bluuebunny/crossref_metadata_2025_split huggingface dataset:
Automation of a Paper-based Screening Tool for Early Sepsis Risk Detection in the Emergency Department
Authors: Lloyd Julia K. , Ahrens Erin A. , Clark Donnie , Nuss Kathryn E. 
Published: June 2019

Background:
Presentation of sepsis is dependent on synthesis of varied clinical information, making identification of septic patients challenging. Common practice is to identify sepsis through a manual screening tool, which may miss opportunities for early sepsis detection. Electronic screening efforts requiring additional documentation by providers may not integrate easily into provider workflow.

Objectives:
To develop an automated sepsis risk screening tool in the electronic health record that would accurately identify patients at risk for sepsis without requiring additional documentation.

Methods:
Criteria in the manual screening tool were mapped to standard documentation routinely entered in the electronic health record (Epic Systems, Corp.). Data elements were scored electronically at arrival and every 15 minutes during their encounter from the medical history, medication record, vital signs, and physical assessment (Fig. 1). Scores that exceeded a predefined sepsis risk threshold triggered a Best Practice Advisory, which alerted bedside staff to perform sepsis huddles and consider appropriate interventions. Statistical comparison of the automated tool to the manual process was completed by two-tail paired t test.

Results:
In an 8-week testing period, the automated sepsis risk screening tool identified 100% of patients flagged by the manual process (N = 29) (Table 1). The electronic tool identified sepsis patients, on average, 68 minutes earlier. This was statistically significant (P < 0.001).

Conclusions/Implications:
The automated sepsis risk screening tool is as accurate as a validated manual process and alerted bedside clinicians earlier. Deployment has potential to improve timely sepsis detection and management of patients without requiring additional documentation by provider.
10,000 Good Catches: Increasing Safety Event Reporting In A Pediatric Health Care System
Authors: Crandall Kristen M. , Almuhanna Ahmed , Cady Rebecca , Fahey Lisbeth , Floyd Tara Taylor , Freiburg Debbie , Hilliard Mary Anne , Kalburgi Sonal , Khan Nafis I. , Patrick DiAnthia , Pavuluri Padmaja , Potter Kelvin , Scafidi Lisa , Sigman Laura , Shah Rahul K. 
Published: June 2019

Background:
In 2014, Children’s National Health System’s executive leadership team challenged the organization to double the number of voluntary safety event reports submitted over a 3-year period; the intent was to increase reliability and promote our safety culture by hardwiring employee event reporting.

Methods:
Following a Donabedian quality improvement framework of structure, process, and outcomes, a multidisciplinary team was formed and areas for improvement were identified. The multidisciplinary team focused on 3 major areas: the perceived ease of reporting (ie, how difficult is it to report an event?); the perceived safety of reporting (ie, will I get in trouble for reporting?); and the perceived impact of reporting (ie, does my report make a difference?) technology, making it safe to report, and how reporting makes a difference. The team developed a key driver diagram and implemented interventions designed to impact the key drivers and to increase reporting.

Results:
Children’s National increased the number of safety event reports from 4,668 in fiscal year 2014 to 10,971 safety event reports in fiscal year 2017. Median event report submission time was decreased by nearly 30%, anonymous reporting decreased by 69%, the number of submitting departments increased by 94%, and the number of reports submitted as “other” decreased from a baseline of 6% to 2%.

Conclusions:
Children’s National Health System’s focus on increasing safety event reporting resulted in increased organizational engagement and attention. This initiative served as a tangible step to improve organizational reliability and the culture of safety and is readily generalizable to other hospitals.
Improving Screening for Sepsis in the Pediatric Emergency Department
Authors: Rutman Lori , Beardsley Elaine , Fenstermacher Sara , Geiger Julie , Zahradnik Nancy 
Published: June 2019

Introduction:
Early recognition of sepsis is critical to providing efficient and effective care for a potentially life-threatening condition. When automated sepsis screening is not available, front-line ED providers, often bedside nurses, must incorporate screening into their busy workflow. The aim of this project was to increase the completion of an ED-based sepsis screening tool in at-risk patients from a baseline of 5–15% to > 50% in 3 months.

