low, placing the child at risk for additional ED visits or admissions for asthma. This article describes the implementation of an ED asthma prescription delivery service designed to improve pharmacy prescription capture and decrease ED revisit rates.

Methods:
A core group developed a service to provide asthma prescriptions and education to patients in their ED room before discharge. The project assessed the percent of ED asthma patients who filled ED asthma prescriptions at the hospital outpatient pharmacy, 7-, 14-, and 30-day ED revisit rates, and patient satisfaction.

Intervention:
Patients/families who chose to participate in the service received asthma prescriptions and education at the ED bedside. Within 1–3 days, ED outreach nurses obtained patient satisfaction survey responses via telephone.

Results:
There was a statistically significant increase in the number of patients who filled ED asthma prescriptions at the hospital outpatient pharmacy (22.2% versus 33.8%; P < 0.0001). The decrease in 7-, 14-, or 30-day ED revisit rates for patients who received the medication delivery service compared with standard of care was not statistically significant. Patients were satisfied to very satisfied with the service.

Conclusion:
Postimplementation of a medication delivery program within the ED, there was an increase in the percentage of patients who filled ED asthma medication prescriptions at the hospital outpatient pharmacy. There was no difference in ED revisit rates for patients who enrolled in the prescription delivery service versus standard of care.
Impact of a Successful Speaking Up Program on Health-Care Worker Hand Hygiene Behavior
Authors: Linam W. Matthew , Honeycutt Michele D. , Gilliam Craig H. , Wisdom Christy M. , Deshpande Jayant K. 
Published: June 2019

Background:
Health-care worker (HCW) hand hygiene (HH) is the cornerstone of efforts to reduce hospital infections but remains low. Real-time mitigation of failures can increase process reliability to > 95% but has been challenging to implement for HH.

Objective:
To sustainably improve HCW HH to > 95%.

Methods:
A hospital-wide quality improvement initiative to improve HH was initiated in February 2012. HCW HH behavior was measured by covert direct observation utilizing multiple-trained HCW volunteers. HH compliance was defined as correct HH performed before and after contact with the patient or the patient’s care area. Interventions focusing on leadership support, HCW knowledge, supply availability, and culture change were implemented using quality improvement science methodology. In February 2014, the hospital began the Speaking Up for Safety Program, which trained all HCWs to identify and mitigate HH failures at the moment of occurrence and addressed known barriers to speaking up.

Results:
Between January 1, 2012, and January 31, 2016, there were 30,514 HH observations, averaging 627 observations per month (9% attending physicians, 12% resident physicians, 46% nurses, 33% other HCW types). HCW HH gradually increased from 75% to > 90% by December 2014. After the Speaking Up for Safety Program, HCW HH has been > 95% for 20 months. Physician HH compliance has been above 90% for over a year.

Conclusion:
Creating a specific process for staff to speak up and prevent HH failures, as part of a multimodal improvement effort, can sustainably increase HCW HH above 95%.
Implementation of the Asthma Control Test in a Large Primary Care Network
Authors: Sangvai Shilpa , Hersey Stephen J. , Snyder Dane A. , Allen Elizabeth D. , Hafer Cindy , Wickliffe Jeanne , Groner Judith A. 
Published: June 2019

Introduction:
Achieving control in asthma is a primary goal of pediatric care, and assessing the degree of control is a principal step in management. The purpose of this quality improvement project was to implement the Asthma Control Test (ACT) and the Childhood Asthma Control Test (C-ACT) in a large primary care network as a means to reliably and consistently assess asthma control at all visit types.

Methods:
A prospective design was used to measure provider documentation of the ACT or C-ACT. Patients (or caregivers) 4 years of age or older with a known diagnosis of asthma were administered the ACT (ages 12 and older) or the C-ACT (ages, 4–11). The quality improvement project, which involved multiple interventions, took place at 11 centers of the Primary Care Network of Nationwide Children’s Hospital from November 2013 to December 2014. A goal was set for a 70% completion rate of the ACT/C-ACT at any visit type for patients 4 years of age or older with asthma.

Results:
Six months after the introduction of the questionnaires, the 70% completion rate was reached. Rates of ACT/C-ACT completion have consistently exceeded 70% through December 2016.

Conclusions:
We demonstrated that the ACT/C-ACT can be integrated into a busy primary care network. It is imperative to work toward better asthma care; consistent assessment of asthma control can be the critical first step.
Integrating a Geneticist in a Multidisciplinary Clinic for Down Syndrome Increases Commitment to Genetic Counseling
Authors: Santoro Stephanie L. , Jacobson Theodora , Lemle Stephanie , Bartman Thomas 
Published: June 2019

Background:
Although most physicians and genetic professionals are familiar with Down syndrome, many families do not have experience with Down syndrome before having a child diagnosed. The American Academy of Pediatrics has specific recommendations for genetic counseling and chromosome analysis for Down syndrome.

