The High-Value Care Rounding Tool: Development and Validity Evidence.

Little is known about current practices in high-value care (HVC) bedside teaching. A lack of instruments for measuring bedside HVC behaviors confounds efforts to assess the impact of curricular interventions. The authors aimed to define observable HVC concepts by developing an instrument to measure the content and frequency of HVC discussions.The authors developed the HVC Rounding Tool in four iterative phases, using Messick's validity framework. Phases 1 and 2 were designed to collect evidence of content validity, Phases 3 and 4 to collect evidence of response process and internal structure. Phase 1 identified HVC topics within the literature. Phase 2 used a modified Delphi approach for construct definition and tool development. Through two rounds, the Delphi panel narrowed 16 HVC topics to 11 observable items, categorized into three domains (quality, cost, and patient values). Phase 3 involved rater training and creation of a codebook. Phase 4 involved three iterations of instrument piloting. Six trained raters, in pairs, observed bedside rounds during 148 patient encounters in 2016. Weighted kappas for each domain demonstrated improvement from the first to third iteration: Quality increased from 0.65 (95% CI 0.55-0.79) to 1.00, cost from 0.58 (95% CI 0.4-0.75) to 0.96 (95% CI 0.80-1.00), and patient values from 0.41 (95% CI 0.19-0.68) to 1.00. Percent positive agreement for all domains improved from 65.3% to 98.1%. This tool, the first with established validity evidence, addresses an important educational gap for measuring the translation of HVC from theoretical knowledge to bedside practice.

Prospective Observational Study on High-Value Care Topics Discussed on Multidisciplinary Rounds.

OBJECTIVES: Establishing a high-value care (HVC) culture within an institution requires a multidisciplinary commitment and participation. Bedside rounds provide an ideal environment for role modeling and learning behaviors that promote an HVC culture. However, little is understood regarding the types of HVC discussions that take place at the bedside and who participates in those discussions. METHODS: A prospective observational study at a tertiary-care, university-affiliated, free-standing children's hospital. The prevalence of HVC discussions was captured by using the HVC Rounding Tool, a previously developed instrument with established validity evidence. For each observed HVC discussion, raters recorded who initiated the discussion and a description of the topic. RESULTS: Raters observed 660 patient encounters over 59 separate dates. Of all patient encounters, 29% (191 of 660; 95% confidence interval: 26%-33%) included at least 1 observed HVC discussion. The attending physician or fellow initiated 41% of all HVC discussions, followed by residents or medical students (31%), families (12%), and nurses (7%). CONCLUSIONS: Despite a recent focus on improving health care value and educating trainees in the practice of HVC, our study demonstrated that bedside discussions of HVC are occurring with a limited frequency at our institution and that attending physicians initiate the majority of discussions. The capacity of the nonphysician team members to contribute to establishing and sustaining an HVC culture may be underused. Multi-institutional studies are necessary to determine if this is a national trend and whether discussions have an impact on patient outcomes and hospital costs.

Outcomes of a Clinical Pathway to Standardize Use of Maintenance Intravenous Fluids.

OBJECTIVES: Improper use of maintenance intravenous fluids (IVFs) may cause serious hospital-acquired harm. We created an evidence-based clinical pathway to guide providers on the indications for IVF, its preferred composition, and appropriate clinical monitoring. METHODS: Pathway implementation was supported by the creation of an electronic order set (PowerPlan) and hospital-wide education. Outcomes were measured among pathway-eligible patients for the years before (July 1, 2014-June 30, 2015) and after (July 1, 2015-June 30, 2016) implementation. An interrupted time series analysis was used to evaluate monthly trends related to IVF use, including the following: median duration, proportions of isotonic and hypotonic IVF, adherence to monitoring recommendations, incidence of associated severe dysnatremia, potassium-containing IVF use in the emergency department, and costs. RESULTS: There were 11 602 pathway-eligible encounters (10 287 patients) across the study. Median IVF infusion hours did not change. Isotonic maintenance IVF use increased significantly from 9.3% to 50.6%, whereas the use of any hypotonic fluid decreased from 94.2% to 56.6%. There were significant increases in daily weight measurement and recommended serum sodium testing. Cases of dysnatremia increased from 2 to 4 among pathway-eligible patients and were mostly associated with hypotonic IVF use. Patients in the emergency department had a significant increase in the number of potassium-containing IVF bags (52.9% to 75.3%). Total hospitalization and laboratory test costs did not change significantly. CONCLUSIONS: This is the first report of outcomes of a clinical pathway to standardize IVF use. Implementation was feasible in both medical and surgical units, with sustained improvements for 1 year. Future improvement work includes increasing PowerPlan use and developing clinical assessment tools.

