Reducing postoperative hypothermia in infants: Quality improvement in China.

BACKGROUND: Unintended postoperative hypothermia in infants is associated with increased mortality and morbidity. We noted consistent hypothermia postoperatively in more than 60% of our neonatal intensive care (NICU) babies. Therefore, we set out to determine whether a targeted quality improvement (QI) project could decrease postoperative hypothermia rates in infants. OBJECTIVES: Our SMART aim was to reduce postoperative hypothermia (<36.5°C) in infants from 60% to 40% within 6 months. METHODS: This project was approved by IRB at Guangzhou Women and Children's Medical Center, China. The QI team included multidisciplinary healthcare providers in China and QI experts from Children's Hospital of Philadelphia, USA. The plan-do-study-act (PDSA) cycles included establishing a perioperative-thermoregulation protocol, optimizing the transfer process, and staff education. The primary outcome and balancing measures were, respectively, postoperative hypothermia and hyperthermia (axillary temperature < 36.5°C, >37.5°C). Data collected was analyzed using control charts. The factors associated with a reduction in hypothermia were explored using regression analysis. RESULTS: There were 295 infants in the project. The percentage of postoperative hypothermia decreased from 60% to 37% over 26 weeks, a special cause variation below the mean on the statistical process control chart. Reduction in hypothermia was associated with an odds of 0.17 (95% CI: 0.06-0.46; p <.001) for compliance with the transport incubator and 0.24 (95% CI: 0.1-0.58; p =.002) for prewarming the OR ambient temperature to 26°C. Two infants had hyperthermia. CONCLUSIONS: Our QI project reduced postoperative hypothermia without incurring hyperthermia through multidisciplinary team collaboration with the guidance of QI experts from the USA.

Translating Value Across Telehealth Stakeholders: A Rapid Review of Telehealth Measurement Evidence and a New Policy Framework to Guide Telehealth Researchers.

Introduction: The surge in virtual care during the pandemic was accompanied by an increase in telehealth data of interest to policy stakeholders and other health care decision makers. However, these data often require substantial preprocessing and targeted analyses to be usable. By deliberately evaluating telehealth services with stakeholder perspectives in mind, telehealth researchers can more effectively inform clinical and policy decision making. Objective: To examine existing literature on telehealth measurement and evaluation and develop a new policy-oriented framework to guide telehealth researchers. Materials and Methods: A systematic rapid review of literature on telehealth measurement and evaluation was conducted by two independent reviewers in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The findings were analyzed and applied to the Supporting Pediatric Research on Outcomes and Utilization of Telehealth Evaluation and Measurement (STEM) Framework through the lens of key health care delivery decision makers to create a STEM Policy Framework Results: An initial search yielded 2,324 peer-reviewed articles and gray literatyre from 2012 to 2022, of which 56 met inclusion criteria. These measured and evaluated telehealth access (41.5%), quality (32.1%), cost (15.1%), experience (5.7%), and utilization (5.7%), consistent with the STEM Framework domains, but there was no universal approach. The STEM Policy Framework focuses this literature by describing data measures for each domain from the perspectives of five stakeholders. Conclusions: Literature describing measurement and evaluation approaches for telehealth is limited and not standardized, with few considering policy stakeholder perspectives. With this proposed STEM Policy Framework, we aim to improve this body of literature and support researchers seeking to inform telehealth policy through their work.

Telemedicine and Pediatric Care in Rural and Remote Areas of Middle-and-Low-Income Countries: Narrative Review.

