Education and documentation strategies to improve malnutrition diagnosis in hospitalized children: A quality improvement project.

BACKGROUND: The Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition (AND/ASPEN) published malnutrition guidelines in 2014. In 2015, our institution implemented a quality improvement project focused on malnutrition identification with the goal to improve the diagnosis of malnutrition in hospitalized children. METHODS: Our project included three approaches: education, nutrition assessment, and documentation initiatives. Education initiatives focused on physicians at all levels of training. Nutrition screening was completed on all patients admitted to our institution. Registered dietitians (RDs) conducted nutrition assessments and identified and documented malnutrition based on AND/ASPEN guidelines. Documentation initiatives included development of automatic text and template changes to allow import of RD-assigned malnutrition diagnosis into physician documentation. We met with members of our clinical documentation integrity team regularly to review the results of these initiatives starting in 2016. RESULTS: The total diagnosed cases of malnutrition increased from 208 cases in 2016 at the start of our monitoring to >800 cases per year in 2020-2022. Unspecified (no severity assigned) protein calorie malnutrition as a percentage of total malnutrition diagnoses decreased from 36.9% in 2016 to <10% since 2018. Children with severe malnutrition have remained the largest portion of children with a malnutrition diagnosis, with >40% of children with malnutrition diagnosed with severe malnutrition. CONCLUSION: Our education and documentation initiatives have led to both improved diagnosis of malnutrition and accurate identification and documentation of malnutrition severity. These initiatives could be utilized to improve malnutrition diagnosis and documentation at other institutions caring for hospitalized children.

A Unique Use of Regional Information Exchange by a Statewide Health System Serving Refugees: "Operation Allies Welcome".

BACKGROUND: In September 2021, a military camp in the United States was identified for an initial relocation of over 6,600 Afghanistan refugees. This case report describes a novel use of existing health information exchange to expedite and provide health care for a large refugee population throughout the state during the duration of their entry into the United States. METHODS: Medical teams of the health systems and military camp partnered to provide a scalable, reliable mechanism for clinical data exchange leveraging an existing regional health information exchange. Exchanges were evaluated for clinical type, originating source, and closed loop communication with the refugee camp and personnel military camp. RESULTS: Approximately 50% of the camp residents were under the age of 18 years. Over 20 weeks, approximately 4.51% of the refugee camp residents were cared for in participating health systems. A total of 2,699 clinical data messages were exchanged, 62% of which were clinical documents. CONCLUSION: All health systems participating in care were offered support to utilize the tool and process set up using the regional health information exchange. The process and guiding principles may be applied to other refugee health care efforts to provide efficient, scalable, and reliable means of clinical data exchange to health care providers in similar situations.

State-by-State Variability in Adolescent Privacy Laws.

OBJECTIVES: Health care providers managing the complex health needs of adolescents must comply with state laws governing adolescent consent and right to privacy. However, these laws vary. Our objectives were to summarize consent and privacy laws state-by-state and assess the implications of variation for compliance with the 21st Century Cures Act and with evidence-based guidance on adolescent care. METHODS: We summarized state laws and regulations on minor consent for the following: health services, substance abuse treatment, prenatal care, mental health care, contraceptive management, immunizations, sexually transmitted infection management, human immunodeficiency viruses testing and treatment, dental care, and sexual assault evaluation. We compared state laws and regulations with American Academy of Pediatrics' evidence-based guidelines to assess consistencies in guidance. RESULTS: We observed notable state-by-state variability in laws governing consent for adolescent patients. No states had identical policies for all services studied. For example, although all states had provisions for consent to management of sexually transmitted infections, there were variable specifications in the age and type of minor, whether this includes human immunodeficiency viruses, and whether confidentiality is protected. Providing confidential care to the adolescent patient has been set as a priority by medical societies; however, guidelines are limited by the need to comply with state laws and regulations. CONCLUSIONS: State laws on consent and privacy for adolescents are highly variable, and many do not reflect pediatric professional standards of care. This inconsistency is a barrier to operationalizing a consistent and equitable experience providing evidence-based medical care and ensuring adolescent privacy protection.

