Changes in medical errors after implementation of a handoff program.

BACKGROUND: Miscommunications are a leading cause of serious medical errors. Data from multicenter studies assessing programs designed to improve handoff of information about patient care are lacking. METHODS: We conducted a prospective intervention study of a resident handoff-improvement program in nine hospitals, measuring rates of medical errors, preventable adverse events, and miscommunications, as well as resident workflow. The intervention included a mnemonic to standardize oral and written handoffs, handoff and communication training, a faculty development and observation program, and a sustainability campaign. Error rates were measured through active surveillance. Handoffs were assessed by means of evaluation of printed handoff documents and audio recordings. Workflow was assessed through time-motion observations. The primary outcome had two components: medical errors and preventable adverse events. RESULTS: In 10,740 patient admissions, the medical-error rate decreased by 23% from the preintervention period to the postintervention period (24.5 vs. 18.8 per 100 admissions, P<0.001), and the rate of preventable adverse events decreased by 30% (4.7 vs. 3.3 events per 100 admissions, P<0.001). The rate of nonpreventable adverse events did not change significantly (3.0 and 2.8 events per 100 admissions, P=0.79). Site-level analyses showed significant error reductions at six of nine sites. Across sites, significant increases were observed in the inclusion of all prespecified key elements in written documents and oral communication during handoff (nine written and five oral elements; P<0.001 for all 14 comparisons). There were no significant changes from the preintervention period to the postintervention period in the duration of oral handoffs (2.4 and 2.5 minutes per patient, respectively; P=0.55) or in resident workflow, including patient-family contact and computer time. CONCLUSIONS: Implementation of the handoff program was associated with reductions in medical errors and in preventable adverse events and with improvements in communication, without a negative effect on workflow. (Funded by the Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, and others.).

Testing a post-discharge nurse-led transitional home visit in acute care pediatrics: the Hospital-To-Home Outcomes (H2O) study protocol.

AIMS: The aims of this study were: (1) to explore the family perspective on pediatric hospital-to-home transitions; (2) to modify an existing nurse-delivered transitional home visit to better meet family needs; (3) to study the effectiveness of the modified visit for reducing healthcare re-use and improving patient- and family-centered outcomes in a randomized controlled trial. BACKGROUND: The transition from impatient hospitalization to outpatient care is a vulnerable time for children and their families; children are at risk for poor outcomes that may be mitigated by interventions to address transition difficulties. It is unknown if an effective adult transition intervention, a nurse home visit, improves postdischarge outcomes for children hospitalized with common conditions. DESIGN: (1) Descriptive qualitative; (2) Quality improvement; (3) Randomized controlled trial. METHODS: Aim 1 will use qualitative methods, through focus groups, to understand the family perspective of hospital-to-home transitions. Aim 2 will use quality improvement methods to modify the content and processes associated with nurse home visits. Modifications to visits will be made based on parent and stakeholder input obtained during Aims 1 & 2. The effectiveness of the modified visit will be evaluated in Aim 3 through a randomized controlled trial. DISCUSSION: We are undertaking the study to modify and evaluate a nurse home visit as an effective acute care pediatric transition intervention. We expect the results will be of interest to administrators, policy makers and clinicians interested in improving pediatric care transitions and associated postdischarge outcomes, in the light of impending bundled payment initiatives in pediatric care.

Reviewer Feedback for Abstract Submissions to the Pediatric Academic Societies Meeting: A Pilot Project.