OBJECTIVES: Caring for children in low- and middle-income countries (LMIC) can be challenging. This review article aims to explore role of telemedicine in supporting pediatric care in LMIC. METHODOLOGY: A narrative review of existing English and Spanish literature was conducted to assess role of telemedicine to support pediatric care in LMIC. RESULTS: Beside medical education and direct pediatric care, telemedicine can provide sub-specialties consultations without extra burden on families. Additionally, telemedicine can help in lowering under-5 mortality by supporting neonatal care, infectious illnesses, and non-communicable diseases (NCDs). Telemedicine can be a gate for universal coverage for all children at a lower cost. For over a decade, it has been implemented successfully and sustained in a few LMIC. However, challenges in implementing telemedicine are enormous. Still, opportunities arise by using simpler technology, low-width band internet, smartphones, instant messaging applications and solar energy. COVID-19 pandemic facilitated acceptance and applicability of telemedicine worldwide including LMIC. Nevertheless, governments must regulate telemedicine by issuing policies and ensuring employment of local experts when possible to meet local resources and cultural competency. CONCLUSION: Telemedicine has proven successful in improving pediatrics care. Many LMIC should take advantage of this innovation to promote equity and access to high quality pediatric care.

Surgical neonates: A retrospective review of procedures and postoperative outcomes at a quaternary children's hospital.

INTRODUCTION: Neonates have a high incidence of respiratory and cardiac perioperative events. Disease severity and indications for surgical intervention often dovetail with an overall complex clinical course and predispose these infants to adverse long-term neurodevelopmental outcomes and increased length of stay. Our aims were to describe severe and nonsevere early postoperative complications to establish a baseline of care outcomes and to identify subgroups of surgical neonates and procedures for future prospective studies. METHODS: Electronic health record data were examined retrospectively for a cohort of patients who had general anesthesia from January 26, 2015 to August 31, 2018. Inclusion criteria were full-term infants with postmenstrual age less than 44 weeks or premature infants less than 60 weeks postmenstrual age undergoing nonimaging, noncardiac surgery. Severe postoperative complications were defined as mortality, reintubation, positive blood culture, and surgical site infection. Nonsevere early postoperative outcomes were defined as hypoglycemia, hyperglycemia, hypothermia, hyperthermia, and readmission within 30 days. RESULTS: About 2569 procedures were performed in 1842 neonates of which 10.9% were emergency surgeries. There were 120 postoperative severe complications and 965 nonsevere postoperative outcomes. Overall, 30-day mortality was 1.8% for the first procedure performed, with higher mortality seen on subgroup analysis for patients who underwent exploratory laparotomy (10.3%) and congenital lung lesion resection (4.9%). Postoperative areas for improvement included hyperglycemia (13.9%) and hypothermia (7.9%). DISCUSSION: The mortality rate in our study was comparable to other studies of neonatal surgery despite a high rate of emergency surgery and a high prevalence of prematurity in our cohort. The early outcomes data identified areas for improvement, including prevention of postoperative glucose and temperature derangements. CONCLUSIONS: Neonates in this cohort were at risk for severe and nonsevere adverse postoperative outcomes. Future studies are suggested to improve mortality and adverse event rates.

A Multicenter Collaborative to Improve Postoperative Pain Management in the NICU.

OBJECTIVES: This quality improvement initiative aimed to decrease unrelieved postoperative pain and improve family satisfaction with pain management. METHODS: NICUs within the Children's Hospitals Neonatal Consortium that care for infants with complex surgical problems participated in this collaborative. Each of these centers formed multidisciplinary teams to develop aims, interventions, and measurement strategies to test in multiple Plan-Do-Study-Act cycles. Centers were encouraged to adopt evidence-based interventions from the Clinical Practice Recommendations, which included pain assessment tools, pain score documentation, nonpharmacologic treatment measures, pain management guidelines, communication of a pain treatment plan, routine discussion of pain scores during team rounds, and parental involvement in pain management. Teams submitted data on a minimum of 10 surgeries per month, spanning from January to July 2019 (baseline), August 2019 to June 2021 (improvement work period), and July 2021 to December 2021 (sustain period). RESULTS: The percentage of patients with unrelieved pain in the 24-hour postoperative period decreased by 35% from 19.5% to 12.6%. Family satisfaction with pain management measured on a 3-point Likert scale with positive responses ≥2 increased from 93% to 96%. Compliance with appropriate pain assessment and numeric documentation of postoperative pain scores according to local NICU policy increased from 53% to 66%. The balancing measure of the percentage of patients with any consecutive sedation scores showed a decrease from 20.8% at baseline to 13.3%. All improvements were maintained during the sustain period. CONCLUSIONS: Standardization of pain management and workflow in the postoperative period across disciplines can improve pain control in infants.

