Improving Head CT Scan Decisions for Pediatric Minor Head Trauma in General Emergency Departments: A Pragmatic Implementation Study.

STUDY OBJECTIVE: To measure the effectiveness of a multimodal strategy, including simultaneous implementation of a clinical decision support system, to sustain adherence to a clinical pathway for care of children with minor head trauma treated in general emergency departments (EDs). METHODS: Prospective, type III hybrid effectiveness-implementation cohort study with a nonrandomized stepped-wedge design and monthly repeated site measures. The study population included pediatric minor head trauma encounters from July 2018 to December 2020 at 21 urban and rural general ED sites in an integrated health care system. Sites received the intervention in 1 of 2 steps, with each site providing control and intervention observations. Measures included guideline adherence, the computed tomography (CT) scan rate, and 72-hour readmissions with clinically important traumatic brain injury. Analysis was performed using multilevel hierarchical modeling with random intercepts for the site and physician. RESULTS: During the study, 12,670 pediatric minor head trauma encounters were cared for by 339 clinicians. The implementation of the clinical pathway resulted in higher odds of guideline adherence (adjusted odds ratio 1.12 [95% confidence interval 1.03 to 1.22]) and lower odds of a CT scan (adjusted odds ratio 0.96 [95% confidence interval 0.93 to 0.98]) in intervention versus control months. Absolute risk difference was observed in both guideline adherence (site median: +2.3% improvement) and the CT scan rate (site median: -6.6% reduction). No 72-hour readmissions with confirmed clinically important traumatic brain injury were identified. CONCLUSION: Implementation of a minor head trauma clinical pathway using a multimodal approach, including a clinical decision support system, led to sustained improvements in adherence and a modest, yet safe, reduction in CT scans among generally low-risk patients in diverse general EDs.

Children's hospital quality ratings: where are we and can we do better?

OBJECTIVE: Hospital quality ratings are intended to guide patients and payers to the highest quality hospitals. Their success in achieving this goal has been limited by inconsistencies between ratings and questionable data collection methods. Despite these shortcomings, their popularity and importance are increasing. The purpose of this review is to identify the strengths and weaknesses of the US News and World Report (USNWR) Best Children's Hospitals Report and Leapfrog Pediatric Care Survey and discuss improvement opportunities. METHODS: A structured literature review was performed analyzing hospital quality surveys. Previously published criteria were used to compare the USNWR Best Children's Hospitals Report and Leapfrog Pediatric Care Survey. RESULTS: This narrative review highlights the strengths and weakness of both the USNWR Best Children's Hospitals Report and the Leapfrog Pediatric Care Survey, including a letter grade comparison. CONCLUSION: Existing children's hospital rating systems are lacking. We suggest specific improvements that may better enable these reports to influence the quality of pediatric care.

Ratings of Physician Communication by Caregivers of Hospitalized Children With and Without Autism.

BACKGROUND AND OBJECTIVES: To investigate caregivers' perceptions of physician communication and hospital ratings for hospitalized children with and without autism and assess associations between perceived quality of physician communication and overall ratings of the hospital. METHODS: We studied survey data from caregivers of 543 patients with autism compared with a 2:1 matched control sample of 1086 patients with similar characteristics but without autism from a single children's hospital. We analyzed survey items related to physician communication and hospital ratings from the Consumer Assessment of Healthcare Physicians and Systems Child Hospital Survey. We constructed multivariable regression models to examine the relationship between caregiver-perceived physician communication and caregivers' overall ratings of the hospital. RESULTS: A similar proportion of caregivers of children with and without autism reported that doctors "always" listened carefully to them (71.4% vs 74.3%; adjusted prevalence ratio 0.96; 95% confidence interval 0.90-1.03) and "always" treated them with respect (80.0% vs 84.1%; adjusted prevalence ratio 0.95; 95% confidence interval 0.90-1.00). Caregivers of children with autism were less likely to "definitely" recommend the hospital (87.0% vs 92.3%; adjusted prevalence ratio 0.94; 95% confidence interval 0.91-0.98). All items related to caregiver-perceived physician communication were associated with the highest hospital rating and the highest recommendation of the hospital in both groups. CONCLUSIONS: When matched on the basis of medical and social factors, caregivers of children with and without autism reported similar frequencies of highest-quality physician communication. Improvement of physician communication with caregivers of medically and socially complex children with and without autism may improve caregivers' overall ratings of the hospital.