Evaluation of effectiveness of a paediatric simulation course in procedural skills for paediatric residents - A pilot study.

OBJECTIVE: To explore the effects of simulation training on paediatric residents' confidence and skills in managing advanced skills in critical care. METHODS: The study was conducted at Alfaisal University, Riyadh, Saudi Arabia, from March to June 2016, and comprised junior residents in paediatrics. All paediatric residents (years 1 and 2) were recruited into two workshops, held one week apart. The first workshop covered lumbar puncture/ cerebrospinal fluid interpretation, oral intubation, bone marrow aspiration, and critical airway management. The second workshop covered chest tube insertion, pleural tap, insertion of central line, and arthrocentesis. The participants were surveyed using a 5-point Likert scale survey pre- and post-course, assessing their confidence. Their practical skills were assessed using a pre-objective structured clinical examination on the same day and post-course objective structured clinical examination a week later on selected skills. The outcome measures were: (1) pre-/post-course confidence rating, and (2) pre-/post-course objective structured clinical examination results. Data was analysed using SPSS 20. RESULTS: Of the 16 participants, 8(50%) were boys and 8(50%) girls. Besides, 13(81%) residents were in year-1 and 3(19%) in year-2. Median post-course confidence level ranks for all the skills were higher (p<0.05). There was no improvement in mean pre-objective structured clinical examination scores (2.31±2.66/ 7.46±3.02) and post- objective structured clinical examination scores (22.54±4.39/ 31.85±6.90) in Year 1 residents (p<0.001). CONCLUSIONS: Simulation course was significantly successful in improving residents' clinical skills and confidence in performing critical tasks.

Departmental collaborative approach for improving in-patient clinical documentation (five years experience).

INTRODUCTION: Health care institutes are cooperative areas where multiple health care services come together and work closely; physician, nurses and paramedics etc,. These multidisciplinary teams usually communicate with each other by documentation. Therefore, accurate documentation in health care organization is considered one of the vital processes. To make the documentation useful, it needs to be accurate, relevant, complete and confidential. OBJECTIVES: The aim of this paper is to demonstrate the effect of the collaborative work in the Department of Pediatrics on improving the quality of inpatient clinical documentation over 5 years. METHODS: Improving clinical documentations went through several collaborative approaches, these include: Departmental Administration involvement, establishment of quality management team, regular departmental collaborative meeting as a monitoring and motivating tool, establishment of the residents quality team, Integration of quality projects into the new residents annual orientation, considering it as a part of the trainee personal evaluation, sending reminders to the consultants and residents on the adherence for admission note initiating and 24 h's verification, utilization of standardized template of admission note and progress note and emphasizing on the adherence to the approved medical abbreviation list only for any abbreviation to be used. RESULTS: During the period between the first quarter of 2012 to the fourth quarter of 2017; a significant improvement was noticed in the overall in-patient clinical documentation compliance rate, as it was ranging from lower 50% in 2012 and 2013, and increased gradually to reach upper 80% in the last quarters of 2016 and 2017. These figures are based on an independent audit that being done by the hospital quality management department and received by the department in a quarterly basis. CONCLUSION: Despite multiple challenges for improving the compliance for clinical documentations, major improvement can be achieved when the collaboration and efforts among all stakeholders being shared and set as a common goal.

Challenges of implementing a standardized process for discharge summaries (5 years experience).

INTRODUCTION: Discharge summaries are essential documents to provide a long-lasting record of a patient's visit to a hospital. It provides an effective method of communication between various hospital services and primary care providers.We conducted a study recently in KFSH&RC recommending that every admitted patient to the Pediatric Department must have a discharge summary initiated as soon as possible within the first five days of hospitalization and to be updated periodically until its completion on the patient's discharge day. Results of this study showed that most of the patients received their discharge summaries within the time limit as recommended by the JCIA standard. OBJECTIVES: The aim of this paper is to present our department's experience in regard to the difficulties, challenges, and outcomes of the adopted work flow for discharge summaries over a period of five years. METHODS: The residents have been instructed to initiate the discharge summaries as soon as possible within the first five days of hospitalization for every patient admitted under the Department of Pediatrics regardless of the expected discharge date. Afterward, it will be the responsibility of the attending junior and senior residents to update the summaries on regular basis as long as the patient under their care. They should transfer the updated summary to the coming resident that will take over the medical care until the discharge day when the most recent update will be forwarded to the attending consultant for final review and signature. RESULTS: Between 2011 and 2016, a significant drop in the number of delinquent records was noted. From 1131 delinquent records at the end of the fourth quarter of 2011, the number has fallen to 15 in the fourth quarter of 2016. Furthermore, compliance to JCIA documentation standards showed sustained improvement since the initiation of the project. The department used to score around 50% in the discharge documentation compliance rate which has improved to be maintained around 80%s in average. CONCLUSIONS: Every new project concerning the quality of patient care provided in any institution is expected to face multiple challenges and difficulties. Proper identifications of the challenges, standardize approach for solutions, sustainability of quality monitoring for an improvement projects can maintain the success for any new project.

Improving Medication Reconciliation compliance at admission: A single department's experience.