Local Problem:
The literature indicates that adherence to completion of appropriately timed genetic counseling is low at 31%. This study was initiated to determine our adherence rates and to improve if needed.

Methods:
In the Down syndrome clinic at Nationwide Children’s Hospital, a subspecialty clinic in the Division of Developmental and Behavioral Pediatrics, a genetic counselor was on-call but did not routinely attend. The intervention consisted of multidisciplinary care with the presence of a clinical geneticist. Statistical Process Control Charts and Fisher’s exact test were used to determine the impact of the intervention.

Results:
Our baseline rate of adherence to genetic counseling was similar to previous publications. Direct genetics involvement in the Down syndrome clinic in place of an on-call genetic counselor led to significant improvement in adherence to genetic counseling recommendations over a 6-month period from 35% to 62%, P < 0.001 and sustained for 6 months. Postclinic adherence rates and subanalyses by age showed similar results. The final postvisit adherence rate of 89% in February 2017 demonstrates continued improvement. Geneticist involvement allowed chromosome reports uploading and karyotype listing in electronic medical records.

Implications and Lessons Learned:
Genetic counseling in newborns with Down syndrome is important, yet was often not received at Nationwide Children’s Hospital before this study. Integrating a geneticist resulted in improvement. Implementing similar models at other institutions can ensure that the correct genetic testing is completed, results documented and families counseled appropriately.
Improving Inpatient Asthma Management: The Implementation and Evaluation of a Pediatric Asthma Clinical Pathway
Authors: Magruder Teresa G. , Narayanan Sridaran , Walley Susan , Powers Tony , Whitlock Hollace , Harrington Kathleen , Wall Terry C. 
Published: June 2019

Introduction:
Asthma exacerbations are a leading cause of pediatric hospitalizations. Despite national guidelines, variability exists in the use and dosing of bronchodilators, oxygen management, and respiratory assessments of patients. We aimed to implement an inpatient Asthma Clinical Pathway (Pathway) to standardize care and reduce length of stay (LOS).

Methods:
A respiratory therapy–driven Pathway was designed for inpatient asthma management. The Pathway included standardized respiratory therapy assessments, bronchodilator dosing, and protocols for progression and clinical worsening. We monitored key process measures. Patients admitted to the Pathway during pilot implementation (March to December 2011) were compared retrospectively with a “Usual Care” cohort admitted during the same period. We compared average LOS, average billed charges per hospitalization (charges), and 30-day readmissions between groups. Statistical process control charts were utilized to analyze LOS and charges for all asthma admissions following Pathway implementation (March 2011 to September 2016). Readmissions and Pathway removals were balancing measures.

Results:
During pilot, Pathway patients (n = 153) compared with “Usual Care” patients (n = 166) had shorter LOS (0.95 versus 1.86 days; P < 0.001) and lower charges ($7,413 versus $11,078; P < 0.001). Readmission rates were not significantly different between groups. LOS for all asthma admissions (n = 3,429) decreased from 2.30 to 1.44 days (P < 0.001) following Pathway implementation. Charges remained stable. The readmission rate (per 100 discharges) for all asthma was 2.42 and not significantly different between Pathway and non-Pathway groups.

Conclusions:
Pathway implementation reduced LOS and stabilized charges while not increasing readmission rates. The Pathway facilitated sustainable widely adopted improvements in asthma care.
A Quality Improvement Collaborative for Pediatric Sepsis: Lessons Learned
Authors: Paul Raina , Melendez Elliot , Wathen Beth , Larsen Gitte , Chapman Laura , Wheeler Derek S. , Wakefield Toni , Macias Charles G. 
Published: June 2019

Background:
Sepsis is a leading cause of morbidity and mortality in children worldwide. Barriers exist for timely recognition and management in emergency care settings. This 1-year quality improvement collaborative sought to reduce mortality from sepsis.

Methods:
Fifteen hospitals participated initially. We included children with a spectrum of illness from sepsis to septic shock. The intervention bundle focused on recognition, escalation of care, and the first hour of resuscitation. We conducted monthly learning sessions and disseminated data reports of site-specific and aggregated metrics to drive rapid cycle improvement.

Results:
Seven sites contributed enough data to be analyzed. Of the 1,173 pediatric patients in the total cohort, 506 presented with severe sepsis/septic shock. Quarterly data demonstrated a mean improvement in initial clinical assessment from 46% to 60% (P < 0.001) and in adherence to the administration of first fluid bolus within 15 minutes from 38% to 46% (P < 0.015). There was no statistically significant improvement in other process metrics. There was no statistically significant improvement in mortality for the total cohort (sepsis to septic shock) or either of the subgroups in either 3- or 30-day mortality.