Experiences of Informatics Health Care Workers Redeployed to Provide Telehealth in a Coronavirus Disease-Screening Hub.

Introduction: Coronavirus disease 2019 (COVID-19) resulted in many health care workers across the country being redeployed to different clinical roles. This study aimed to evaluate the unique experience of team members in our health system from clinical informatics who were redeployed to provide emergency telehealth care in a clinical role. Methods: Clinical informatics team members were redeployed during the first month of the pandemic onset in March 2020 to a clinic providing virtual screening for COVID-19. Participants completed an anonymous survey after 90 days. Results: During the study period, 76 clinical informatics team members provided telehealth and 85.3% of those eligible responded to the survey. Respondents felt prepared with clinical protocols and technical tools. The most common stressors were rapidly changing clinical protocols. Participants enjoyed the chance to work with patients and aiding during a pandemic. Conclusions: Clinical informatics team members redeployed to a virtual care screening hub endorsed positive experiences and the majority said that they would provide virtual care again. This experience gave important insights on how informatics skills can aid in a rapid coordinated telehealth response.

Health Care Disparities and Access to Video Visits Before and After the COVID-19 Pandemic: Findings from a Patient Survey in Primary Care.

Background:In 2020, the Centers for Medicare & Medicaid Services reimbursement structure was relaxed to aid in the rapid adoption nationally of telemedicine during the COVID-19 pandemic. Due to limited access to internet service, cellular phone data, and appropriate devices, many patients may be excluded from telemedicine services.Methods:In this study, we present the findings of a survey of patients at an urban primary care clinic regarding their access to the tools needed for telemedicine before and after the COVID-19 pandemic. Patients provided information about their access to internet services, phone and data plans, and their perceived access to and interest in telemedicine. The survey was conducted in 2019 and then again in September of 2020 after expansion of telemedicine services.Results:In 2019, 168 patients were surveyed; and in 2020, 99 patients participated. In both surveys, 30% of respondents had limited phone data, no data, or no phone at all. In 2019, the patient responses showed a statistically significant difference in phone plan types between patients with different insurance plans (p < 0.10), with a higher proportion (39%) of patients with Medicaid or Medicaid waiver having a prepaid phone or no phone at all compared with patients with commercial insurance (26%). The overall awareness rate increased from 17% to 43% in the 2020 survey.Conclusions:This survey illustrated that not all patients had access to devices, cellular data, and internet service, which are all needed to conduct telemedicine. In this survey, patients with Medicaid or Medicaid waiver insurance were less likely to have these tools than those with a commercial payor. Finally, patients' access to these telemedicine tools correlated with their interest in using telemedicine visits. Providing equitable telemedicine care requires attention to and mitigation strategies for these gaps in access.

The fractal structure of communities of practice: Implications for business organization.

Communities of practice (COP) are informal (sometimes formal) groupings of professionals with shared interests that form to facilitate the exchange of expertise and shared learning or to function as professional support networks. We analyse a dataset on the size of COPs and show that their distribution has a fractal structure similar to that found in huntergatherer social organisation and the structure of human personal social networks. Small communities up to about 40 in size can be managed democratically, but all larger communities require a leadership team structure. We show that frequency of interaction declines as size increases, as is the case in personal social networks. This suggests that professional work-oriented organisations may be subject to the same kinds of constraint imposed on human social organisation by the social brain. We discuss the implications for business management structure.

Clinical Decision Support in the Electronic Medical Record to Increase Rates of Influenza Vaccination in a Pediatric Emergency Department.

