Improving Use of Antibiotics for Pediatric Pneumonia in Community Hospital Emergency Departments.

BACKGROUND AND OBJECTIVES: The majority of pediatric patients present to community-hospital emergency departments (EDs). Pneumonia is among the most common reasons for ED visits; however, prescribing narrow-spectrum antibiotics occurs at rates below established best practices. We sought to increase prescription of narrow-spectrum antibiotics for pediatric pneumonia in 5 community hospital EDs using an interdisciplinary learning collaborative. We aimed to increase use of narrow spectrum antibiotics from 60% to 80% by December 2018. METHODS: A collaborative of 5 community hospitals developed quality improvement teams who held quarterly meetings over a 1 year period engaging teams in Plan-Do-Study-Act cycles. Interventions included deployment of an evidenced based guideline, educational interventions, and order set modification. Preintervention data were collected for 12 months. Using a standardized data form, teams collected monthly data during the intervention period and for an additional year after to assess for sustainability. Teams evaluated data using statistical process control charts and included any patient 3 months to 18 years with a diagnosis of pneumonia. RESULTS: The aggregated rate of narrow-spectrum antibiotic prescriptions increased from 60% during the baseline period to 78% during the intervention period. During the year after active implementation, this aggregate rate increased to 92%. Differences in prescribing patterns were noted by provider type, but narrow-spectrum antibiotic use improved for both general emergency medicine and pediatric providers. No return visits to the ED for failure of antibiotic treatment within 72 hours occurred. CONCLUSIONS: An interdisciplinary community hospital learning collaborative increased prescribing narrow-spectrum antibiotics by both general and pediatric ED providers.

Frequency and Nature of Communication and Handoff Failures in Medical Malpractice Claims.

BACKGROUND: The Joint Commission has identified miscommunication as a leading cause of sentinel events, the most serious adverse events, but it is unclear what role miscommunications play in malpractice claims. We sought to determine the proportion of medical malpractice claims involving communication failure and describe their nature, including providers involved, locations, miscommunications types, costs, and the potential for handoff tools to avert risk and associated costs. METHODS: We retrospectively reviewed a random sample of malpractice claims from 2001 to 2011, collected in CRICO Strategies' Comparative Benchmarking System, a national claims database. Two researchers reviewed cases to determine if a claim involved communication failure, its type, and potential preventability using a communication tool. Interrater reliability was assessed by dual review of 50 cases (81% agreement, κ = 0.62 for evidence of miscommunication). Claimant demographics, case characteristics, and financial data were analyzed. RESULTS: Communication failures were identified in 49% of claims. Claims with communication failures were significantly less likely to be dropped, denied, or dismissed than claims without (54% versus 67%, P = 0.015). Fifty-three percent of claims with communication failures involved provider-patient miscommunication, and 47% involved provider-provider miscommunication. The information types most frequently miscommunicated were contingency plans, diagnosis, and illness severity. Forty percent of communication failures involved a failed handoff; the majority could potentially have been averted by using a handoff tool (77%). Mean total costs for cases involving communication failures were higher ($237,600 versus $154,100, P = 0.005). CONCLUSIONS: Communication failures are a significant contributing cause of malpractice claims and impose a substantial financial burden on the healthcare system. Interventions to improve transmission of critical patient information have the potential to substantially reduce malpractice expenditures.

Changing the Paradigm of School-Based Physical Therapist Service Delivery: Using Evidence to Support Intensive Intervention.

PURPOSE: The purpose of this article is to highlight the paradigm shift away from the typical model of direct service delivery of consistent frequency and duration in the school setting to accommodate an intensive progressive resistive exercise intervention. School-based physical therapists describe how they applied an evidence-based intensive intervention with multiple students in an urban public school district. SUMMARY OF KEY POINTS: The school-based physical therapists had to modify the typical service delivery model and overcome other challenges to implement this intensive intervention approach. Substantial improvements in strength and functional activities were observed in multiple students and measured across several months. CONCLUSIONS AND RECOMMENDATIONS FOR CLINICAL PRACTICE: An intensive intervention model appears effective and feasible in the school setting. Evidence-based intervention approaches should be considered when the student could benefit. VIDEO ABSTRACT: For more insights from the authors, see Supplemental Digital Content 1, available at: http://links.lww.com/PPT/A339.

Emergency department staff perceptions about the care of children with mental health conditions.