Discharge Best Practices of High-Risk Infants From Regional Children's Hospital NICUs.

OBJECTIVES: Lack of discharge preparedness after NICU hospitalization is associated with risk of readmission and parental stress. Complex infants cared for at regional children's hospital NICUs would benefit from a systematic approach to transition home. Our objective was to identify potential best practices for NICU discharge and examine priorities for incorporating these best practices in regional children's hospital NICUs. METHODS: We used techniques from quality improvement, including fish bone and key driver diagrams, yielding 52 potential best practice statements for discharge preparation. Using the modified Delphi method, we surveyed stakeholders on their level of agreement for the statement to be included in the final guideline regarding discharge processes and parental education. Consensus was defined as 85% agreement among respondents. To identify implementation feasibility and understand unit-level priorities, a prioritization and feasibility assessment survey was used to rank the top best practices and performed gap analyses for the first prioritized intervention. RESULTS: Fifty of the 52 statements met the predefined criteria for consensus. The prioritization survey of potential best practice statements named assessment of families' social determinants of health with a standardized tool as the top priority among respondents. Conducting gap analyses enabled an understanding of current practice, barriers, and affordances, allowing for implementation planning. CONCLUSIONS: This multicenter and interdisciplinary expert panel reached a consensus on multiple potential best practices for complex discharge preparation from regional children's hospital NICUs. Better support for families navigating the complex NICU discharge process has the potential to improve infant health outcomes.

The Use of Telehealth to Improve Handoffs Between Neonatologists and Primary Care Providers for Medically Complex Infants.

As part of the Supporting Pediatric Research Outcomes Utilizing Telehealth (SPROUT) collaboration, three institutions (University of California, Davis, Children's Hospital Colorado, and Children's Hospital of Philadelphia) sought to improve communication with primary care providers (PCPs) using telehealth. This project connected families of neonatal intensive care unit (NICU) patients, their PCPs, and their NICU team through telehealth to provide an enhanced hospital handoff. This case series reports four cases that exemplify the benefits of these enhanced hospital handoffs: Case 1: assisting with changing care plans after NICU discharge, Case 2: demonstrating physical findings, Case 3: incorporation of additional subspecialties through telehealth, Case 4: arranging care for remote patients. Although these cases demonstrate some of the potential benefits of these handoffs, further study is needed to determine acceptability of these handoffs and to see whether they impact patient outcomes.

Comparison of Parental In-Person Visitation and Webcam Usage Patterns at a Single-Center Neonatal Intensive Care Unit.

Purpose: Barriers to parents visiting the neonatal intensive care unit (NICU) in person for infant bonding include socioeconomic status, distance from NICU, and having children at home. Use of NICU bedside webcam can increase access to parent-infant interaction. This study aimed to describe the pattern of webcam logins by parents, relationship of logins to in-person visitation, and maternal factors affecting usage. Methods: In this retrospective cohort study, data pertaining to parental webcam logins and in-person visitation, maternal screening for depression, anxiety, and stress, and family sociodemographics were collected from medical records. Relationships between chart variables and webcam or in-person visitation were measured using Pearson's correlation coefficient and Mann-Whitney U test, as applicable. Login data were obtained from weeks 2 through 5 of NICU stay of the infant, while depression, anxiety, and stress scores were obtained in the second week as standard procedure by a dedicated NICU social worker. Results: A total of 59 mother-baby dyads were included. Percentage of days visited and webcam logins decreased from week 2 to week 5. A higher rate of webcam login was documented for all parents on days they did not visit in person. Parents who lived ≥15 miles away (P=0.004) and those with government insurance (P=0.01) visited in person significantly less, although webcam logins showed no difference between groups. One negative correlation was found between percentage of in-person visits and DASS-21 depression score (P=0.03), but no such correlation was seen with webcam logins. Conclusions: Parents utilized NICU webcams to connect with their infants when unable to be at the bedside. Webcam use reduced visitation disparities known to be exacerbated by insurance status, home-to-hospital distance, and psychological distress.