Methods:
A key driver diagram was developed (Fig. 1). We used statistical process control to evaluate changes in sepsis screening over time.

Results:
At baseline, 15% of ED patients with fever were screened using the electronic, nurse-initiated tool. We noted a single point outside the upper control limit (special cause variation) in October 2015 concurrent with implementation of a clinical pathway for septic shock, but this improvement was not sustained over time. Special cause was again noted with a shift of 8 points above the centerline in June 2016 following an educational push and reminders for ED nurses, increasing overall screening to 30%. Further improvement (special cause) was noted after significant modifications were made to the screening tool in June 2017 (Fig. 2).

Conclusion:
Quality improvement methodologies (development of a SMART aim, key driver diagram, and multiple plan-do-study-act cycles) led to improvement in screening at-risk patients for sepsis.
Assessing Barriers to Uveitis Screening in Patients with Juvenile Idiopathic Arthritis Through Semi-Structured Interviews
Authors: Ballenger Laura R. , Ardoin Stacy P. , Driest Kyla D. 
Published: June 2019

Introduction:
Uveitis is a significant complication in patients with juvenile idiopathic arthritis (JIA) and can be asymptomatic until vision loss develops. Published guidelines recommend uveitis screening eye examinations every 3–12 months depending on multiple factors, but no literature evaluates adherence with and barriers to obtaining these screening eye examinations. This study assesses barriers in nonadherent patients to establish key drivers for future interventions.

Methods:
We identified patients with JIA who were nonadherent with uveitis screening guidelines through the electronic medical record (EMR). A rheumatologist conducted semistructured interviews with the patients or guardians regarding the patients’ most recent eye examinations, knowledge of the screening frequency, and barriers to completing the eye examinations. The results were qualitatively analyzed to determine any categorical variables present.

Results:
Ninety-two patients were identified as nonadherent, and the rheumatologist interviewed 45 patients or guardians. Categories identified following the interviews were system problems, access to care issues, and knowledge deficits. The largest category identified was system problems that included most recent eye examination not being in the EMR, the wrong eye provider identified in the EMR or difficulty with scheduling eye appointments.

Conclusions:
This qualitative study identified categories of barriers to obtaining screening eye examinations in patients with JIA. Identification of these barriers will facilitate the development of a specific aim and key driver diagram to guide future quality improvement interventions.
A Retrospective Review of a Bed-mounted Projection System for Managing Pediatric Preoperative Anxiety
Authors: Caruso Thomas J. , Tsui Jeremy H. , Wang Ellen , Scheinker David , Sharek Paul J. , Cunningham Christine , Rodriguez Samuel T. 
Published: June 2019

Introduction:
Most children undergoing anesthesia experience significant preoperative anxiety. We developed a bedside entertainment and relaxation theater (BERT) as an alternative to midazolam for appropriate patients undergoing anesthesia. The primary aim of this study was to determine if BERT was as effective as midazolam in producing cooperative patients at anesthesia induction. Secondary aims reviewed patient emotion and timeliness of BERT utilization.

Methods:
We conducted a retrospective cohort study of pediatric patients undergoing anesthesia at Lucile Packard Children’s Hospital Stanford between February 1, 2016, and October 1, 2016. Logistic regression compared induction cooperation between groups. Multinomial logistic regression compared patients’ emotion at induction. Ordinary least squares regression compared preoperative time.

Results:
Of the 686 eligible patients, 163 were in the BERT group and 150 in the midazolam. Ninety-three percentage of study patients (290/313) were cooperative at induction, and the BERT group were less likely to be cooperative (P = 0.04). The BERT group was more likely to be “playful” compared with “sedated” (P < 0.001). There was a reduction of 14.7 minutes in preoperative patient readiness associated with BERT (P = 0.001).