PURPOSE: To describe and evaluate a pilot project to provide reviewer comments to authors who submitted abstracts to the Hospital-based medicine topic area for the Pediatric Academic Societies (PAS) 2021 annual meeting METHODS: Abstract reviewers were encouraged via email to include reviewer comments for authors in their abstract reviews. Unedited comments were emailed to authors shortly after the abstract decision notifications were sent. We quantified the number of reviewers who commented per abstract. Additionally, we surveyed authors and reviewers to evaluate the perceived impact of the pilot project. RESULTS: For 123 abstracts submitted to the Hospital-based medicine topic area, every abstract received comments from at least one reviewer, and a median (IQR) of 4 (3-5) reviewers commented per abstract. The response rates for the author and reviewer surveys were 61/114 (54%) and 54/84 (64%), respectively, and both groups of respondents generally favored the pilot program. The majority of authors (59%) made changes to their project based on the feedback provided and 96% reported that they would like to continue to receive reviewer feedback for future PAS abstract submissions. Reviewers reported spending a mean of 11 minutes reviewing each abstract. Most (85%) felt that they spent the same or slightly more (1%-25%) time reviewing than in prior years. Multiple open-ended comments were provided, largely positive. CONCLUSION: A pilot program to incorporate reviewer feedback into abstract decision notification for a large national research meeting was successful. This approach should be considered for future meetings to enhance this integral component of academic development.

Association Between Physician Risk Assessment, Hierarchical Condition Categories, and Utilization of Medical Services.

Hierarchical Condition Categories (HCCs) are a common risk adjustment tool that may support alignment of care management resources with the clinical needs of a population. The authors examined the association between HCC scores and physician-determined clinical risk (CR) scores, annual charges, and utilization of medical care. CR score was defined as the anticipated risk for "ED or a hospital admission" within the following year. For each of the top 50 high-risk patients identified by total HCC score, the patient's primary care physician (PCP) entered a CR score based on their judgement. A total of 128 PCPs entered scores on 6167 patients of all ages across 31 primary care practices in the Finger Lakes Region of New York. Multiple correlation between HCC scores and physician CR scores was 44.0% (P < 0.001); only 18.5% of PCPs had a correlation >60%. There was a positive association between CR score and charges (slope 19.7K; P < 0.001) and between HCC score and charges (slope 25.7K; P < 0.001). Both HCC and CR scores were positively correlated (P < 0.001) with medical/surgical admissions, emergency department (ED) visits, and utilization of advanced imaging. Across a broad range of patients, HCC scores had a moderate-to-weak correlation with physician-determined CR scores for patients' risk of an ED visit or hospital admission. Both CR scores and HCCs scores were positively associated with charges and utilization. HCCs may assist in the allocation of health resources, but the relatively weak correlation with physician-determined CR scores warrants caution.

A Quality Improvement Approach to Decreasing Postdischarge Acute Care Reuse Among Children With Asthma.

OBJECTIVES: To reduce 7-day acute care reuse among children with asthma after discharge from an academic children's hospital by standardizing the delivery of clinical care and patient education. METHODS: A diverse group of stakeholders from our tertiary care children's hospital and local community agencies used quality improvement methods to implement a series of interventions within inpatient, emergency department (ED), and outpatient settings. These interventions were designed to improve admission, inpatient care, and discharge processes for children hospitalized because of asthma and included a focus on (1) resident education, (2) patient access to medication and asthma education, and (3) gaps in existing asthma clinical care pathways in the ED and ICU. The primary outcome was the rate of 7-day acute care reuse (combined hospital readmissions and ED revisits) after discharge from an index hospitalization for asthma, measured through a monthly review of electronic health record data and compared with a 6-month baseline period of reuse data. RESULTS: The mean 7-day reuse rate for asthma after discharge was 3.7% during the 6 months baseline period (n = 107) and 1.0% during the 15-month intervention period (n = 302). This included a shift in our median from 3.3% to 0% with an 8-month period of no 7-day reuse. CONCLUSIONS: An interprofessional quality improvement team successfully achieved and sustained a 73% reduction in mean 7-day asthma-related acute care reuse after discharge by standardizing provider training, care processes, and patient education.

Caregiver Perspectives on Communication During Hospitalization at an Academic Pediatric Institution: A Qualitative Study.