OBJECTIVES: Vaccination against influenza has been shown to decrease the morbidity and mortality from the virus; however, rates remain below the Healthy People 2020 target of 70%. The emergency department (ED) provides a unique opportunity to administer influenza vaccines; however, interventions must be efficient to be successful. During the 2014 to 2015 season, an electronic medical record (EMR) intervention was implemented in an effort to increase influenza vaccination rates. METHODS: Using Lean methodology, a multidisciplinary team designed a series of triggers, alerts, and orders in the EMR to address the barriers to adoption and their root causes. The EMR functionality was implemented for the 2014 to 2015 influenza season. Reports on compliance with each EMR step were completed for the 2014 to 2015 and 2015 to 2016 influenza seasons. RESULTS: In the 2013 to 2014 influenza season, the ED administered 42 doses of the vaccine, representing 0.3% of eligible visits. After implementation of the EMR tool, the ED administered 1320 doses of influenza vaccine. This represents approximately 8.8% of qualified patients based on age group and eventual discharge from the ED. The results were sustained during the 2015 to 2016 influenza season with 1031 doses administered, representing 6% of eligible visits. CONCLUSIONS: The ED influenza vaccination program vaccinated approximately 20 times the number of eligible patients after automated EMR screening and ordering. Using knowledge of a multidisciplinary team, integration into the existing workflow, and visual cues in the EMR, we were able to increase the number of influenza vaccines administered substantially.

Measuring success: perspectives from three optimization programs on assessing impact in the age of burnout.

Electronic health record (EHR) optimization has been identified as a best practice to reduce burnout and improve user satisfaction; however, measuring success can be challenging. The goal of this manuscript is to describe the limitations of measuring optimizations and opportunities to combine assessments for a more comprehensive evaluation of optimization outcomes. The authors review lessons from 3 U.S. healthcare institutions that presented their experiences and recommendations at the American Medical Informatics Association 2020 Clinical Informatics conference, describing uses and limitations of vendor time-based reports and surveys utilized in optimization programs. Compiling optimization outcomes supports a multi-faceted approach that can produce assessments even as time-based reports and technology change. The authors recommend that objective measures of optimization must be combined with provider and clinician-defined value to provide long term improvements in user satisfaction and reduce EHR-related burnout.

Electronic Communication of the Health Record and Information With Pediatric Patients and Their Guardians.

Communication of health data has evolved rapidly with the widespread adoption of electronic health records (EHRs) and communication technology. What used to be sent to patients via paper mail, fax, or e-mail may now be accessed by patients via their EHRs, and patients may also communicate securely with their medical team via certified technology. Although EHR technologies have great potential, their most effective applications and uses for communication between pediatric and adolescent patients, guardians, and medical teams has not been realized. There are wide variations in available technologies, guiding policies, and practices; some physicians and patients are successful in using certified tools but others are forced to limit their patients' access to e-health data and associated communication altogether. In general, pediatric and adolescent patients are less likely than adult patients to have electronic access and the ability to exchange health data. There are several reasons for these limitations, including inconsistent standards and recommendations regarding the recommended age for independent access, lack of routine EHR support for the ability to filter or proxy such access, and conflicting laws about patients' and physicians' rights to access EHRs and ability to communicate electronically. Effective, safe electronic exchange of health data requires active collaboration between physicians, patients, policy makers, and health information technology vendors. This policy statement addresses current best practices for these stakeholders and delineates the continued gaps and how to address them.

Comparison of Antibiotic Dosing Before and After Implementation of an Electronic Order Set.

BACKGROUND: To maximize resources, the antimicrobial stewardship program at a pediatric tertiary care hospital made pediatric dosing specific guidance within the electronic health record available to all hospitals within the health system. OBJECTIVE: The objective of this study was to compare the appropriateness of antibiotic dosing before and after the implementation of an electronic intravenous (IV) antibiotic order set. METHODS: This was a retrospective cohort study evaluating orders from patients younger than 18 years who received cefepime, piperacillin-tazobactam, tobramycin, or gentamicin at 12 health-system hospitals. Antibiotic dosing regimens and order set use were evaluated in patients who received the specified antibiotics during the 6-month time frame prior to and following electronic order set availability at each hospital. RESULTS: In the before and after implementation periods, 360 and 387 total antibiotic orders were included, respectively. Most orders were gentamicin (55.8% in the before implementation period and 54.5% in the after implementation period) followed by piperacillin-tazobactam (22.5% in the before period and 22.2% in the after period). Overall, 663 orders were classified as appropriate (88.8%). Appropriateness was similar in the before or after implementation periods (87.8 vs. 89.7%, p = 0.415). There was a significant difference in appropriateness if a blank order versus the electronic IV antibiotic order set was used (82.8 vs. 90.5%; p = 0.024). CONCLUSION: No difference in antibiotic appropriateness overall was found in the before and after implementation periods. However, when specifically compared with the appropriateness of dosing when blank order forms were used, dosing was more appropriate when electronic antibiotic order sets were used.

