Validation of a Crisis Standards of Care Model for Prioritization of Limited Resources During the Coronavirus Disease 2019 Crisis in an Urban, Safety-Net, Academic Medical Center.

OBJECTIVES: The coronavirus disease 2019 pandemic has overwhelmed healthcare resources even in wealthy nations, necessitating rationing of limited resources without previously established crisis standards of care protocols. In Massachusetts, triage guidelines were designed based on acute illness and chronic life-limiting conditions. In this study, we sought to retrospectively validate this protocol to cohorts of critically ill patients from our hospital. DESIGN: We applied our hospital-adopted guidelines, which defined severe and major chronic conditions as those associated with a greater than 50% likelihood of 1- and 5-year mortality, respectively, to a critically ill patient population. We investigated mortality for the same intervals. SETTING: An urban safety-net hospital ICU. PATIENTS: All adults hospitalized during April of 2015 and April 2019 identified through a clinical database search. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 365 admitted patients, 15.89% had one or more defined chronic life-limiting conditions. These patients had higher 1-year (46.55% vs 13.68%; p < 0.01) and 5-year (50.00% vs 17.22%; p < 0.01) mortality rates than those without underlying conditions. Irrespective of classification of disease severity, patients with metastatic cancer, congestive heart failure, end-stage renal disease, and neurodegenerative disease had greater than 50% 1-year mortality, whereas patients with chronic lung disease and cirrhosis had less than 50% 1-year mortality. Observed 1- and 5-year mortality for cirrhosis, heart failure, and metastatic cancer were more variable when subdivided into severe and major categories. CONCLUSIONS: Patients with major and severe chronic medical conditions overall had 46.55% and 50.00% mortality at 1 and 5 years, respectively. However, mortality varied between conditions. Our findings appear to support a crisis standards protocol which focuses on acute illness severity and only considers underlying conditions carrying a greater than 50% predicted likelihood of 1-year mortality. Modifications to the chronic lung disease, congestive heart failure, and cirrhosis criteria should be refined if they are to be included in future models.

"Meds-in-Hand" Intervention to Reduce Critical Process Delays in Pediatric Human Immunodeficiency Virus Post-Exposure Prophylaxis.

Pediatric human immunodeficiency virus post-exposure prophylaxis is frequently indicated, but delays in medication receipt are common. Using plan-do-study-act cycles, we developed a multidisciplinary collaboration to reduce critical process delays in our pediatric emergency department. Interruptions decreased from a median 1 per month pre-intervention to zero per month during the intervention.

A Web Application for Adrenal Incidentaloma Identification, Tracking, and Management Using Machine Learning.

BACKGROUND: Incidental radiographic findings, such as adrenal nodules, are commonly identified in imaging studies and documented in radiology reports. However, patients with such findings frequently do not receive appropriate follow-up, partially due to the lack of tools for the management of such findings and the time required to maintain up-to-date lists. Natural language processing (NLP) is capable of extracting information from free-text clinical documents and could provide the basis for software solutions that do not require changes to clinical workflows. OBJECTIVES: In this manuscript we present (1) a machine learning algorithm we trained to identify radiology reports documenting the presence of a newly discovered adrenal incidentaloma, and (2) the web application and results database we developed to manage these clinical findings. METHODS: We manually annotated a training corpus of 4,090 radiology reports from across our institution with a binary label indicating whether or not a report contains a newly discovered adrenal incidentaloma. We trained a convolutional neural network to perform this text classification task. Over the NLP backbone we built a web application that allows users to coordinate clinical management of adrenal incidentalomas in real time. RESULTS: The annotated dataset included 404 positive (9.9%) and 3,686 (90.1%) negative reports. Our model achieved a sensitivity of 92.9% (95% confidence interval: 80.9-97.5%), a positive predictive value of 83.0% (69.9-91.1)%, a specificity of 97.8% (95.8-98.9)%, and an F1 score of 87.6%. We developed a front-end web application based on the model's output. CONCLUSION: Developing an NLP-enabled custom web application for tracking and management of high-risk adrenal incidentalomas is feasible in a resource constrained, safety net hospital. Such applications can be used by an institution's quality department or its primary care providers and can easily be generalized to other types of clinical findings.