OBJECTIVE: Communication among those involved in a child's care during hospitalization can mitigate or exacerbate family stress and confusion. As part of a broader qualitative study, we present an in-depth understanding of communication issues experienced by families during their child's hospitalization and during the transition to home. METHODS: Focus groups and individual interviews stratified by socioeconomic status included caregivers of children recently discharged from a children's hospital after acute illnesses. An open-ended, semistructured question guide designed by investigators included communication-related questions addressing information shared with families from the medical team about discharge, diagnoses, instructions, and care plans. By using an inductive thematic analysis, 4 investigators coded transcripts and resolved differences through consensus. RESULTS: A total of 61 caregivers across 11 focus groups and 4 individual interviews participated. Participants were 87% female and 46% non-white. Analyses resulted in 3 communication-related themes. The first theme detailed experiences affecting caregiver perceptions of communication between the inpatient medical team and families. The second revealed communication challenges related to the teaching hospital environment, including confusing messages associated with large multidisciplinary teams, aspects of family-centered rounds, and confusion about medical team member roles. The third reflected caregivers' perceptions of communication between providers in and out of the hospital, including types of communication caregivers observed or believed occurred between medical providers. CONCLUSIONS: Participating caregivers identified various communication concerns and challenges during their child's hospitalization and transition home. Caregiver perspectives can inform strategies to improve experiences, ease challenges inherent to a teaching hospital, and determine which types of communication are most effective.

Socioeconomic status influences the toll paediatric hospitalisations take on families: a qualitative study.

BACKGROUND: Stress caused by hospitalisations and transition periods can place patients at a heightened risk for adverse health outcomes. Additionally, hospitalisations and transitions to home may be experienced in different ways by families with different resources and support systems. Such differences may perpetuate postdischarge disparities. OBJECTIVE: We sought to determine, qualitatively, how the hospitalisation and transition experiences differed among families of varying socioeconomic status (SES). METHODS: Focus groups and individual interviews were held with caregivers of children recently discharged from a children's hospital. Sessions were stratified based on SES, determined by the percentage of individuals living below the federal poverty level in the census tract or neighbourhood in which the family lived. An open-ended, semistructured question guide was developed to assess the family's experience. Responses were systematically compared across two SES strata (tract poverty rate of <15% or ≥15%). RESULTS: A total of 61 caregivers who were 87% female and 46% non-white participated; 56% resided in census tracts with ≥15% of residents living in poverty (ie, low SES). Interrelated logistical (eg, disruption in-home life, ability to adhere to discharge instructions), emotional (eg, overwhelming and exhausting nature of the experience) and financial (eg, cost of transportation and meals, missed work) themes were identified. These themes, which were seen as key to the hospitalisation and transition experiences, were emphasised and described in qualitatively different ways across SES strata. CONCLUSIONS: Families of lower SES may experience challenges and stress from hospitalisations and transitions in different ways than those of higher SES. Care delivery models and discharge planning that account for such challenges could facilitate smoother transitions that prevent adverse events and reduce disparities in the postdischarge period. TRIAL REGISTRATION NUMBER: NCT02081846; Pre-results.

Optimizing a Nurse-led Transitional Home Visit Program in Preparation for a Randomized Control Trial.

INTRODUCTION: The Hospital to Home Outcomes study began with the end goal of evaluating the effectiveness of a single, nurse-led transitional home visit (home visit) program, for acutely ill, pediatric patients, which had been piloted at our institution. As part of the overall study design, building on prior randomized control trials that utilized a run-in period prior to the trial, our study team designed an optimization period to test the home visit and study procedures under real-world conditions. METHODS: For this optimization project, there were 3 process improvement goals: to improve the referral process to the home visit, to optimize the home visit content, and to define and operationalize measures of patient- and family-centered outcomes to be used in the subsequent randomized control trial. During the optimization period, a multidisciplinary study team met weekly to review family and stakeholder feedback about the iterative modifications made to the home visit process, content, and outcome measures. RESULTS: Optimization home visits were completed with 301 families across a variety of discharge diagnoses. The outcomes planned for the clinical trial were tested and refined. Feedback from families and stakeholders indicated that the content changes made to the home visits resulted in increased family knowledge of warning signs to monitor postdischarge. Thirty-one percent of families reported that they altered the care of their child after the home visit. CONCLUSION: Through iterative testing, informed by multistakeholder feedback, we leveraged patient and family engagement to maximize the effectiveness and generalizability of the home visit intervention.