Conclusions:
Although most patients were cooperative for induction in both groups, the midazolam group was more cooperative. The BERT reduced the preinduction time and was associated with an increase in patients feeling “playful.”
Quality Initiative to Improve time to Antibiotics for Febrile Pediatric Patients with Potential Neutropenia
Authors: Monroe Kathy , Cohen Clay T. , Whelan Kimberly , King Amber , Maloney Lisa , Deason Janet , Nichols John Charles , Friedman Gregory K. , Kutny Matthew , Hayes Leslie 
Published: June 2019

Introduction:
In patients who are immunocompromised, fever may indicate a life-threatening infection. Prompt time to antibiotic administration in febrile patients at risk for neutropenia has been identified by national and international panels as a key benchmark of quality care in emergent situations. A quality improvement initiative to improve health care provided in a pediatric emergency department (ED) is described.

Methods:
A clinical pathway was previously initiated in a pediatric ED with a goal of improving time to antibiotics for febrile neutropenia patients. An agreed upon pathway and order set being initiated. Improvements were seen but not to the desired level. This project involved an improvement cycle that focused on nonvalue added time in the workflow.

Results:
Percent of patients receiving antibiotics within the goal time of 1 hour increased from 40% to 80% with the intervention. Process measures including arrival to ED bed time, ED bed to antibiotic order time and antibiotic order time to delivery time were followed.

Conclusion:
Clinical guidelines, order sets and detailed understanding of the actual workflow at the point of care delivery can be instrumental in achieving the goals of reducing time to antibiotics.
Applying Lessons from an Inaugural Clinical Pathway to Establish a Clinical Effectiveness Program
Authors: Algaze Claudia A. , Shin Andrew Y. , Nather Chealsea , Elgin Krisa H. , Ramamoorthy Chandra , Kamra Komal , Kipps Alaina K. , Yarlagadda Vamsi V. , Mafla Monica M. , Vashist Tanushree , Krawczeski Catherine D. , Sharek Paul J. 
Published: June 2019

Introduction:
Clinical effectiveness (CE) programs promote standardization to reduce unnecessary variation and improve healthcare value. Best practices for successful and sustainable CE programs remain in question. We developed and implemented our inaugural clinical pathway with the aim of incorporating lessons learned in the build of a CE program at our academic children’s hospital.

Methods:
The Lucile Packard Children’s Hospital Stanford Heart Center and Center for Quality and Clinical Effectiveness partnered to develop and implement an inaugural clinical pathway. Project phases included team assembly, pathway development, implementation, monitoring and evaluation, and improvement. We ascertained Critical CE program elements by focus group discussion among a multidisciplinary panel of experts and key affected groups. Pre and postintervention compared outcomes included mechanical ventilation duration, cardiovascular intensive care unit, and total postoperative length of stay.

Results:
Twenty-seven of the 30 enrolled patients (90%) completed the pathway. There was a reduction in ventilator days (mean 1.0 + 0.5 versus 1.9 + 1.3 days; P < 0.001), cardiovascular intensive care unit (mean 2.3 + 1.1 versus 4.6 + 2.1 days; P < 0.001) and postoperative length of stay (mean 5.9 + 1.6 versus 7.9 + 2.7 days; P < 0.001) compared with the preintervention period. Elements deemed critical included (1) project prioritization for maximal return on investment; (2) multidisciplinary involvement; (3) pathway focus on best practices, critical outcomes, and rate-limiting steps; (4) active and flexible implementation; and (5) continuous data-driven and transparent pathway iteration.

Conclusions:
We identified multiple elements of successful pathway implementation, that we believe to be critical foundational elements of our CE program.
A Longitudinal and Sustainability Assessment of Pediatric Interfacility Transport Handover Standardization
Authors: Sochet Anthony A. , Ryan Kelsey S. , Miller Walter , Bartlett Jennifer L. , Nakagawa Thomas A. , Bingham Ladonna 
Published: June 2019

Introduction:
Standardization of interfacility transport handover is associated with improved shared mental model development, efficiency, and teaming. We sought to build upon previously published data by evaluating 1-year follow-up data, assessing face-validity, and describing sustainability.