Quality of life and psychological functioning of pediatric and young adult patients with Gaucher disease, type 1.

This study examined the health-related quality of life (HRQoL) and psychological functioning of children and young adults with Gaucher disease, type 1 (GD1). Thirty-two (17 pediatric, 15 young adult) patients with GD1 and one parent completed age-appropriate assessments of HRQoL, emotional, and behavioral health. The HRQoL of children with GD1 was compared with a healthy sample and to children diagnosed with Fabry disease (FD; another lysosomal storage disease), while young adults were compared to a healthy sample and to patients with self-reported chronic illnesses. Children with GD1 reported significantly lower HRQoL across all domains relative to healthy counterparts yet comparable HRQoL compared to children with FD. Young adults reported mildly lower physical functioning than healthy peers, but no differences in HRQoL relative to the chronic illness sample. Parent-reported symptom severity was associated with poorer HRQOL in children but not young adults. Few group differences in psychological functioning were observed, except young children showed more school problems than the normative average and there was a trend toward internalizing symptoms. Overall, results consistently identified younger patients with GD1 as more affected than older patients in HRQoL and psychological domains. Implementation of psychosocial interventions may be particularly beneficial during early childhood.

Quality improvement in tracheostomy care: A multidisciplinary approach to standardizing tracheostomy care to reduce complications.

PURPOSE: Develop a model for quality improvement in tracheostomy care and decrease tracheostomy-related complications. METHODS: This study was a prospective quality improvement project at an academic tertiary care hospital. A multidisciplinary team was assembled to create institutional guidelines for clinical care during the pre-operative, intra-operative, and post-operative periods. Baseline data was compiled by retrospective chart review of 160 patients, and prospective tracking of select points over 8 months in 73 patients allowed for analysis of complications and clinical parameters. RESULTS: Implementation of a quality improvement team was successful in creating guidelines, setting baseline parameters, and tracking data with run charts. Comparison of pre- and post-guideline data showed a trend toward decreased rate of major complications from 4.38% to 2.74% (p = 0.096). Variables including time to tracheotomy for prolonged intubation, surgical technique, day of first tracheostomy tube change, and specialty performing surgery did not show increased risk of complications. There were increased tracheostomy-related complications in cold months (p = 0.04). CONCLUSIONS: An interdisciplinary quality improvement team can improve tracheostomy care by identifying system factors, standardizing care among specialties, and providing continuous monitoring of select data points.

Evaluation of incidental adrenal masses at a tertiary referral and trauma center.

BACKGROUND: Incidental adrenal masses are those that are found on imaging performed for any nonadrenal evaluation. Published guidelines define accepted follow-up criteria for incidental adrenal masses; however, adherence to these guidelines and barriers to appropriate follow-up are not well understood. We aimed to describe practice patterns for the discovery, evaluation, and follow-up of incidental adrenal masses. METHODS: Medical records of patients with an incidental adrenal mass underwent retrospective review at a tertiary referral and level-1 trauma center, as well as regional ambulatory care locations. Individuals ≥18 years of age with an incidental adrenal mass identified during 2016 were included. Patterns of evaluation, follow-up, and associated adrenal diagnoses were determined. RESULTS: From a total of 19,171 cross-sectional imaging procedures (computed tomography and magnetic resonance imaging), 244 patients with new incidental adrenal masses were identified. A majority (52%) were discovered as part of an evaluation in the emergency department. Of 153 patients with an identifiable primary care provider, approximately 75% had an in-network primary care provider, and 12 (7.8%) had both follow-up imaging and biochemical evaluation. Twenty-three percent of patients with an in-network primary care provider underwent an appropriate cross-sectional imaging procedure in follow-up compared to 29% for a non-network primary care provider (P = .54). Patients with a mass described with benign terminology were less likely to undergo follow-up imaging compared to those with indeterminate terminology (5% vs 37%, P < .001). Patients with imaging ordered as an outpatient were more likely to receive follow-up with imaging (22.8% outpatient vs 11.5% inpatient, P = .042). There was no difference between any groups regarding biochemical evaluation, which inappropriately was performed in only 15% of patients with an incidental adrenal mass. CONCLUSION: To optimize follow-up of incidental adrenal masses, efforts should be made to assure and prioritize inpatient/emergency department incidental findings and to communicate to the appropriate primary care provider the necessary next steps for evaluation. Further, efforts to increase biochemical testing should be pursued.