Communication Challenges: A Qualitative Look at the Relationship Between Pediatric Hospitalists and Primary Care Providers.

OBJECTIVE: Primary care providers (PCPs) and hospitalists endorse the importance of effective communication yet studies illustrate critical communication problems between these 2 provider types. Our objective was to develop deeper insight into the dimensions of and underlying reasons for communication issues and determine ways to improve communication and remove barriers by eliciting the perspectives of pediatric PCPs and hospitalists. METHODS: Using qualitative methods, 2 sets of focus groups were held: 1) mix of local PCPs serving diverse populations, and 2) hospitalists from a free-standing, pediatric institution. The open-ended, semistructured question guides included questions about communication experiences, patient care responsibilities, and suggestions for improvement. Using inductive thematic analysis, investigators coded the transcripts, and resolved differences through consensus. RESULTS: Six PCP (n = 27) and 3 hospitalist (n = 15) focus groups were held. Fifty-six percent of PCPs and 14% of hospitalists had been practicing for >10 years. Five major themes were identified: problematic aspects of communication, perceptions of provider roles, push-pull, postdischarge responsibilities/care, and proposed solutions. Aspects of communication included specific problem areas with verbal and written communication. Perceptions of provider roles highlighted the issue of PCPs feeling devalued. Push-pull described conflicting expectations about a counterpart's role and responsibilities. Postdischarge responsibilities/care addressed unclear responsibilities related to patient follow-up. Proposed solutions were suggested for ways to improve communication. CONCLUSIONS: Deficiencies in communication hinder successful collaboration and can cause tension between providers in inpatient and outpatient settings. Understanding specific issues that contribute to poor communication like perceptions about provider roles is critical to improving relationships and facilitating combined efforts to improve patient care.

The Family Perspective on Hospital to Home Transitions: A Qualitative Study.

BACKGROUND AND OBJECTIVE: Transitions from the hospital to home can be difficult for patients and families. Family-informed characterization of this vulnerable period may facilitate the identification of interventions to improve transitions home. Our objective was to develop a comprehensive understanding of hospital-to-home transitions from the family perspective. METHODS: Using qualitative methods, focus groups and individual interviews were held with caregivers of children discharged from the hospital in the preceding 30 days. Focus groups were stratified based upon socioeconomic status. The open-ended, semistructured question guide included questions about communication and understanding of care plans, transition home, and postdischarge events. Using inductive thematic analysis, investigators coded the transcripts, resolving differences through consensus. RESULTS: Sixty-one caregivers participated across 11 focus groups and 4 individual interviews. Participants were 87% female and 46% nonwhite; 38% were the only adult in their household, and 56% resided in census tracts with ≥15% of residents living in poverty. Responses from participants yielded a conceptual model depicting key elements of families' experiences with hospital-to-home transitions. Four main concepts resulted: (1) "In a fog" (barriers to processing and acting on information), (2) "What I wish I had" (desired information and suggestions for improvement), (3) "Am I ready to go home?" (discharge readiness), and (4) "I'm home, now what?" (confidence and postdischarge care). CONCLUSIONS: Transitions from hospital to home affect the lives of families in ways that may affect patient outcomes postdischarge. The caregiver is key to successful transitions, and the family perspective can inform interventions that support families and facilitate an easier re-entry to the home.

Multidisciplinary handoffs improve perceptions of communication.

