bluuebunny/crossref_metadata_2025_split huggingface dataset:
Improving Human Papilloma Virus Vaccination Rates: Quality Improvement
Authors: Bowden Michelle , Yaun Jason , Bagga Bindiya 
Published: June 2019

Background:
Human papilloma virus (HPV) is a sexually transmitted infection with a national prevalence of greater than 70 million. Most infections are among persons 15–24 years of age. The HPV vaccine has nearly 100% efficacy when administered before natural exposure. However, national vaccination rates remain less than 50%. Our objective was to improve the rate of initiation of the HPV vaccination series in a resident teaching practice.

Methods:
We used the Plan Do Study Act methodology for quality improvement. Eligible patients included children 9 through 13 years of age who presented to a general pediatric clinic. We established baseline data by reviewing HPV immunization rates taken from a convenience sample of ≤20 patients per month over 7 months. A key driver diagram guided interventions including resident communication, nursing staff education, family knowledge, and an electronic medical record prompt beginning at age 9. Using standard run chart rules, we plotted monthly postintervention vaccination rates over 7 months of data collection.

Results:
Baseline data included 136 patients age 9–13. Run chart monitoring revealed an increase in our HPV vaccination rate from 53% at baseline to 62% by October 2015. Additionally, we observed a statistically significant increase in mean vaccination rates from 50% to 69% (odds ratio 2.071; P = 0.0042). We noted an increase in vaccination rates after resident education initiatives and after implementation of an electronic medical record prompt.

Conclusions:
Simple and practical interventions involving residents led to a marked increase in HPV vaccination in our patient population.
Using Length of Stay to Understand Patient Flow for Pediatric Inpatients
Authors: Stockwell David C. , Thomas Cherie , Fieldston Evan S. , Hall Matt , Czaja Angela S. , Stalets Erika L. , Biehler Jefry , Sheehan Maeve , Foglia Dorothy , Byrd Susan , McClead Richard E. 
Published: June 2019

Objectives:
Develop and test a new metric to assess meaningful variability in inpatient flow.

Methods:
Using the pediatric administrative dataset, Pediatric Health Information System, that quantifies the length of stay (LOS) in hours, all inpatient and observation encounters with 21 common diagnoses were included from the calendar year 2013 in 38 pediatric hospitals. Two mutually exclusive composite groups based on diagnosis and presence or absence of an ICU hospitalization termed Acute Care Composite (ACC) and ICU Composite (ICUC), respectively, were created. These composites consisted of an observed-to-expected (O/E) LOS as well as an excess LOS percentage (ie, the percent of day beyond expected). Seven-day all-cause risk-adjusted rehospitalizations was used as a balancing measure. The combination of the ACC, the ICUC, and the rehospitalization measures forms this new metric.

Results:
The diagnosis groups in the ACC and the ICUC included 113,768 and 38,400 hospitalizations, respectively. The ACC had a median O/E LOS of 1.0, a median excess LOS percentage of 23.9% and a rehospitalization rate of 1.7%. The ICUC had a median O/E LOS of 1.1, a median excess LOS percentage of 32.3%, and rehospitalization rate of 4.9%. There was no relationship of O/E LOS and rehospitalization for either ACC or ICUC.

Conclusions:
This metric shows variation among hospitals and could allow a pediatric hospital to assess the performance of inpatient flow.
A Quality Improvement Initiative to Increase and Sustain Influenza Vaccination Rates in Pediatric Oncology and Stem Cell Transplant Patients
Authors: Wong Chris I. , Billett Amy L. , Weng Shicheng , Eng Kelly , Thakrar Usha , Davies Kimberly J. 
Published: June 2019

Introduction:
Influenza vaccination of pediatric oncology and stem cell transplant (SCT) patients is crucial due to high risk of complications. Achieving high vaccination rates to prevent illness is often limited by competing demands and intensive treatment. A quality improvement (QI) initiative beginning influenza season 2012–2013 aimed to achieve and sustain high vaccination rates in active patients > 6 months of age, receiving cancer therapy or SCT within 6 months before or at any time during the season, and > 100 days after allogeneic SCT.