Pet loss and continuing bonds in children and adolescents.

There is little research available regarding the impact of pet loss on children. In the current mixed-methods study, we explored the different ways that children use continuing bonds (CB) to cope following the death of a pet. We studied 32 children (5-18 years) and their parents. Children answered four questionnaires and the Continuing Bonds Interview. Parents answered a demographic questionnaire. Results suggest that all children utilize CB while grieving the loss of a pet, although CB expression varies depending on the age of the child, the level of grief following the loss, and the strength of attachment to the pet.

Addressing Disparities in Mother's Milk for VLBW Infants Through Statewide Quality Improvement.

OBJECTIVES: Among very low birth weight infants born from January 2015 to December 2017, the Massachusetts statewide quality improvement collaborative aimed to increase provision of (1) any mother's milk at discharge or transfer from a baseline of 63% to ≥75%, (2) exclusive mother's milk at discharge or transfer from a baseline of 45% to ≥55%, and (3) to reduce racial and ethnic disparities in provision of mother's milk. METHODS: We used the Institute for Healthcare Improvement Breakthrough Series framework in which our main process measures were receipt of prenatal education regarding human milk education, first milk expression within 6 hours after birth, and any skin-to-skin care on 4 weekly audit days in the first month. We examined changes over time among all very low birth weight infants and for 3 racial and ethnic subgroups (non-Hispanic white, non-Hispanic black, and Hispanic) using control and run charts, respectively. RESULTS: Of 1670 infants eligible to receive mother's milk at 9 hospitals, 43% of their mothers were non-Hispanic white, 19% were non-Hispanic black, 19% were Hispanic, 11% were of other races or ethnicities, and 7% were unknown. Hospital teams conducted 69 interventions. We found improvement in all 3 process measures but not for our main outcomes. Improvements in process measures were similar among racial and ethnic subgroups. Hospitals varied substantially in the rate of any mother's milk at discharge or transfer according to race and ethnicity. CONCLUSIONS: Our collaborative achieved similar improvements in process measures focused within the first month of hospitalization among all racial and ethnic subgroups. Reduction in racial and ethnic disparities in mother's milk at discharge was not reached. Future efforts will focus on factors that occur later in the hospitalization.

Racial and Ethnic Disparities in the Use of Mother's Milk Feeding for Very Low Birth Weight Infants in Massachusetts.

OBJECTIVE: To examine the extent to which maternal race/ethnicity is associated with mother's milk use among hospitalized very low birth weight (VLBW) infants and maternal receipt of hospital breastfeeding support practices (human milk prenatal education, first milk expression <6 hours after delivery, lactation consultation <24 hours, any skin-to-skin care <1 month). STUDY DESIGN: We studied 1318 mother-VLBW infant pairs in 9 Massachusetts level 3 neonatal intensive care units (NICUs) between January 2015 and November 2017. We estimated associations of maternal race/ethnicity with any and exclusive mother's milk on day 7, on day 28, and at discharge/transfer and hospital practices. We estimated HRs comparing the probability of continued milk use over the hospitalization by race/ethnicity and tested mediation by hospital practices, adjusting for birth weight and gestational age and including hospital and plurality as random effects. RESULTS: Mothers were 48% non-Hispanic white, 21% non-Hispanic black, and 20% Hispanic. Initiation of mother's milk was similar across groups, but infants of Hispanic mothers (hazard ratio [HR], 2.71; 95% CI, 2.05-3.59) and non-Hispanic black mothers (HR, 1.55; 95% CI, 1.17-2.07) stopped receiving milk earlier in the hospitalization compared with infants of non-Hispanic white mothers. Hispanic mothers had lower odds of providing skin-to-skin care at <1 month (OR, 0.61; 95% CI, 0.43-0.87) compared with non-Hispanic whites. CONCLUSIONS: Hispanic and non-Hispanic black mothers were less likely than non-Hispanic white mothers to continue providing milk for their VLBW infants throughout the NICU stay.

