Scaling-up social needs screening in practice: a retrospective, cross-sectional analysis of data from electronic health records from Bronx county, New York, USA.

OBJECTIVES: There has been renewed focus on health systems integrating social care to improve health outcomes with relatively less related research focusing on 'real-world' practice. This study describes a health system's experience from 2018 to 2020, following the successful pilot in 2017, to scale social needs screening of patients within a large urban primary care ambulatory network. SETTING: Academic medical centre with an ambulatory network of 18 primary care practices located in an urban county in New York City (USA). PARTICIPANTS: This retrospective, cross-sectional study used electronic health records of 244 764 patients who had a clinical visit between 10 April 2018 and 8 December 2019 across any one of 18 primary care practices. METHODS: We organised measures using the RE-AIM framework domains of reach and adoption to ascertain the number of patients who were screened and the number of providers who adopted screening and associated documentation, respectively. We used descriptive statistics to summarise factors comparing patients screened versus those not screened, the prevalence of social needs screening and adoption across 18 practices. RESULTS: Between April 2018 and December 2019, 53 093 patients were screened for social needs, representing approximately 21.7% of the patients seen. Almost one-fifth (19.6%) of patients reported at least one unmet social need. The percentage of screened patients varied by both practice location (range 1.6%-81.6%) and specialty within practices. 51.8% of providers (n=1316) screened at least one patient. CONCLUSIONS: These findings demonstrate both the potential and challenges of integrating social care in practice. We observed significant variability in uptake across the health system. More research is needed to better understand factors driving adoption and may include harmonising workflows, establishing unified targets and using data to drive improvement.

Costs of ambulatory pediatric healthcare-associated infections: Central-line-associated bloodstream infection (CLABSIs), catheter-associated urinary tract infection (CAUTIs), and surgical site infections (SSIs).

OBJECTIVE: Ambulatory healthcare-associated infections (HAIs) occur frequently in children and are associated with morbidity. Less is known about ambulatory HAI costs. This study estimated additional costs associated with pediatric ambulatory central-line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTI), and surgical site infections (SSIs) following ambulatory surgery. DESIGN: Retrospective case-control study. SETTING: Four academic medical centers. PATIENTS: Children aged 0-22 years seen between 2010 and 2015 and at risk for HAI as identified by electronic queries. METHODS: Chart review adjudicated HAIs. Charges were obtained for patients with HAIs and matched controls 30 days before HAI, on the day of, and 30 days after HAI. Charges were converted to costs and 2015 USD. Mixed-effects linear regression was used to estimate the difference-in-differences of HAI case versus control costs in 2 models: unrecorded charge values considered missing and a sensitivity analysis with unrecorded charge considered $0. RESULTS: Our search identified 177 patients with ambulatory CLABSIs, 53 with ambulatory CAUTIs, and 26 with SSIs following ambulatory surgery who were matched with 382, 110, and 75 controls, respectively. Additional cost associated with an ambulatory CLABSI was $5,684 (95% confidence interval [CI], $1,005-$10,362) and $6,502 (95% CI, $2,261-$10,744) in the 2 models; cost associated with a CAUTI was $6,660 (95% CI, $1,055, $12,145) and $2,661 (95% CI, -$431 to $5,753); cost associated with an SSI following ambulatory surgery at 1 institution only was $6,370 (95% CI, $4,022-$8,719). CONCLUSIONS: Ambulatory HAI in pediatric patients are associated with significant additional costs. Further work is needed to reduce ambulatory HAIs.

Integrating Social Needs Screening and Community Health Workers in Primary Care: The Community Linkage to Care Program.

Clinic-based social needs screening has been associated with increased access to social services and improved health outcomes. Using a pragmatic study design in an urban pediatric practice, we used logistic regression to identify factors associated with successful social service uptake. From December 2017 to November 2018, 4948 households were screened for social needs, and 20% self-reported at least one. Of the 287 households with unmet needs who were referred and interested in further assistance, 43% reported successful social service uptake. Greater than 4 outreach encounters (adjusted odds ratio = 1.92; 95% confidence interval = 1.06-3.49) and follow-up time >30 days (adjusted odds ratio = 0.43; 95% confidence interval = 0.25-0.73) were significantly associated with successful referrals. These findings have implementation implications for programs aiming to address social needs in practice. Less than half of households reported successful referrals, which suggests the need for additional research and an opportunity for further program optimization.