Multicenter study assessing physicians' and transport teams' attitudes and expectations about utilizing telemedicine to manage critical neonatal transports.

BACKGROUND: Managing critically ill neonates has unique challenges, and the transport team plays an important role in stabilizing and facilitating the transfer of these neonates from lower-level nurseries to tertiary centers, and the use of telemedicine in transport (tele-transport) can potentially benefit patient care. We conducted a multicenter study to assess the readiness for utilizing telemedicine as an adjunct to guide the care of critically ill neonates among physicians and transport team members (TTMs). This is the first multicenter study that explored physicians' and TTMs' perceptions of telemedicine usage and its value in neonatal transport. METHODS: A confidential, voluntary survey on pre-implementation attitudes toward telemedicine usage during neonatal transport was conducted as part of a quality improvement initiative. This survey involved physicians and TTMs from four academic institutions whose responses were entered into an online survey using REDCap®. The survey inquired about satisfaction with the current practice of phone consultation and the perception of using telemedicine to optimize the management of neonates during transport. RESULTS : The overall response rate for the survey was 60.1%; 82 of 127 (64.6%) physicians and 64 of 116 (55.2%) TTMs responded to the surveys. Half of the physicians and less than one-fourth of the TTMs had prior experience with telemedicine other than that used on neonatal transport. TTMs expressed greater concern about the inconvenience of video (55% vs. physicians 35% agree or strongly agree) and its time consumption (84% vs. physicians 50%). More than 70% of physicians and less than half of TTMs endorsed the potential for added value and quality improvement with video capability. Almost half of TTMs reported concern about video calls reducing their autonomy in patient care. Physicians expressed confidence in management decisions they would make after video calls (72% confident or very confident) and less confidence (49%) about both the phone assessment by TTMs and their decisions based on phone assessment. In contrast, TTMs were confident or very confident (94%) in both sharing their assessment over the phone and executing patient management after a phone call, compared with 70% for decisions made after video calls. CONCLUSIONS : Physicians and TTMs had distinct opinions on the use of telemedicine during neonatal transport. Physicians were more likely than TTMs to agree with statements about the potential for improving quality of care, while TTMs were more likely than physicians to say video calls would be time-consuming and inconvenient. We speculate some differences may stem from the TTMs' concern about losing their autonomy. Therefore, during implementation, it is critical for physicians and TTMs to agree on a shared mental model of indications for telemedicine during transport and its value to the patient care.

Acceptability of Telehealth for Gender-Affirming Care in Transgender and Gender Diverse Youth and Their Caregivers.

Gender-affirming care (GAC) is critical to the well-being of transgender and gender diverse youth and was limited by COVID-19 stay-at-home orders. Telehealth created opportunities for youth to continue receiving lifesaving care. We examined the attitudes of patients (n=21) and caregivers (n=38) receiving telehealth-delivered GAC (TGAC) from May to July 2020. Participants completed surveys after telehealth visits. Descriptive statistics compared telehealth with in-person visits across key domains. Overall, 86.5% of patients and 95.4% of caregivers were satisfied with medical TGAC and 94.3% and 93.3% were satisfied with behavioral health TGAC. Future research should determine the effectiveness of TGAC and identify areas for improvement.

Evaluation of pediatric rheumatology telehealth satisfaction during the COVID-19 pandemic.