Conclusions:
A quality improvement collaborative focused on improving timely recognition and management of pediatric sepsis to septic shock led to some process improvements but did not show improvement in mortality. Future national efforts should standardize definitions and processes of care for sepsis to septic shock, including the identification of a “time zero” for measuring the timeliness of treatment.
Using a Quality Improvement Approach to Engage Families in Emergency Room Sepsis Huddles
Authors: Wiener Ethan , McGrath Meaghan N. , Schlucter Juliette , Pereira-Argenziano Lucy , Carr Amanda , Piasio Nicole , Levy Fiona H. 
Published: June 2019

Background:
Interdisciplinary team huddles are a key component of the Sepsis Collaborative’s Recognition Bundle in the Emergency Department (ED). Family Engagement (FE) is essential to ensure best outcomes. Working with families as partners we co-produced a simulation-based training model including, clinical scenarios, family-centered competencies, and debriefs. This model engages family advisors who serve as coaches of standardized patients and interdisciplinary teams in an immersive learning experience.

Objective:
Apply our training model to standardize engagement of families during sepsis huddles in the ED.

Methods:
Using a quality improvement framework, we developed our key driver diagram (Fig. 1) and focused on development of standardized language as our first intervention to facilitate partnership with families during sepsis huddles. A succession of 6 improvement cycles were implemented (Fig. 2) with unique attending, nurse, and resident learner groups.

Results:
Based on family and clinician feedback (Fig. 3), the following standardized elements were developed: (1) explanation of sepsis huddle that invites families to partner and share concerns; (2) direct language to explain the term sepsis; (3) explanation of next steps, timeline, and confirmed point of contact. This language guided providers to engage more clearly and consistently.

Conclusions:
Our co-produced training approach resulted in the development of standardized language as 1 component to support Family Engagement in ED sepsis huddles. Clinicians shared that family feedback was essential in the creation of succinct, meaningful, and mutually engaging language. Though not measured in this intervention, clinicians shared the perception that this training improved efficiency and priority to engage families in huddles.
Electronic Screening Tool and Shock Huddle Process for Children at Risk for Sepsis
Authors: Stinson Hannah R. , Stevens Erica , Koetter Paige , Setlik Jennifer , Viteri Shirley , Frizzola Meg 
Published: June 2019

Background:
Nemours created an electronic screening tool for severe sepsis/septic shock (SS/SS) called the Shock Score (Table 1). At a threshold score, a Shock Huddle (SH) is initiated, and the patient is assessed by the Shock RN (pediatric intensive care unit nurse with enhanced training on sepsis) with the primary team (Fig. 1).

Objectives:
We sought to describe the characteristics of the score and the demographics of patients who underwent an SH.

Methods:
One thousand seven hundred forty-eight admissions were screened over 109 days. Cases of SS/SS were identified by chart review of patients with an elevated score, transfers to the intensive care unit via the medical emergency team, and patients with International Classification of Disease-10 codes of R65.20/R65.21. A subset (1,323 admissions) was used to evaluate the score characteristics.

Results:
There were 58 cases of SS/SS. Five cases were missed by the score due to a missed high risk condition or delay in documentation. One hundred twenty SH were completed on 51 unique patients. Seventy-three percent had a high risk condition. Nearly 40% of SHs involved diagnostic or therapeutic intervention (Table 2). The score had an area under the receiver operating characteristic curve (AUROC) 0.8, sensitivity 0.9 (0.72–0.97), specificity 0.44 (0.35–0.54), negative predictive value 0.95 (0.84–0.99), and positive predictive value 0.28 (0.19–0.38).

Conclusions/Implications:
The score demonstrates acceptable characteristics as a screening tool to identify children at risk for sepsis. Nearly 40% of SHs included a diagnostic or therapeutic intervention. Misses of the score were related to high risk conditions that were not scored by the electronic medical record and delays in documentation.
Escalation Huddles: Facilitating Sepsis Activations Using Hospital-wide Escalation Processes
Authors: Lockwood Justin , Wathen Beth , Rolison Elise , Reese Jennifer , Bajaj Lalit , Swanson Angela , Carpenter Todd 
Published: June 2019

Background:
Bedside huddles can be valuable parts of hospital sepsis responses. These huddles, however, risk duplication of effort with existing care escalation systems, and they may also be of value in settings other than sepsis. Streamlining care escalation processes may present an opportunity to improve sepsis responses.

Objectives:
To facilitate team-based discussion of patients with suspected sepsis as a step toward reducing time to first antibiotic administration.

Methods:
Existing care escalation frameworks were amended (Figs. 1, 2) and incorporated into rapid cycle process improvement initiatives on non-ICU units. New sepsis response resources were created to facilitate team communication, intravenous (IV) access, and timely antibiotic delivery (Fig. 3).