The design and conduct of Project RedDE: A cluster-randomized trial to reduce diagnostic errors in pediatric primary care.

BACKGROUND: Diagnostic errors contribute to the large burden of healthcare-associated harm experienced by children. Primary care settings involve high diagnostic uncertainty and limited time and information, creating ideal conditions for diagnostic errors. We report on the design and conduct of Project RedDE, a stepped-wedge, cluster-randomized controlled trial of a virtual quality improvement collaborative aimed at reducing diagnostic errors in pediatric primary care. METHODS: Project RedDE cluster-randomized pediatric primary care practices into one of three groups. Each group participated in a quality improvement collaborative targeting the same three diagnostic errors (missed diagnoses of elevated blood pressure and adolescent depression and delayed diagnoses of abnormal laboratory studies), but in a different sequence. During the quality improvement collaborative, practices worked both independently and collaboratively, leveraging general quality improvement strategies (e.g. process mapping) in addition to error-specific content (e.g. pocket guides for blood pressure norms) delivered during the intervention phase for each error. The quality improvement collaborative intervention included interactive learning sessions and webinars, quality improvement coaching at the team level, and repeated evaluation of failures via root cause analyses. Pragmatic data were collected monthly, submitted to a centralized data aggregator, and returned to the practices in the form of run charts comparing each practice's progress over time to that of the group. The primary analysis used patients as the unit of analysis and compared diagnostic error proportions between the intervention and baseline periods, while secondary analyses evaluated the sustainability of observed reductions in diagnostic errors after the intervention period ended. RESULTS: A total of 43 practices were recruited and randomized into Project RedDE. Eleven practices withdrew before submitting any data, and one practice merged with another participating practice, leaving 31 practices that began work on Project RedDE. All but one of the diverse, national pediatric primary care practices that participated ultimately submitted complete data. Quality improvement collaborative participation was robust, with an average of 63% of practices present on quality improvement collaborative webinars and 85% of practices present for quality improvement collaborative learning sessions. Complete data included 30 months of outcome data for the first diagnostic error worked on, 24 months of outcome data for the second, and 16 months of data for the third. LESSONS LEARNED AND LIMITATIONS: Contamination across study groups was a recurring concern; concerted efforts were made to mitigate this risk. Electronic health records played a large role in teams' success. CONCLUSION: Project RedDE, a virtual quality improvement collaborative aimed at reducing diagnostic errors in pediatric primary care, successfully recruited and retained a diverse, national group of pediatric primary care practices. The stepped-wedge, cluster-randomized controlled trial design allowed for enhanced scientific efficiency.

Epidemiology of and Risk Factors for Harmful Anti-Infective Medication Errors in a Pediatric Hospital.

BACKGROUND: Literature is limited on pediatric anti-infective medication errors. There is a pressing need for additional research, as studies suggest high rates of overall pediatric medication errors and known harmful side effect profiles for anti-infective medications with narrow dosing ranges. This study aimed to identify risk factors related to harmful anti-infective medication errors in pediatric patients. METHODS: A retrospective chart review of all voluntary error reports involving anti-infective medication errors and pediatric patients (0 to < 22 years old) reported June 2014-December 2015 was conducted. Error reports were generated using the hospital's general error reporting system and a pharmacy-based patient surveillance reporting system and were stratified based on the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Medication Error Index. Harmful errors were compared to nonharmful errors using Fisher's exact test. RESULTS: Of 338 anti-infective medication-related error reports, 13.6% of voluntarily reported errors reached the patient and 1.5% resulted in harm to the patient and required additional monitoring, interventions, and/or prolonged hospitalization. Antibacterials comprised 93.8% of all error reports, with beta-lactams (63.0%), macrolides (6.5%) and glycopeptides (6.2%) the most common classes. When using Fisher's exact test to compare harmful and nonharmful medication errors, the risk factor significantly associated with harmful errors was anti-infective class (p = 0.001). CONCLUSION: Voluntarily reported anti-infective medication errors within the pediatric patient population often reached the patient, and specific anti-infective medications are potentially of higher risk. Further investigation and additional quality and patient safety strategies may be needed for these higher-risk profile medications.

Pediatric Type 1 Diabetes: Reducing Admission Rates for Diabetes Ketoacidosis.