Characteristics of the National Applicant Pool for Clinical Informatics Fellowships (2016-2017).

We conducted a national study to assess the numbers and diversity of applicants for 2016 and 2017 clinical informatics fellowship positions. In each year, we collected data on the number of applications that programs received from candidates who were ultimately successful vs. unsuccessful. In 2017, we also conducted an anonymous applicant survey. Successful candidates applied to an average of 4.2 and 5.5 programs for 2016 and 2017, respectively. In the survey, unsuccessful candidates reported applying to fewer programs. Assuming unsuccessful candidates submitted between 2-5 applications each, the total applicant pool numbered 42-69 for 2016 (competing for 24 positions) and 52-85 for 2017 (competing for 30 positions). Among survey respondents (n=33), 24% were female, 1 was black and none were Hispanic. We conclude that greater efforts are needed to enhance interest in clinical informatics among medical students and residents, particularly among women and members of underrepresented minority groups.

Before the Flood: Impact of Coordination of Care and Direct Admissions on Emergency Department Volumes.

BACKGROUND: Transfers of pediatric patients occur to access specialty and subspecialty care, but incur risk, and consume resources. Direct admissions to medical and surgical wards may improve patient experience and mitigate resource utilization. OBJECTIVE: We sought to identify common elements for direct admissions, as well as the pattern of disposition for patients referred to our emergency department (ED). DESIGN: A retrospective qualitative analysis of patients transferred to our pediatric hospital for 12 months was performed. Different physician groups were evaluated for use of direct admissions or evaluation in the ED. Patients referred to the ED were additionally tracked to evaluate their eventual disposition. RESULTS: A total of 3982 transfers occurred during the 12-month analysis period. Of those, 3463 resulted in admission, accounting for 32.55% of all admissions. Transfers accepted by nonsurgical services accounted for 82% of the transfers, whereas 18% were facilitated by one of the surgical services. Direct admissions accounted for 1707 (44.8%) of all referrals and were used more often by nonsurgical services. Of patients referred to the ED (2101 or 55.2% of all referrals), most patients were admitted and 343 (16% of those referred to the ED) were discharged home. CONCLUSIONS: The direct admission process helped avoid ED assessments for some patients; however, some patients referred to the ED were able to be evaluated, treated, and discharged. Consistent triage of the patients being transferred as direct admissions may improve ED throughput and potentially improve the patient's experience, reduce redundant services, and expedite care.

Adherence to pediatric diabetic ketoacidosis guidelines by community emergency departments' providers.

BACKGROUND: Diabetic ketoacidosis (DKA) is a common presentation of type I diabetes mellitus to the emergency departments. Most children with DKA are initially managed in community emergency departments where providers may not have easy access to educational resources or pediatric-specific guidelines and protocols that are readily available at pediatric academic medical centers. The aim of this study is to evaluate adherence of community emergency departments in the state of Indiana to the pediatric DKA guidelines. METHODS: We performed a retrospective chart review of patients, age 18 years of age or under, admitted to the pediatric intensive care unit with a diagnosis of DKA. RESULTS: A total of 100 patients were included in the analysis. Thirty-seven percent of patients with DKA were managed according to all six guideline parameters. Only 39% of patients received the recommended hourly blood glucose checks. Thirty percent of patients received intravenous insulin bolus, which is not recommended. CONCLUSIONS: Non-adherence to pediatric DKA guidelines still exists in the state of Indiana. Further, larger studies are needed to reveal the etiology of non-adherence to pediatric DKA guidelines and strategies to improve that adherence.