Evaluating the Feasibility of Incorporating In-Person Interpreters on Family-Centered Rounds: A QI Initiative.

OBJECTIVES: No best practice has been defined for incorporating in-person interpreters into family-centered rounds (FCRs) for patients with limited English proficiency (LEP). We hypothesized that addressing barriers to scheduling in-person interpreters would make FCR encounters more likely, and thus ensure more equitable care for LEP patients. METHODS: A quality improvement initiative was conducted from October 2014 to March 2016 to arrange in-person interpreters for LEP patients during FCRs on the inpatient pediatric service of a large, urban, tertiary care center in Boston. Main interventions included establishing a protocol for scheduling interpreters for rounds and the implementation of a form to track process adherence. Our primary outcome was the percentage of FCR encounters with LEP patients with an interpreter present. Our balancing measures were patient satisfaction, which was assessed using validated surveys administered weekly by nonphysician team members through convenience sampling of families present on the wards, and rounds duration. RESULTS: There were 614 encounters with LEP patients during the intervention, 367 of which included in-person interpreters. The percentage of encounters with LEP patients involving interpreters increased from 0% to 63%. Form completion, our primary process measure, reached 87% in the most recent phase. English-proficient and LEP patients reported similar satisfaction with their rounding experience amid a modest increase in rounds duration (preintervention, 105 minutes; postintervention, 130 minutes; P = .056). CONCLUSIONS: Using quality improvement as a framework to address key barriers, we successfully implemented a process that increased the participation of in-person interpreters on FCRs on a busy pediatric service.

Four- and five-factor models of the WAIS-IV in a clinical sample: Variations in indicator configuration and factor correlational structure.

A growing body of research supports the validity of 5-factor models for interpreting the Wechsler Adult Intelligence Scale-Fourth Edition (WAIS-IV). The majority of these studies have utilized the WAIS-IV normative or clinical sample, the latter of which differs in its diagnostic composition from the referrals seen at outpatient neuropsychology clinics. To address this concern, 2 related studies were conducted on a sample of 322 American military Veterans who were referred for outpatient neuropsychological assessment. In Study 1, 4 hierarchical models with varying indicator configurations were evaluated: 3 extant 5-factor models from the literature and the traditional 4-factor model. In Study 2, we evaluated 3 variations in correlation structure in the models from Study 1: indirect hierarchical (i.e., higher-order g), bifactor (direct hierarchical), and oblique models. The results from Study 1 suggested that both 4- and 5-factor models showed acceptable fit. The results from Study 2 showed that bifactor and oblique models offer improved fit over the typically specified indirect hierarchical model, and the oblique models outperformed the orthogonal bifactor models. An exploratory analysis found improved fit when bifactor models were specified with oblique rather than orthogonal latent factors. (PsycINFO Database Record

Safety-Net Academic Hospital Experience in Following Up Noncritical Yet Potentially Significant Radiologist Recommendations.

OBJECTIVE: In this retrospective study, we identified the types of noncritical recommendations radiologists issued over a 15-day period, the percentage of noncritical radiology recommendations that were not acted on or acknowledged in the medical records, potential causes for recommendations not being acted on, and the potential risk of harm to patients. MATERIALS AND METHODS: We conducted a retrospective review of radiology reports and patient records from January 1, 2014, to January 15, 2014, at a large tertiary academic center and regional safety-net hospital. RESULTS: A total of 6851 reports were reviewed; 857 (13%) contained at least one noncritical recommendation, with 978 total recommendations. The two most common recommendations were additional imaging (63%, n = 615) and clinical correlation (23%, n = 229). The majority of radiology recommendations were followed (67%, n = 655), but 323 cases (33%) contained no evidence that recommendations were followed. Of those that were not followed, 39% (n = 126) had no documentation in the medical records of the recommendation being acknowledged. Of those, 32% (n = 40) had important findings, half of which (n = 20) could have benefited from a verbal communication (18 mass lesions, two instances of fetal death). CONCLUSION: Radiologists' recommendations contained in written reports of noncritical findings may not be consistently followed or acknowledged in the medical records. Our study shows that a few report recommendations that were not consistently followed or acknowledged contained findings that referred to potentially harmful conditions. The results triggered an investment in systems improvement at the studied institution.