BACKGROUND: Diabetes ketoacidosis (DKA) is a life-threatening complication of type 1 diabetes mellitus (T1DM). Reducing DKA admissions in children with T1DM requires a coordinated, comprehensive management plan. We aimed to decrease DKA admissions, 30-day readmissions, and length of stay (LOS) for DKA admissions. METHODS: A multipronged intervention was designed in 2011 to reach all patients: (1) increase insulin pump use and basal-bolus regimen versus sliding scales, (2) transform educational program, (3) increased access to medical providers, and (4) support for patients and families. A before-after study was conducted comparing performance outcomes in years 2007-2010 (preintervention) to 2012-2014 (postintervention) using administrative data and Wilcoxon rank sum and Fischer exact tests. RESULTS: DKA admissions decreased by 44% postintervention (16.7 vs 9.3 per 100 followed patient-years; P = .006), unique patient 30-day readmissions decreased from 20% to 5% postintervention (P = .001), and median LOS significantly decreased postintervention (P < .0001). Although not an original goal of the study, median hemoglobin A1C of a subset of the population transitioned from sliding scale decreased, 10.3% to 8.9% (P < .02). CONCLUSIONS: When clinical and widespread program interventions were used, significant reductions in DKA hospitalizations, 30-day readmissions, and LOS occurred for pediatric T1DM. Continuous performance improvement efforts are needed for improving DKA outcomes.

The Armstrong Institute Resident/Fellow Scholars: A Multispecialty Curriculum to Train Future Leaders in Patient Safety and Quality Improvement.

The objective was to determine if a year-long, multispecialty resident and fellow quality improvement (QI) curriculum is feasible and leads to improvements in QI beliefs and self-reported behaviors. The Armstrong Institute Resident/Fellow Scholars (AIRS) curriculum incorporated (a) a 2-day workshop in lean sigma methodology, (b) year-long interactive weekly small-group lectures, (c) mentored QI projects, and (d) practicum-based components to observe frontline QI efforts. Pre-post evaluation was performed with the Quality Improvement Knowledge Application Tool (QIKAT) and the Systems Thinking Scale (STS) using the Wilcoxon matched-pairs signed-rank test. Sixteen residents and fellows started the AIRS curriculum and 14 finished. Scholars' pre and post mean scores significantly improved: STS 3.06 pre versus 3.60 post (P < .01) and QIKAT 1.24 pre versus 2.46 post (P < .01). Most scholars (92%) agreed that skills learned in the curriculum will help in their future careers. A multispecialty QI curriculum for trainees is feasible and increases QI beliefs and self-reported behaviors.

State-Mandated Hospital Infection Reporting Is Not Associated With Decreased Pediatric Health Care-Associated Infections.

OBJECTIVES: State governments increasingly mandate public reporting of central line-associated blood stream infections (CLABSIs). This study tests if hospitals located in states with state-mandated, facility-identified, pediatric-specific public CLABSI reporting have lower rates of CLABSIs as defined by the Agency for Healthcare Research and Quality's Pediatric Quality Indicator 12 (PDI12). METHODS: Utilizing the Kids' Inpatient Databases from 2000 to 2009, we compared changes in PDI12 rates across three groups of states: states with public CLABSI reporting begun by 2006, states with public reporting begun by 2009 and never-reporting states. In the baseline period (2000-2003), no states mandated public CLABSI reporting. A multivariable, hospital-level random intercept, logistic regression was performed comparing changes in PDI12 rates in states with public reporting to changes in PDI12 rates in never-reporting states. RESULTS: 4,705,857 discharge records were eligible for PDI12. PDI12 rates significantly decreased in all reporting groups, comparing baseline to the post-public reporting period (2009): Never Reporters 88% decrease (95% CI, 86%-89%), Reporting Begun by 2006 90% decrease (95% CI, 83%-94%), and Reporting Begun by 2009 74% decrease (95% CI, 72%-76%). The Never Reporting Group had comparable decreases in PDI12 rates to the Reporting Begun by 2006 group (P = 0.4) and significantly larger decreases in PDI12 rates compared to the Reporting Begun by 2009 group (P < 0.001), despite having no states with public reporting. CONCLUSIONS: Public CLABSI reporting alone appears to be insufficient to affect administrative data-based measures of pediatric CLABSI rates or children may be inadequately targeted in current public reporting efforts.

Interventions to reduce pediatric medication errors: a systematic review.