Results:
An Escalation Huddle system was created to bring local care teams together early during clinical deterioration, including cases of suspected sepsis. Rapid Response Team activation is available but not mandated. An Urgent IV & Blood Draw algorithm was created to facilitate IV access using a protocolized progression through existing hospital resources. An Inpatient Suspected Sepsis order set was created with antibiotic decision support and recommendations for evaluation of organ dysfunction. These processes have been improved through 3 “Plan, Do, Study, Act” cycles.

Conclusions:
Rather than create a separate sepsis response system, we chose to enhance existing hospital-wide escalation processes by formalizing an Escalation Huddle system and developing new tools to enhance sepsis responses within that system. We anticipate this approach will facilitate discussion of suspected sepsis cases and improve sepsis responses while avoiding inefficient or duplicative escalation actions by care team members.
De-escalation of Care Through Pediatric Intensive Care Unit Liberation Rounds and a Daily Checklist
Authors: Kawai Yu , Rohlik Gina M. , Neu Lori L. , Mujic Anna J. , Duncan Julie M. , Feigal Scott A. , Rowekamp Debra J. , Fetterly Britt M. , Fryer Karen R. , Conlon Patricia M. , Huskins W. Charles , Schiltz Brenda M. , Ouellette Yves , Nemergut Michael E. , Kahoud Robert J. , Arteaga Grace M. 
Published: June 2019

Introduction:
Pediatric intensive care unit (PICU) Liberation Bundle
1
was implemented to standardize weaning of ICU support after clinical stabilization and to prevent iatrogenicity by timely assessment of pain, extubation readiness, sedation, delirium, withdrawal, early mobilization, and family engagement. By implementing a PICU Liberation bedside rounding process and a de-escalation daily rounding checklist, we hypothesized that the PICU Liberation Bundle compliance will improve and the risk for iatrogenic conditions can be minimized.

Methods:
The “old” rounding process used a nursing script organized by organ systems while the “new” process (Fig. 1) focused on PICU Liberation Bundle elements and the addition of a physician-completed checklist (Fig. 2). Independent observers collected data during rounds. All checklists completed over the first 50 days after deployment were analyzed.

Results:
There was an increase in frequency of PICU Liberation Bundle elements discussed during the “new” process with similar rounding time compared with the “old” process (Table 1). The overall compliance with the checklist was 90.4% (322 of 356 total patient-days). The medical plan was modified 62 times in 14.0% (45 of 322) of the checklists completed. The 5 most frequently modified tasks were converting intravenous to per os meds (13), initiating bowel regimen (11), initiating GI prophylaxis (9), consulting physical therapy/occupational therapy/physical medicine and rehabilitation services (9), and initiating sleep enhancement protocol (6) accounting for 77.4% (48/62) of all amendments made.

Conclusions:
PICU Liberation rounding process improved adherence with the PICU Liberation Bundle elements, and the checklist caught numerous missed opportunities, thereby increasing the frequency of timely de-escalation of care and minimizing the risk of iatrogenic conditions without lengthening rounding time.
Optimizing Performance: Revolutionizing the Sepsis Team with a Fresh Start
Authors: Acevedo Mina , Wilson Michele 
Published: June 2019

Introduction:
Improving Pediatric Sepsis Outcomes (IPSO) is an extensive project that requires commitment over several years. The seventh key driver of IPSO, Optimizing Performance, is a vital section to ensure progress is sustained over time. Initially, the sepsis team at Loma Linda University Children’s Hospital was motivated, but over time enthusiasm dwindled and physicians disengaged.

Methods:
To optimize performance, quality improvement methods of the Shewhart cycle were utilized to examine the team, foster engagement, and ultimately stimulate progress.
1
Strategies were built on the concept of “make a C2ASE for the team,” where Clarity & Consistency, Accountability, Support, and Empowerment (C2ASE) is the formula for success. The mission was highlighted, and a charter was created. Team members were held accountable, and decisions were made at biweekly meetings. Support was obtained through Children’s Hospital Association webinars, office calls, and coaching sessions. The team was empowered through appreciation, recognition, and celebrations of milestones together.

Results:
Following revitalization efforts, physician attendance at committee meetings improved from 17% to 45% as shown in Figure 1. Subsequently, in a 5-month period, the following sepsis processes were established: screening, huddle, order set, video, screensavers, webpage, dashboard, a launch in 1 care setting, and over 300 submitted data files.

Conclusion:
A disengaged sepsis team was revolutionized by making a C2ASE, via Clarity of the mission, Consistency in expectations, Accountability for actions, seeking Support and Empowering the team. The results of the revitalized commitment rejuvenated morale and stimulated progress to fight pediatric sepsis at Loma Linda University Children’s Hospital.