Validity and Reliability of a Tool to Assess Quality Improvement Knowledge and Skills in Pediatrics Residents.

BACKGROUND: Residency programs are expected to educate residents in quality improvement (QI). Effective assessments are needed to ensure residents gain QI knowledge and skills. Limitations of current tools include poor interrater reliability and requirement for scorer training. OBJECTIVE: To provide evidence for the validity of the Assessment of Quality Improvement Knowledge and Skills (AQIKS), which is a new tool that provides a summative assessment of pediatrics residents' ability to recall QI concepts and apply them to a clinical scenario. METHODS: We conducted a quasi-experimental study to measure the AQIKS performance in 2 groups of pediatrics residents: postgraduate year (PGY) 2 residents who participated in a 1-year longitudinal QI curriculum, and a concurrent control group of PGY-1 residents who received no formal QI training. The curriculum included 20 hours of didactics and participation in a resident-led QI project. Three faculty members with clinical QI experience, who were not involved in the curriculum and received no additional training, scored the AQIKS. RESULTS: Complete data were obtained for 30 of 37 residents (81%) in the intervention group, and 36 of 40 residents (90%) in the control group. After completing a QI curriculum, the intervention group's mean score was 40% higher than at baseline (P < .001), while the control group showed no improvement (P = .29). Interrater reliability was substantial (κ = 0.74). CONCLUSIONS: The AQIKS detects an increase in QI knowledge and skills among pediatrics residents who participated in a QI curriculum, with better interrater reliability than currently available assessment tools.

Impact of Parental Presence at Infants' Bedside on Neonatal Abstinence Syndrome.

BACKGROUND: Despite increased incidence of neonatal abstinence syndrome (NAS) over the past decade, minimal data exist on benefits of parental presence at the bedside on NAS outcomes. OBJECTIVE: To examine the association between rates of parental presence and NAS outcomes. METHODS: This was a retrospective, single-center cohort study of infants treated pharmacologically for NAS using a rooming-in model of care. Parental presence was documented every 4 hours with nursing cares. We obtained demographic data for mothers and infants and assessed covariates confounding NAS severity and time spent at the bedside. Outcomes included length of stay (LOS) at the hospital, extent of pharmacotherapy, and mean Finnegan withdrawal score. Multiple linear regression modeling assessed the association of parental presence with outcomes. RESULTS: For the 86 mother-infant dyads, the mean parental presence during scoring was on average 54.4% (95% confidence interval [CI], 48.8%-60.7%) of the infant's hospitalization. Maximum (100%) parental presence was associated with a 9 day shorter LOS (r = -0.31; 95% CI, -0.48 to -0.10; P < .01), 8 fewer days of infant opioid therapy (r = -0.34; 95% CI, -0.52 to -0.15; P < .001), and 1 point lower mean Finnegan score (r = -0.35; 95% CI, -0.52 to -0.15; P < .01). After adjusting for breastfeeding, parental presence remained significantly associated with reduced NAS score and opioid treatment days. CONCLUSIONS: More parental time spent at the infant's bedside was associated with decreased NAS severity. This has important implications for clinical practice guidelines for NAS.

Increasing Trainee Reporting of Adverse Events With Monthly Trainee-Directed Review of Adverse Events.