BACKGROUND AND OBJECTIVE: Medication errors cause appreciable morbidity and mortality in children. The objective was to determine the effectiveness of interventions to reduce pediatric medication errors, identify gaps in the literature, and perform meta-analyses on comparable studies. METHODS: Relevant studies were identified from searches of PubMed, Embase, Scopus, Web of Science, the Cochrane Library, and the Cumulative Index to Nursing Allied Health Literature and previous systematic reviews. Inclusion criteria were peer-reviewed original data in any language testing an intervention to reduce medication errors in children. Abstract and full-text article review were conducted by 2 independent authors with sequential data extraction. RESULTS: A total of 274 full-text articles were reviewed and 63 were included. Only 1% of studies were conducted at community hospitals, 11% were conducted in ambulatory populations, 10% reported preventable adverse drug events, 10% examined administering errors, 3% examined dispensing errors, and none reported cost-effectiveness data, suggesting persistent research gaps. Variation existed in the methods, definitions, outcomes, and rate denominators for all studies; and many showed an appreciable risk of bias. Although 26 studies (41%) involved computerized provider order entry, a meta-analysis was not performed because of methodologic heterogeneity. Studies of computerized provider order entry with clinical decision support compared with studies without clinical decision support reported a 36% to 87% reduction in prescribing errors; studies of preprinted order sheets revealed a 27% to 82% reduction in prescribing errors. CONCLUSIONS: Pediatric medication errors can be reduced, although our understanding of optimal interventions remains hampered. Research should focus on understudied areas, use standardized definitions and outcomes, and evaluate cost-effectiveness.

Operation care: a pilot case management intervention for frequent emergency medical system users.

OBJECTIVES: This study aims to determine if a prehospital case management intervention reduces transport and nontransport emergency medical system (EMS) responses to frequent EMS users. METHODS: The 25 most frequent EMS users in a major metropolitan area were identified, and 10 were enrolled in the intervention. These patients received linkage to psychosocial and medical resources through weekly case management visits for 5 to 12 weeks between May and August 2008. Main outcome measures were the number of transport and nontransport EMS responses to patients during the intervention as compared with predicted EMS responses based on each patient's previous year's EMS use. Transport data were available for all patients, but nontransport data were unavailable for 1 patient who was homeless and 6 patients living in apartment buildings. Secondary outcome measures included cost savings to the entire health care system and the Baltimore City Fire Department. RESULTS: Transport responses decreased 32% over the 76 predicted transport responses during the intervention, and nontransport responses decreased 79% over the 24 predicted nontransport responses during the intervention. Including the dedicated case manager's salary, this represented a cost savings to the entire health care system and to the Baltimore City Fire Department of $14 461 and $6311, respectively, over 12 weeks. CONCLUSIONS: Prehospital case management may reduce EMS use in high-frequency EMS users and create significant cost savings to municipalities and the health care system. Additional large-scale studies are needed to validate these findings.

Medication errors in paediatric care: a systematic review of epidemiology and an evaluation of evidence supporting reduction strategy recommendations.

BACKGROUND: Although children are at the greatest risk for medication errors, little is known about the overall epidemiology of these errors, where the gaps are in our knowledge, and to what extent national medication error reduction strategies focus on children. OBJECTIVE: To synthesise peer reviewed knowledge on children's medication errors and on recommendations to improve paediatric medication safety by a systematic literature review. DATA SOURCES: PubMed, Embase and Cinahl from 1 January 2000 to 30 April 2005, and 11 national entities that have disseminated recommendations to improve medication safety. STUDY SELECTION: Inclusion criteria were peer reviewed original data in English language. Studies that did not separately report paediatric data were excluded. DATA EXTRACTION: Two reviewers screened articles for eligibility and for data extraction, and screened all national medication error reduction strategies for relevance to children. DATA SYNTHESIS: From 358 articles identified, 31 were included for data extraction. The definition of medication error was non-uniform across the studies. Dispensing and administering errors were the most poorly and non-uniformly evaluated. Overall, the distributional epidemiological estimates of the relative percentages of paediatric error types were: prescribing 3-37%, dispensing 5-58%, administering 72-75%, and documentation 17-21%. 26 unique recommendations for strategies to reduce medication errors were identified; none were based on paediatric evidence. CONCLUSIONS: Medication errors occur across the entire spectrum of prescribing, dispensing, and administering, are common, and have a myriad of non-evidence based potential reduction strategies. Further research in this area needs a firmer standardisation for items such as dose ranges and definitions of medication errors, broader scope beyond inpatient prescribing errors, and prioritisation of implementation of medication error reduction strategies.