Methods:
We identified key drivers and barriers to success from an initially developed vaccination process that proved to be burdensome. Change ideas were implemented through multiple tests of change during the QI initiative. Iterations within and across 4 subsequent seasons included patient identification through chemotherapy orders, provider education, incorporating vaccination into routine work-flow, continuous data analysis and feedback, and use of new reporting technology.

Results:
Initial vaccination rates were < 70%, increasing to 89% after the QI initiative began and subsequently sustained between 85% and 90%. Active patients were significantly more likely to be vaccinated during the initiative (odds ratio, 3.7; 95% CI, 2.9–4.6) as compared with the first 2 seasons.

Conclusions:
High influenza vaccination rates can be achieved and maintained in a pediatric oncology/SCT population using strategies that correctly identify patients at highest risk and minimize process burden.
Electronically-augmented Huddle Improved Antibiotic Delivery for Sepsis in the Pediatric Intensive Care Unit
Authors: Woods-Hill Charlotte Z. , Biedron Lauren M. , Rigby Valerie A. , Kaminski Sharon , Papili Kelly E. , Fitzgerald Julie C. , Weiss Scott L. 
Published: June 2019

Background:
Delayed antimicrobial therapy is an independent risk factor for mortality and prolonged organ dysfunction in sepsis. Barriers to timely antibiotic administration include lack of situational awareness about medication status and inconsistent communication with ordering clinicians.

Objectives:
The specific aim of this project was to achieve antibiotic administration within 60 minutes of order for ≥ 70% of suspected sepsis episodes in pediatric intensive care unit patients.

Methods:
In the 55-bed pediatric intensive care unit of an academic referral center, a standardized workflow to decrease antibiotic administration time for patients with suspected sepsis was iteratively implemented from 2012 to 2017. An electronic orderset (phase 1) and best practice alert for “stat” antibiotic ordering (phase 2) were combined with a scripted multidisciplinary bedside “sepsis huddle” (phase 3). Subsequently, a bedside, 1-touch electronic notification button was introduced (phase 4), which triggered automated phone alerts to the clinical team until antibiotic administration was complete (Fig. 1).

Results:
There was a progressive decrease in time from antibiotic order to administration from phase 1 through 4 (Table 1; Fig. 2). This improvement has been sustained, with ≥ 70% of suspected sepsis episodes meeting goal antibiotic administration time for 12 months following phase 4. On-time administration was more likely for episodes with versus without a huddle (90% versus 70%).

Conclusions/Implications:
Combining automated, timed reminders with a multidisciplinary huddle improved situational awareness about challenges to timely antibiotic delivery and decreased time to administration for critically ill children with suspected sepsis. Follow-up work includes integrating the 1-touch notification process into an automated sepsis recognition algorithm.
Time to Huddle: Initiating the Bedside Sepsis Huddle on an Acute Care Pediatric Unit
Authors: Lowerre Tracy S. , Silverman Jonathan A. , McGehee Jill M. 
Published: June 2019

Background:
Rapid recognition and prompt treatment of sepsis within 1 hour may improve sepsis outcomes in children.

Objectives:
To develop and implement a sepsis screening tool and huddle process to improve early recognition and treatment of sepsis on an inpatient pediatric unit.

Methods:
Sepsis huddle implementation entailed house-wide education on early recognition of sepsis, antibiotic administration, and fluid bolus delivery methods. We used rapid Plan Do Study Act (PDSA) cycles to enhance documentation and communication among care providers during sepsis huddles. The team developed pocket cards for all team members to screen patients for sepsis based on Systemic Inflammatory Response Syndrome (SIRS) criteria (Goldstein, 2005). A paper huddle form was developed and adapted to ensure all the bundle elements were implemented within the 1 hour goal. We added a sepsis huddle section to the vital sign band of the electronic medical record. Standardized sepsis order sets ensured consistent care between the ED, inpatient units, and PICU.

Results:
Between April 24 and December 1, there were 112 huddles, 28 rapid response activations, and 14 immediate transfers to a higher level of care. The pediatric department met the goal of 70% of first dose STAT antibiotics administered within 1 hour. Our Vizient observed to expected sepsis mortality has dropped from 1.37 (FY 2016) to 0.99 (FY 2017, preliminary data). (Table 1)
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.