Methods:
We performed a pre-post, retrospective cohort study in a stand-alone, tertiary, pediatric referral center for children 0–18 years of age transported to our pediatric intensive care unit, neonatal intensive care unit, or emergency department from October 2016 to November 2017. Handover was standardized using multidisciplinary checklists, didactics, and simulation. Data were collected for three 8-week periods (preintervention, postintervention, and 1-year follow-up). Outcomes included shared mental model index (shared mental model congruence expressed as an index, percent congruence regarding healthcare data), teaming data (efficiency, attendance, interruptions, interdependence), and face validity (5-point, Likert scale questionnaires). Statistics included 1-way analysis of variance, Kruskal-Wallis, chi-square, and descriptive statistics.

Results:
One hundred forty-eight handovers (50 preintervention, 50 postintervention, and 48 at 1-year) were observed in the emergency department (41%), pediatric intensive care unit (45%), and neonatal intensive care unit (14%). No differences were noted in demographics, diagnoses, PIM-3-ROM, length of stay, mortality, ventilation, or vasoactive use. Sustained improvements were observed in shared mental model congruence expressed as an index (38% to 82%), physician attendance (76% to 92%), punctuality (91.5% to 97.5%), interruptions (40% to 10%), provision of anticipatory guidance (42% to 85%), and handover summarization (42% to 85%, all P < 0.01). Efficiency was maintained throughout (mean duration 4.5 ± 2.1 minutes). Face validity data revealed handover satisfaction, effective communication, and perceived professionalism.

Conclusions:
Enhancements in teaming, shared mental model development, and face validity were achieved and sustained 1-year following handover standardization with only minimal reeducation during the study period.
Standardization of Radiologic Procedures for Pediatric Videofluoroscopic Swallow Studies: A Service-based Quality Improvement Initiative
Authors: Thompson Benjamin , Lundine Jennifer P. , Madhoun Lauren , Hu Houchun , Holliman-Wade Dominic , Bates D. Gregory 
Published: June 2019

Introduction:
The videofluoroscopic swallow study (VFSS) remains the primary method to evaluate swallowing function in infants and children. However, limited standards exist to guide the image acquisition during pediatric VFSSs, leading to inadequate images, variable assessment quality, and potential for suboptimal diagnostic accuracy. The goal of this quality improvement project was to standardize the radiological procedure for radiologists at our institution.

Methods:
A multidisciplinary team of project leaders established 3 imaging standards to target (magnification, the field of view, and pulse repetition rate), based on the best available evidence. The team used the Institute for Healthcare Improvement’s Model for Improvement to guide the project, identified key drivers, and implemented specific interventions. Project leaders observed a total of 170 VFSS examinations, performed by radiology faculty, fellows, and residents over 24 months. The primary outcome for this project was physician compliance with 3 established imaging standards: field of view, magnification, and pulse repetition rate. Project leaders collected data without the radiologists’ knowledge, and also recorded average radiation exposure as a balancing measure during this process.

Results:
At baseline, compliance with all 3 criteria was 20%. Following interventions designed to improve radiologist performance with the 3 identified standards, the compliance rate reached 100% for the last 50 recorded VFSSs. During this same time, there was no meaningful increase in average radiation exposure compared with the 6 months before the implementation of this project.

Conclusions:
Compliance with standardized image acquisition of VFSSs can be accomplished using a systematic quality improvement protocol targeting simple, inexpensive interventions.
Trigger Criteria to Increase Appropriate Palliative Care Consultation in the Neonatal Intensive Care Unit
Authors: Humphrey Lisa , Schlegel Amy , Seabrook Ruth , McClead Richard 
Published: June 2019

Introduction:
Pediatric palliative care (PPC) seeks longitudinal relationships with patients facing life-threatening conditions. The majority of pediatric deaths occur within the first year of life, especially neonatal intensive care unit (NICU); however, the consultation by PPC in the NICU is not routine. This project sought to improve the PPC’s presence within 1 NICU for patients facing life-limiting conditions through quality improvement techniques.