Modification of an Established Pediatric Asthma Pathway Improves Evidence-Based, Efficient Care.

OBJECTIVE: In September 2011, an established pediatric asthma pathway at a tertiary care children's hospital underwent significant revision. Modifications included simplification of the visual layout, addition of evidence-based recommendations regarding medication use, and implementation of standardized admission criteria. The objective of this study was to determine the impact of the modified asthma pathway on pathway adherence, percentage of patients receiving evidence-based care, length of stay, and cost. METHODS: Cases were identified by using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Data were analyzed for 24 months before and after pathway modification. Statistical process control was used to examine changes in processes of care, and interrupted time series was used to examine outcome measures, including length of stay and cost in the premodification and postmodification periods. RESULTS: A total of 5584 patients were included (2928 premodification; 2656 postmodification). Pathway adherence was high (79%-88%) throughout the study period. The percentage of patients receiving evidence-based care improved after pathway modification, and the results were sustained for 2 years. There was also improved efficiency, with a 30-minute (10%) decrease in emergency department length of stay for patients admitted with asthma (P = .006). There was a nominal (<10%) increase in costs of asthma care for patients in the emergency department (P = .04) and no change for those admitted to the hospital. CONCLUSIONS: Modification of an existing pediatric asthma pathway led to sustained improvement in provision of evidence-based care and patient flow without adversely affecting costs. Our results suggest that continuous re-evaluation of established clinical pathways can lead to changes in provider practices and improvements in patient care.

Resource utilization after implementing a hospital-wide standardized feeding tube placement pathway.

BACKGROUND/PURPOSE: Children requiring gastrostomy/gastrojejunostomy tubes (GT/GJ) are heterogeneous and medically complex patients with high resource utilization. We created and implemented a hospital-wide standardized pathway for feeding device placement. This study compares hospital resource utilization before and after pathway implementation. METHODS: We performed a retrospective cohort study comparing outcomes through one year of follow-up for consecutive groups of children undergoing GT/GJ placement prepathway (n=298, 1/1/2010-12/31/2011) and postpathway (n=140, 6/1/2013-7/31/2014) implementation. We determined the change in the rate of hospital resource utilization events and time to first event. RESULTS: Prior to implementation, 145 (48.7%) devices were placed surgically, 113 (37.9%) endoscopically and 40 (13.4%) using image guidance. After implementation, 102 (72.9%) were placed surgically, 23 (16.4%) endoscopically and 15 (10.7%) using image guidance. Prior to implementation, 174/298 (58.4%) patients required additional hospital resource utilization compared to 60/143 (42.0%) corresponding to a multivariate adjusted 38% reduced risk of a subsequent feeding tube related event. CONCLUSIONS: Care of tube-feeding dependent patients is spread among multiple specialists leading to variability in the preoperative workup, intraoperative technique and postoperative care. Our study shows an association between implementation of a standardized pathway and a decrease in hospital resource utilization.

Hypersensitivity to efavirenz treated with corticosteroids in a 6-year-old child.

We report a case of the successful use of corticosteroids to treat hypersensitivity caused by efavirenz in a pediatric patient. A 6-year-old HIV-infected patient developed a diffuse erythematous rash and fever after being switched to a regimen containing efavirenz. Use of prednisone at a dose of 1 mg/kg every other day for 2 weeks on rechallenge resulted in successful reinstitution of the regimen.