BACKGROUND: Communication errors during handoffs are a leading cause of sentinel events. The Accreditation Council for Graduate Medical Education 2011 duty hour standards (DHS) increase the frequency of handoffs. OBJECTIVE: The goal of this study was to determine if a multidisciplinary group handoff bundle improves communication while working within the 2011 DHS. METHODS: During 1-month pilot programs of the 2011 DHS, 2 groups were observed. Group A adopted a multidisciplinary group handoff bundle, including presence of residents and charge nurses, a standardized mnemonic in verbal and written form, and resident training. Group B received only a mnemonic pocket card. Residents completed preintervention and postintervention Likert scale surveys to assess handoff perceptions. Within-group preintervention to postintervention changes were analyzed by using the signed rank test. Measuring communication errors, an institutional tool was used to track unanticipated patient occurrences (UPOs) postintervention for both groups. RESULTS: Significant improvements for the preintervention to postintervention surveys regarding the perceptions of quality of handoffs received, effective and efficient delivery of handoffs, comfort in giving handoffs, and handoff practices focusing on safety (all, P ≤ .05) were observed in group A. There were no significant changes in group B. Overall, 17% of collected group A UPO forms and 11% of group B UPO forms had at least 1 UPO recorded. The most common reason for a UPO was unaddressed nursing concerns. CONCLUSIONS: A multidisciplinary group of residents and charge nurses and a handoff bundle was associated with improved resident perceptions of handoffs and communication within the 2011 DHS.

Watch and learn: an innovative video trigger curriculum to increase resident screening for social determinants of health.

OBJECTIVE: To determine the effectiveness of an innovative curriculum, using trigger videos modeling screening for social determinants of health (SDH), on the comfort and screening practices of pediatric residents during well-child care. METHODS: A nonrandomized controlled study of an educational intervention was performed. Resident surveys assessing knowledge, comfort, and screening practices for SDH were performed pre- and post-intervention. Subsets of control and intervention residents were observed pre- and post-intervention to determine changes in SDH screening practices. RESULTS: Thirty-six residents completed the study. Intervention residents spent more time screening (P = .04), and inquired more frequently about family supports (P = .046) and housing conditions (P = .045). Intervention residents were less likely to note lack of knowledge and discomfort as barriers to screening. CONCLUSIONS: A curriculum incorporating trigger videos modeling SDH screening increased screening time and inquiry for a number of SDH by pediatric residents. Fewer barriers to screening were noted following the curriculum.

A collaborative system to improve compartment syndrome recognition.

BACKGROUND AND OBJECTIVE: Acute compartment syndrome (ACS) is a rare but serious complication of extremity injury that can cause permanent damage or death. ACS development is variable and unpredictable, and delay in recognition or treatment of ACS can lead to significant morbidity. Our objective was to create a reliable system for recognition of patients at risk and monitoring for ACS that could withstand frequent provider turnover. METHODS: Using the Model for Improvement, we identified key drivers and failure modes for 2 processes: resident and nurse practitioner proper order entry and bedside nurse proper documentation of monitoring. Interventions were tested in frequent plan-do-study-act cycles. Effective interventions were used in combination to test for sustainability. RESULTS: Proper order entry increased from 23% at baseline to 90%. Proper documentation for patients with correct orders increased from 15% to 70%. Individual interventions, including pocket card distribution, electronic medical record order set, and direct discussion by team leaders, were associated with improvement among residents but were not sustained with team turnover. Incorporating all 4 individual interventions into the on-boarding process for residents produced consistent success. Nursing documentation improved with education and maintenance of proper order entry. CONCLUSIONS: We built a reliable, sustainable system to recognize and monitor patients at risk for ACS. Interventions designed to minimally disrupt existing workflows were individually associated with improvement. We achieved sustainability through staff turnover when we incorporated the interventions into routine orientation for new staff. Hospitals can use existing orders and protocols to sustain surveillance for ACS and other acute conditions.