BACKGROUND AND OBJECTIVES: The objective of this research is to improve compliance of the medication reconciliation process at the time of patient admission in the Department of Pediatrics at King Faisal Specialist Hospital and Research Centre, Riyadh, Kingdom of Saudi Arabia using an innovative evidence-based approach. MATERIALS AND METHODS: Most of the recent efforts at our institution to revamp the medication reconciliation process have failed. Thus, we implemented an innovative evidence-based approach to improve the compliance of the reconciliation process at admission. This approach focused on the Department of Pediatrics at King Faisal Specialist Hospital and Research Centre (KFSH&RC). We established specific educational and monitoring programs that were run over a two-month period, from June to July 2015. The educational program consisted of focused hands-on daily interactive training sessions presented to a small group of residents, i.e., 5-6 residents per session, for a period of one week. One resident was identified as a "Super-User" to provide ongoing support for the other residents involved in the process. A close monitoring process was also implemented, which included daily follow up and encouragement from three assigned consultants. In addition, periodic independent audit report results prepared by Healthcare Information Technology Affairs (HITA) were communicated to the Department of Pediatrics regarding physician compliance in the medication reconciliation process. RESULTS: Physician compliance for admission medication reconciliation documentation in ICIS ranged from (0-15%) between the first quarter of 2012 and the first quarter 2015, we designated the official hospital audit for the first quarter of 2015 as a baseline audit report. Between the first quarter of 2012 and 2015, the physician compliance for admission medication reconciliation was ranged between 0 to 15% according to the official hospital audit. We implemented our initiative during the months of June and July 2015. During that time, there was a gradual improvement in the number of admission medication reconciliations reported by the independent audits of our general Pediatrics Ward (B1), which represents the majority of pediatric admissions. The 57% of 26 patients had medication reconciliation completed by the first report dated 16 June 2015. This percentage improved to 92% out of a total of 13 patients at the last report on 12 July 2015. This consistent improvement also occurred in other areas where pediatric patients were admitted including the B3-1 (from 88% to 90%), the NICU 1 (from 83% to 100%) and the NICU 2 (from 90% to 100%). CONCLUSIONS: By structuring and implementing intensive educational and monitoring programs, a marked improvement in the compliance of medication reconciliation at the time of admission for the pediatric patient population was achieved. We believe that our department-based results would be generalizable if a similar hospital-wide programme was to be rigorously implemented.

Hemolytic disease of the newborn caused by anti-Wright (anti-Wra): case report and review of literature.

Antibodies to red cell antigens that are found at low frequency in the general population are rare causes of hemolytic disease of the newborn. To understand how to detect these cases, we provide a basic review of routine antenatal maternal antibody testing and report a case of a neonate with severe HDN caused by anti-Wright (anti-Wra), successfully managed with transfusion, phototherapy, and high-dose intravenous immunoglobulin. When hemolysis in a newborn is suspected in the absence of major blood group incompatibility or commonly detected maternal red cell antibodies, a direct antiglobulin test should be performed. A positive DAT should alert the clinician to the presence of maternal antibodies against low-incidence antigens. Antibodies to the Wra antigen are one such rare cause of HDN.

Use of targeted neonatal echocardiography to prevent postoperative cardiorespiratory instability after patent ductus arteriosus ligation.

OBJECTIVES: To investigate the value of targeted neonatal echocardiography (TnECHO) in predicting cardiorespiratory instability after patent ductus arteriosus (PDA) ligation, and to evaluate the impact of TnECHO-directed care. STUDY DESIGN: We reviewed serial echocardiography evaluations of 62 preterm infants after PDA ligation to investigate the relationship between indices of myocardial performance and postoperative cardiorespiratory instability. A predictive model was developed based on TnECHO criteria, with targeted initiation of intravenous milrinone. A comparative evaluation was performed between matched infants in the previous era (epoch 1; n=25) and current era (epoch 2; n=27) of TnECHO-guided treatment. RESULTS: Left ventricular output <200 mL/kg/min at 1 hour after PDA ligation was a sensitive predictor of systemic hypotension and the need for inotropes, and was used for initiation of i.v. milrinone infusion in epoch 2. Infants treated with milrinone had a lower incidence of ventilation failure (15% vs 48%; P=.02) and less need for inotropes (19% vs 56%; P=.01), and showed a trend toward improved oxygenation (P=.08). CONCLUSION: TnECHO facilitates early detection of infants at greatest risk for subsequent cardiorespiratory deterioration. Administration of milrinone to neonates with low cardiac output may lead to improved postoperative stability.

Short-term outcome of very low-birth-weight infants in a tertiary care hospital in Saudi Arabia.

BACKGROUND AND OBJECTIVE: Published data on short-term outcomes of very low birth weight infants from Saudi Arabia are limited. In the present study, our objective was to describe and analyze the outcomes of very low birth weight infants admitted to our neonatal intensive care unit and to compare the results with data published by the National Institute of Child Health and Development. DESIGN AND SETTING: This study was a retrospective analysis of prospectively collected data from a single tertiary care center over a three years period. PATIENTS AND METHODS: Biodemographic data and data regarding multiple outcome measures were analyzed for infants with birth weight of 1500 g or less. Data were obtained from our neonatal intensive care unit database. RESULTS: Our results included a total of 186 infants with birth weights of 1500 g or less. Of these infants, 154 (82.8%) survived to discharge. Seventy-six (40.9%) were male, and mean (SD) gestational age (GA) was 29 (2.9) weeks with a range of 21 weeks, 6 days to 36 weeks, 2 days. Mean (SD) birth weight was 1062 (302) g with a range of 420 to 1495 g. Fifty-seven (30.6%) infants were characterized as small for gestational age. Antenatal steroids were given to 74.2% of mothers. Eighty-five percent of infants were born by cesarean section. The rate of bronchopulmonary dysplasia was 17.7%, patent ductus arteriosus 31.2%, intraventricular hemorrhage 12.9%, periventricular leukomalacia 3.8%, necrotizing enterocolitis 7.5%, retinopathy of prematurity 28.3%, and late-onset sepsis was 21.9%. CONCLUSION: In this population of very low birth weight infants, survival rates and complications of prematurity were comparable to international data.