Methods:
A trigger list of severe, life-threatening conditions impacting neonates was created and implemented to increase PPC consultation within the NICU. Interventions to improve compliance with the trigger list included the collaborative creation of the trigger list, education, modification of PPC staff modeling, and expansion of the perinatal palliative care program.

Results:
Over the 2 years that the project occurred, 31 prenatal and postnatal patients were eligible for PPC consultation based on the trigger list. Of these, 24 received PPC consultation. The primary outcome measure of the project was to increase PPC consultations for those NICU infants identified on a severe diagnosis “trigger” list from 25% to 80% and to maintain this increase for 6 months. This project achieved 100% compliance within 12 months.

Conclusions:
Utilization of quality improvement methodology to address PPC underutilization within an NICU successfully led to the implementation of a trigger list for patients with severe diagnoses to receive PPC services. Such modeling could be used in other health systems to improve palliative care referrals.
Decreasing Door-to-Door Times for Infliximab Infusions in a Children's Hospital Observation Unit
Authors: Sandberg Kelly C. , Lucien Janet N. , Stoll Denise , Yanney Erica , Mezoff Adam 
Published: June 2019

Introduction:
Children with inflammatory bowel disease (IBD) often require infliximab infusions to manage their disease. Infusions administered in the hospital setting require the patient and their families to devote many hours away from home. Changing to a rapid infusion protocol has been shown in the literature to be safe and has the potential to decrease time spent in the hospital receiving infusions.

Methods:
We describe stepwise changes made over a 4-month period to improve infliximab infusion efficiency and lessen the time spent in the hospital by IBD patients and their families. These changes included the implementation of a standardized order set, defaulting to rapid infusions for eligible patients, eliminating the post-infusion observation window, and improving the pharmacy's efficiency in preparing infusion medications. We utilized several established quality improvement tools, including a smart aim, key driver diagram, plan-do-study-act cycles, and statistical process control charts to measure these interventions.

Results:
Within three months of starting, the average door-to-door time patients spent in the hospital decreased by 128 minutes (2 hours 8 minutes). This improvement amounts to 768 minutes (12 hours 48 minutes) per year of time returned for normal childhood activities outside of the hospital. There were no infusion reactions during the period monitored.

Conclusions:
Implementation of a rapid infliximab infusion protocol made an impressive impact on freed family time without sacrificing patient safety. The changes we implemented could be helpful to other centers interested in decreasing in-hospital time for patients with IBD and their families.
A Retrospective Review of Physician-related Patient Complaints from a Tertiary Pediatric Hospital
Authors: Chaulk David , Krueger Carsten , Stang Antonia S. 
Published: June 2019

Background:
Trends in patient concerns can identify systematic problems in health care delivery that may not be detected when addressing individual concerns. It can be difficult identifying trends without using a standardized taxonomy. The study objectives were to describe patient complaints from a tertiary care pediatric hospital and categorize them using a standardized complaint taxonomy.

Methods:
Physician-based patient complaints were compiled from April 2011 to May 2014 from a tertiary pediatric hospital. These complaints were coded independently by 2 reviewers using the Reader taxonomy, a published standardized taxonomy. Complaints were placed into 3 domains: clinical, management, and relationships then organized into categories. Inter-rater reliability for domain classification between the 2 reviewers was calculated using Cohen’s unweighted κ.

Results:
Eighty-seven patient complaints were identified, representing approximately 1 per 10,000 physician–patient encounters. Half (48/87) were related to care in the emergency department. When adjusted for volume, pediatric hospital medicine had the highest number of complaints, with 12.1 per 10,000 encounters. The majority of patient complaints, 66% (57/87), were of the clinical domain (κ = 0.61). Sixty percent (52/87) were in the relationship domain (κ = 0.68), and 16% (14/87) were in the management domain (κ = 0.65).

Conclusions:
We found a low overall complaint rate. Our results indicate that interventions to improve patient experience should initially be targeted at emergency and hospital medicine on the clinical and relationship domains. The inter-rater reliability of the Reader taxonomy was moderate with implications for processing patient complaints at a hospital level.