OBJECTIVE: Underreporting of adverse events by physicians is a barrier to improving patient safety. In an effort to increase resident and medical student (hereafter "trainee") reporting of adverse events, trainees developed and led a monthly conference during which they reviewed adverse event reports (AERs), identified system vulnerabilities, and designed solutions to those vulnerabilities. METHODS: Monthly conferences over the 22-month study period were led by pediatric trainees and attended by fellow trainees, departmental leadership, and members of the hospital's quality improvement team. Trainees selected which AERs to review, with a focus on common near misses. Discussions were directed toward the development of potential solutions to issues identified in the reports. Trainee submissions of AERs were tracked monthly. RESULTS: The mean number of AERs submitted by trainees increased from 6.7 per month during the baseline period to 14.1 during the study period (P < .001). The average percent of reports submitted by trainees increased from a baseline of 27.6% to 46.1% during the study period (P = .0059). There was no significant increase in reporting by any other group (attending, nursing, or pharmacy). Multiple meaningful solutions to identified system vulnerabilities were developed with trainee input. CONCLUSIONS: Trainee-led monthly adverse event review conferences sustainably increased trainee reporting of adverse events. These conferences had the additional benefit of having trainees use their unique perspective as frontline providers to identify important system vulnerabilities and develop innovative solutions.

Radiology Residency Quality Improvement Curriculum: Lessons Learned.

Quality improvement (QI) skills in radiology are required as part of the Accreditation Council for Graduate Medical Education Diagnostic Radiology Milestones competencies. Although feasibility of QI curricula has been demonstrated in radiology before, there are still barriers to widespread implementation. Here, we share our experience with designing the curriculum structure and selecting content. We describe the QI projects that have been performed and discuss lessons learned, including successes, challenges, and future directions. This information is relevant for many radiology programs currently planning to implement or revise existing QI curricula.

Increasing Medication Possession at Discharge for Patients With Asthma: The Meds-in-Hand Project.

BACKGROUND AND OBJECTIVES: Many patients recently discharged from an asthma admission do not fill discharge prescriptions. If unable to adhere to a discharge plan, patients with asthma are at risk for re-presentation to care. We sought to increase the proportion of patients discharged from an asthma admission in possession of their medications (meds in hand) from a baseline of 0% to >75%. METHODS: A multidisciplinary improvement team performed 3 plan-do-study-act cycles over 2 years and, using a statistical process control chart, tracked the proportion of patients admitted with asthma discharged with meds in hand as the primary outcome. An exploratory, retrospective analysis of insurance data was conducted with a convenience sample of Medicaid-insured patients, comparing postdischarge utilization between patients discharged with meds in hand and usual care. Generalized estimating equations accounted for nonindependence in the data. RESULTS: Changes to the discharge process culminated in the development of a discharge medication delivery service. Outpatient pharmacist delivery of discharge medications to patient rooms achieved the project aim of 75% of patients discharged with meds in hand. In a subset of patients for whom all insurance claims were available, those discharged with meds in hand had lower odds of all-cause re-presentation to the emergency department within 30 days of discharge, compared with patients discharged with usual care (odds ratio, 0.22; 95% confidence interval, 0.05-0.99). CONCLUSIONS: Our initiative led to several discharge process improvements, including the creation of a medication delivery service that increased the proportion of patients discharged in possession of their medications and may have decreased unplanned visits after discharge.

Leveraging Trainees to Improve Quality and Safety at the Point of Care: Three Models for Engagement.

Trainees, as frontline providers who are acutely aware of quality improvement (QI) opportunities and patient safety (PS) issues, are key partners in achieving institutional quality and safety goals. However, as academic medical centers accelerate their initiatives to prioritize QI and PS, trainees have not always been engaged in these efforts. This article describes the development of an organizing framework with three suggested models of varying scopes and time horizons to effectively involve trainees in the quality and safety work of their training institutions. The proposed models, which were developed through a literature review, expert interviews with key stakeholders, and iterative testing, are (1) short-term, team-based, rapid-cycle initiatives; (2) medium-term, unit-based initiatives; and (3) long-term, health-system-wide initiatives. For each, the authors describe the objective, scope, duration, role of faculty leaders, steps for implementation in the clinical setting, pros and cons, and examples in the clinical setting. There are many barriers to designing the ideal training environments that fully engage trainees in QI/PS efforts, including lack of protected time for faculty mentors, time restrictions due to rotation-based training, and structural challenges. However, one of the most promising strategies for overcoming these barriers is integrating QI/PS principles into routine clinical care. These models provide opportunities for trainees to successfully learn and apply quality and safety principles to routine clinical care at the team, unit, and system level.