Pediatric hospitalist perceptions of the impact of duty hour changes on education and patient care.

OBJECTIVE: The goal of this study was to measure the impact of the new 2011 Accreditation Council for Graduate Medical Education duty hour standards (DHS) on education, patient care, and overall satisfaction as perceived by pediatric hospitalist faculty. METHODS: We undertook a nonrandomized but controlled study of 23 pediatric hospitalist faculty members during a trial of the new DHS in 2011. During the intervention (January), residents piloted schedules that complied with the new DHS, and in the control period (February), resident schedules complied with previous DHS. Daily surveys solicited faculty perceptions of the amount and quality of teaching provided, time with patients, quality of patient care, and overall faculty satisfaction. Faculty were also surveyed on their years of experience as a hospitalist and clinical teaching activity. Multiple logistic regression analysis with generalized estimating equations was used to examine outcome associations after adjusting for census and accounting for multiple attending reports. RESULTS: Census volumes were higher in the control group. During the intervention, faculty were less likely to rate their quality of teaching (odds ratio [OR]: 0.40 [95% confidence interval (CI): 0.18-0.88]) and overall satisfaction with the shift (OR: 0.23 [95% CI: 0.08-0.66]) as good/excellent compared with controls. During the intervention, more years of experience as a hospitalist were associated with rating quality of patient care provided as good/excellent (OR: 1.77 [95% CI: 1.23-2.54]). CONCLUSIONS: Faculty were less likely to rate their quality of teaching and overall satisfaction as good/excellent during a trial of the 2011 DHS. In addition, more experienced faculty were more likely to rate the quality of care highly.

Resident confidence addressing social history: is it influenced by availability of social and legal resources?

BACKGROUND: Pediatric residency clinics caring for underserved populations are often staffed with varying levels of social and legal resources, though their effects on residents' knowledge and practice have not been studied. Aim To examine the effects of clinic-based social and legal resources on resident knowledge and screening patterns for social determinants of health. METHODS: A cross-sectional study of residents from 3 continuity clinics with different social and legal resources was performed. Resident surveys assessing their knowledge and screening practices, and direct observation of social history taking was compared. RESULTS: Forty resident surveys revealed that those from clinics with more social and legal resources had greater confidence in their knowledge, screened more frequently, and spent more time taking social histories as assessed on direct observation. CONCLUSIONS: Residents who practiced in continuity clinics with increased social and legal resources were more confident in their knowledge and screened for social determinants of health more frequently.

Utilizing improvement science methods to improve physician compliance with proper hand hygiene.

OBJECTIVE: In 2009, The Joint Commission challenged hospitals to reduce the risk of health care-associated infections through hand hygiene compliance. At our hospital, physicians had lower compliance rates than other health care workers, just 68% on general pediatric units. We used improvement methods and reliability science to increase compliance with proper hand hygiene to >95% by inpatient general pediatric teams. METHODS: Strategies to improve hand hygiene were tested through multiple plan-do-study-act cycles, first by 1 general inpatient medical team and then spread to 4 additional teams. At the start of each rotation, residents completed an educational module and posttest about proper hand hygiene. Team compliance data were displayed daily in the resident conference room. Real-time identification and mitigation of failures by a hand-washing champion encouraged shared accountability. Organizational support ensured access to adequate hand hygiene supplies. The main outcome measure was percent compliance with acceptable hand hygiene, defined as use of an alcohol-based product or hand-washing with soap and turning off the faucet without using fingers or palm. Compliance was defined as acceptable hand hygiene before and after contact with the patient or care environment. Covert bedside observers recorded at least 8 observations of physicians' compliance per day. RESULTS: Physician compliance with proper hand hygiene improved to >95% within 6 months and was sustained for 11 months. CONCLUSIONS: Instituting a hand-washing champion for immediate identification and mitigation of failures was key in sustaining results. Improving physician compliance with proper hand hygiene is achievable and a first step in decreasing health care-associated infections.