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.

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.

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.

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.

"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.

The correlation and level of agreement between end-tidal and blood gas pCO2 in children with respiratory distress: a retrospective analysis.

BACKGROUND: To investigate the correlation and level of agreement between end-tidal carbon dioxide (EtCO2) and blood gas pCO2 in non-intubated children with moderate to severe respiratory distress. METHODS: Retrospective study of patients admitted to an intermediate care unit (InCU) at a tertiary care center over a 20-month period with moderate to severe respiratory distress secondary to asthma, bronchiolitis, or pneumonia. Patients with venous pCO2 (vpCO2) and EtCO2 measurements within 10 minutes of each other were eligible for inclusion. Patients with cardiac disease, chronic pulmonary disease, poor tissue perfusion, or metabolic abnormalities were excluded. RESULTS: Eighty EtCO2-vpCO2 paired values were available from 62 patients. The mean +/- SD for EtCO2 and vpCO2 was 35.7 +/- 10.1 mmHg and 39.4 +/- 10.9 mmHg respectively. EtCO2 and vpCO2 values were highly correlated (r = 0.90, p < 0.0001). The correlations for asthma, bronchiolitis and pneumonia were 0.74 (p < 0.0001), 0.83 (p = 0.0002) and 0.98 (p < 0.0001) respectively. The mean bias +/- SD between EtCO2 and vpCO2 was -3.68 +/- 4.70 mmHg. The 95% level of agreement ranged from -12.88 to +5.53 mmHg. EtCO2 was found to be more accurate when vpCO2 was 35 mmHg or lower. CONCLUSION: EtCO2 is correlated highly with vpCO2 in non-intubated pediatric patients with moderate to severe respiratory distress across respiratory illnesses. Although the level of agreement between the two methods precludes the overall replacement of blood gas evaluation, EtCO2 monitoring remains a useful, continuous, non-invasive measure in the management of non-intubated children with moderate to severe respiratory distress.

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.

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.

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.

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.

Improving the Management of Vaso-Occlusive Episodes in the Pediatric Emergency Department.

OBJECTIVES: Vaso-occlusive episodes (VOEs) account for the majority of emergency department (ED) visits for children with sickle cell disease (SCD). We hypothesized that addressing key barriers to VOE care would improve receipt of analgesics and outcomes. METHODS: A quality improvement (QI) initiative was conducted from September 2010 to April 2014 to streamline VOE care in an urban pediatric ED. Four interventions were used: a standardized time-specific VOE protocol; intranasal fentanyl as the first parenteral pain medication; an SCD pain medication calculator; and provider and patient/family education. Data were collected for 3 outcome measures (mean time from triage to first parenteral opioid and admission/discharge decision, and proportion discharged from the ED); 1 process measure (mean time from triage to initiation of patient-controlled analgesia); and 4 balancing measures (mean time from triage to second intravenous opioid dose, 24-hour ED readmission, respiratory depression, and length of stay). RESULTS: There were 289 ED visits in the study period. Improvements were seen in mean time to: first dose of parenteral opioid (56 to 23 minutes); second opiate intravenous dose (106 to 83 minutes); admission and discharge decisions (163 to 109 minutes and 271 to 178 minutes, respectively); and initiation of patient-controlled analgesia (216 to 141 minutes). The proportion discharged from the ED increased from 32% to 48% (χ(2) = 6.5402, P = .01). No increase in 24-hour readmission, respiratory depression, or inpatient length of stay was observed. CONCLUSIONS: Using VOE-specific interventions, we significantly improved VOE care for children. Studies are needed to determine if these results can be replicated.

Quality improvement educational practices in pediatric residency programs: survey of pediatric program directors.

BACKGROUND: The Accreditation Council for Graduate Medical Education requires residents to learn quality improvement (QI) methods to analyze, change, and improve their practice. Little is known about how pediatric residency programs design, implement, and evaluate QI curricula to achieve this goal. We sought to describe current QI educational practices, evaluation methods, and program director perceptions through a national survey. METHODS: A survey of QI curricula was developed, pilot tested, approved by the Association of Pediatric Program Directors (APPD), and distributed to pediatric program directors. Descriptive statistics were used to analyze the data. RESULTS: The response rate was 53% (104 of 197). Most respondents reported presence of a QI curriculum (85%, 88 of 104), including didactic sessions (83%) and resident QI projects (88%). Continuous process improvement was the most common methodology addressed (65%). The most frequent topics taught were "Making a Case for QI" (68%), "PDSA [plan-do-study-act] Cycles" (66%), and "Measurement in QI" (60%). Projects were most frequently designed to improve clinical care (90%), hospital operations (65%), and the residency (61%). Only 35% evaluated patient outcomes, and 17% had no formal evaluation. Programs had a mean of 6 faculty members (standard deviation 4.4, range 2-20) involved in teaching residents QI. Programs with more faculty involved were more likely to have had a resident submit an abstract to a professional meeting about their QI project (<5 faculty, 38%; 5-9, 64%; >9, 92%; P = .003). Barriers to teaching QI included time (66%), funding constraints (39%), and absent local QI expertise (33%). Most PPDs (65%) believed that resident input in hospital QI was important, but only 24% reported resident involvement. Critical factors for success included an experiential component (56%) and faculty with QI expertise (50%). CONCLUSIONS: QI curricular practices vary greatly across pediatric residency programs. Although pediatric residency programs commit a fair number of resources to QI education and believe that resident involvement in QI is important, fundamental QI topics are overlooked in many programs, and evaluation of existing curricula is limited. Success as perceived by pediatric program directors appears to be related to the inclusion of a QI project and the availability of faculty mentors.

Pediatric resident education in quality improvement (QI): a national survey.

OBJECTIVE: To assess pediatric residents' perceptions of their quality improvement (QI) education and training, including factors that facilitate learning QI and self-efficacy in QI activities. METHODS: A 22-question survey questionnaire was developed with expert-identified key topics and iterative pretesting of questions. Third-year pediatric residents from 45 residency programs recruited from a random sample of 120 programs. Data were analyzed by descriptive statistics, chi-square tests, and qualitative content analysis. RESULTS: Respondents included 331 residents for a response rate of 47%. Demographic characteristics resembled the national profile of pediatric residents. Over 70% of residents reported that their QI training was well organized and met their needs. Three quarters felt ready to use QI methods in practice. Those with QI training before residency were significantly more confident than those without prior QI training. However, fewer than half of respondents used standard QI methods such as PDSA cycles and run charts in projects. Residents identified faculty support, a structured curriculum, hands-on projects, and dedicated project time as key strengths of their QI educational experiences. A strong QI culture was also considered important, and was reported to be present in most programs sampled. CONCLUSIONS: Overall, third-year pediatric residents reported positive QI educational experiences with strong faculty support and sufficient time for QI projects. However, a third of residents thought that the QI curricula in their programs needed improvement, and a quarter lacked self-efficacy in conducting future QI activities. Continuing curricular improvement, including faculty development, is warranted.

Lyme disease presenting with persistent headache.

Increased intracranial pressure in patients with Lyme disease is an uncommon but reported finding. We discuss 2 patients from Lyme endemic areas who initially presented with headache, nausea, and vomiting and were eventually found to have increased intracranial pressure, a mild cerebrospinal fluid pleocytosis, and positive Lyme titers. It has been shown that increased intracranial pressure in association with neuroborreliosis can lead to blindness. In endemic areas, it is important for practitioners to consider Lyme disease when patients present with persistent headache, especially in those who have evidence of increased intracranial pressure.