Multifaceted quality improvement initiative to decrease pediatric asthma readmissions.

BACKGROUND: Asthma is the most common chronic disease of childhood and a leading cause of hospitalization in children. A primary goal of asthma control is prevention of hospitalizations. A hospital admission is the single strongest predictor of future hospital admissions for asthma. The 30-day asthma readmission rate at our institution was significantly higher than that of other hospitals in the Children's Hospital Association. As a result, a multifaceted quality improvement project was undertaken with the goal of reducing the 30-day inpatient asthma readmission rate by 50% within two years. METHODS: Analysis of our institution's readmission patterns, value stream mapping of asthma admission, discharge, and follow-up processes, literature review, and examination of comparable successful programs around the United States were all utilized to identify potential targets for intervention. Interventions were implemented in a stepwise manner, and included increasing inhaler availability after discharge, modifying asthma education strategies, and providing in-home post-discharge follow-up. The primary outcome was a running 12-month average 30-day inpatient readmission rate. Secondary outcomes included process measures for individual interventions. RESULTS: From a peak of 7.98% in January 2013, a steady decline to 1.65% was observed by July 2014, which represented a 79.3% reduction in 30-day readmissions. CONCLUSION: A significant decrease in hospital readmissions for pediatric asthma is possible, through comprehensive, multidisciplinary quality improvement that spans the continuum of care.

Striatal Activity and Reward Relativity: Neural Signals Encoding Dynamic Outcome Valuation.

The striatum is a key brain region involved in reward processing. Striatal activity has been linked to encoding reward magnitude and integrating diverse reward outcome information. Recent work has supported the involvement of striatum in the valuation of outcomes. The present work extends this idea by examining striatal activity during dynamic shifts in value that include different levels and directions of magnitude disparity. A novel task was used to produce diverse relative reward effects on a chain of instrumental action. Rats (Rattus norvegicus) were trained to respond to cues associated with specific outcomes varying by food pellet magnitude. Animals were exposed to single-outcome sessions followed by mixed-outcome sessions, and neural activity was compared among identical outcome trials from the different behavioral contexts. Results recording striatal activity show that neural responses to different task elements reflect incentive contrast as well as other relative effects that involve generalization between outcomes or possible influences of outcome variety. The activity that was most prevalent was linked to food consumption and post-food consumption periods. Relative encoding was sensitive to magnitude disparity. A within-session analysis showed strong contrast effects that were dependent upon the outcome received in the immediately preceding trial. Significantly higher numbers of responses were found in ventral striatum linked to relative outcome effects. Our results support the idea that relative value can incorporate diverse relationships, including comparisons from specific individual outcomes to general behavioral contexts. The striatum contains these diverse relative processes, possibly enabling both a higher information yield concerning value shifts and a greater behavioral flexibility.

Hunger-Driven Motivational State Competition.

Behavioral choice is ubiquitous in the animal kingdom and is central to goal-oriented behavior. Hypothalamic Agouti-related peptide (AgRP) neurons are critical regulators of appetite. Hungry animals, bombarded by multiple sensory stimuli, are known to modify their behavior during times of caloric need, rapidly adapting to a consistently changing environment. Utilizing ARCAgRP neurons as an entry point, we analyzed the hierarchical position of hunger related to rival drive states. Employing a battery of behavioral assays, we found that hunger significantly increases its capacity to suppress competing motivational systems, such as thirst, anxiety-related behavior, innate fear, and social interactions, often only when food is accessible. Furthermore, real-time monitoring of ARCAgRP activity revealed time-locked responses to conspecific investigation in addition to food presentation, further establishing that, even at the level of ARCAgRP neurons, choices are remarkably flexible computations, integrating internal state, external factors, and anticipated yield. VIDEO ABSTRACT.