OBJECTIVE: The number of children with mental health (MH) conditions who present to the emergency department (ED) is increasing. This study aimed to gain insight into the lived experiences of ED staff caring for children with MH conditions and to understand perceptions of current ED resources and what is needed to optimize care. METHODS: This was a qualitative study informed by complexity science theory utilizing a phenomenological approach. We used purposeful sampling from urban and nonurban EDs with varying pediatric volume. Participants were pediatric emergency care coordinators and other ED staff. Semi-structured interviews were completed. The initial codebook was created using a concept driven approach. Constant comparative analysis and deductive reasoning was employed for thematic analysis. RESULTS: Thematic saturation by consensus was achieved with 24 interviews. Analysis found an overarching theme of moral distress of ED staff, compounded by frustration with barriers to care and perceptions of negative impact on care of other ED patients. Participants suggested the need for creation of patient, caregiver, ED staff, and ED leadership resources to enhance care. CONCLUSIONS: ED staff perceive children with MH conditions experience significant barriers to optimal care in the ED, which causes ED provider moral distress. Additionally, other ED patients are perceived to be subsequently negatively impacted. Our findings highlight urgency for funding for more resources that are dedicated to children in the ED setting to ensure both safe, patient-centered care, and to reduce the distress described by ED staff who care for them.

Reducing the Cranial CT Rate for Pediatric Minor Head Trauma at Three Community Hospitals.

OBJECTIVE: Efforts to reduce the rate of computerized cranial tomography (CT) in pediatric patients with minor head trauma (MHT) have focused on academic medical centers. However, community hospitals deliver the majority of pediatric emergency care. We aimed to reduce cranial CT utilization in patients presenting with MHT at 3 community hospital emergency departments (EDs). METHODS: Multidisciplinary stakeholder teams at each site oversaw the quality improvement effort, which included education about an evidence-based guideline for MHT and individual provider feedback on CT rates. Given the variation in hospital structure, we tailored the specifics of the intervention to each site. We used statistical process control methodology to measure CT rates over time. The primary balancing measure was returned to the ED within 72 hours with clinically important traumatic brain injury. RESULTS: We included 3,215 pediatric ED visits for MHT: 1,253 in the baseline period and 1,962 in the intervention period. The CT rate dropped from 18% in the baseline period to 13% in the intervention period, a 28% relative reduction. Pediatric providers saw 72% of the intervention period encounters and drove this reduction. There was no increase in the number of children who returned to their local ED within 72 hours with clinically important traumatic brain injury. CONCLUSIONS: We safely reduced the proportion of children with MHT who received a cranial CT through a multicenter community ED quality improvement initiative. We did not see an increase in missed clinically important traumatic brain injury.

A method to identify pediatric high-risk diagnoses missed in the emergency department.

BACKGROUND: Diagnostic error can lead to increased morbidity, mortality, healthcare utilization and cost. The 2015 National Academy of Medicine report "Improving Diagnosis in Healthcare" called for improving diagnostic accuracy by developing innovative electronic approaches to reduce medical errors, including missed or delayed diagnosis. The objective of this article was to develop a process to detect potential diagnostic discrepancy between pediatric emergency and inpatient discharge diagnosis using a computer-based tool facilitating expert review. METHODS: Using a literature search and expert opinion, we identified 10 pediatric diagnoses with potential for serious consequences if missed or delayed. We then developed and applied a computerized tool to identify linked emergency department (ED) encounters and hospitalizations with these discharge diagnoses. The tool identified discordance between ED and hospital discharge diagnoses. Cases identified as discordant were manually reviewed by pediatric emergency medicine experts to confirm discordance. RESULTS: Our computerized tool identified 55,233 ED encounters for hospitalized children over a 5-year period, of which 2161 (3.9%) had one of the 10 selected high-risk diagnoses. After expert record review, we identified 67 (3.1%) cases with discordance between ED and hospital discharge diagnoses. The most common discordant diagnoses were Kawasaki disease and pancreatitis. CONCLUSIONS: We successfully developed and applied a semi-automated process to screen a large volume of hospital encounters to identify discordant diagnoses for selected pediatric medical conditions. This process may be valuable for informing and improving ED diagnostic accuracy.

An Intervention to Improve Caregiver Adherence to Oral Rehydration Therapy.

OBJECTIVE: To improve oral rehydration therapy (ORT) after discharge for children presenting to the emergency department (ED) with acute gastroenteritis (AGE). METHODS: We designed and implemented a quality improvement initiative to improve caregiver adherence to ORT in children 6 months to 21 years old with AGE. The intervention consisted of ORT "kits" with rehydration supplies and caregiver instructions. In the preintervention period we monitored patient/caregiver adherence to ORT recommendations and additionally monitored ORT kit and educational material distribution during the intervention phase via a caregiver survey after discharge. We utilized statistical process control methodology to assess responses to the intervention. As a balancing measure, we monitored the ED length of stay for patients with AGE. RESULTS: Over the study period from November 2013 to April 2015, we included 174 encounters during the preintervention period and 256 encounters during the intervention period. More than 9 of 10 children received ORT kits in the intervention period. Self-reported adherence to ORT between the 2 time periods remained constant. The ED length of stay did not change between the preintervention and intervention period. CONCLUSIONS: Despite successful distribution of novel ORT materials and education for caregivers of children with AGE in a pediatric ED, caregiver self-reported adherence to ORT postdischarge visit was unchanged. An unexpected high baseline adherence to ORT practices may have limited improvement.