BACKGROUND: During the Coronavirus disease 2019 pandemic, ambulatory pediatric rheumatology healthcare rapidly transformed to a mainly telehealth model. However, pediatric patient and caregiver satisfaction with broadly deployed telehealth programs remains largely unknown. This study aimed to evaluate patient/caregiver satisfaction with telehealth and identify the factors associated with satisfaction in a generalizable sample of pediatric rheumatology patients. METHODS: Patients with an initial telehealth video visit with a rheumatology provider between April and June 2020 were eligible. All patients/caregivers were sent a post-visit survey to assess a modified version of the Telehealth Usability Questionnaire (TUQ) and demographic and clinical characteristics. TUQ total and sub-scale (usefulness, ease of use, effectiveness, satisfaction) scores were calculated and classified as "positive" based on responses of "agree" or "strongly agree" on a 5-point Likert scale. Results were analyzed using standard descriptive statistics and Wilcoxon signed rank testing. The association between demographic and clinical characteristics with TUQ scores was assessed using univariate linear regression. RESULTS: 597 patients/caregivers met inclusion criteria, and the survey response rate was 42% (n = 248). Juvenile idiopathic arthritis was the most common diagnosis (33.5%). The majority of patients were diagnosed greater than 6 months previously (72.6%) and were prescribed chronic medications (59.7%). The median total TUQ score was 4 (IQR: 4-5) with positive responses in 81% of items. Of the subscales, usefulness scores were lowest (median: 4, p < 0.001). Telehealth saves time traveling was the highest median item score (median = 5, IQR: 4-5). Within subscales, items that scored significantly lower included convenience, providing for needs, seeing rheumatologist as well as in person, and being an acceptable way to receive rheumatology services (all p < 0.001). There were no significant demographic or clinical features associated with TUQ scores. CONCLUSIONS: Our results suggest telehealth is a promising mode of healthcare delivery for pediatric rheumatic diseases but also identifies opportunities for improvement. Innovation and research are needed to design a telehealth system that delivers high quality and safe care that improves healthcare outcomes. Since telehealth is a rapidly emerging form of pediatric rheumatology care, improved engagement and training of patients, caregivers, and providers may help improve the patient experience in the future.

STEPP IN: A Multicenter Quality Improvement Collaborative Standardizing Postoperative Handoffs.

OBJECTIVE: To reduce care failures by 30% through implementation of standardized communication processes for postoperative handoff in NICU patients undergoing surgery over 12 months and sustained over 6 months. METHODS: Nineteen Children's Hospitals Neonatal Consortium centers collaborated in a quality improvement initiative to reduce postoperative care failures in a surgical neonatal setting by decreasing respiratory care failures and all other communication failures. Evidence-based clinical practice recommendations and a collaborative framework supported local teams' implementation of standardized postoperative handoff communication. Process measures included compliance with center-defined handoff staff presence, use of center-defined handoff tool, and the proportion of handoffs with interruptions. Participant handoff satisfaction was the balancing measure. Baseline data were collected for 8 months, followed by a 12-month action phase and 7-month sustain phase. RESULTS: On average, 181 postoperative handoffs per month were monitored across sites, and 320 respondents per month assessed the handoff process. Communication failures specific to respiratory care decreased by 73.2% (8.2% to 4.6% and with a second special cause signal to 2.2%). All other communication care failures decreased by 49.4% (17% to 8.6%). Eighty-four percent of participants reported high satisfaction. Compliance with use of the handoff tool and required staff attendance increased whereas interruptions decreased over the project time line. CONCLUSIONS: Team engagement within a quality improvement framework had a positive impact on the perioperative handoff process for high-risk surgical neonates. We improved care as demonstrated by a decrease in postoperative care failures while maintaining high provider satisfaction.

Acceptability, Feasibility, and Quality of Telehealth for Adolescent Health Care Delivery During the COVID-19 Pandemic: Cross-sectional Study of Patient and Family Experiences.

BACKGROUND: Data regarding the acceptability, feasibility, and quality of telehealth among adolescents and young adults (AYA) and their parents and caregivers (caregivers) are lacking. OBJECTIVE: The aim of this study was to assess the noninferiority of telehealth versus in-person visits by comparing acceptability with respect to efficiency, effectiveness, equity, patient-centeredness, and confidentiality. METHODS: Cross-sectional web-based surveys were sent to caregivers and AYA following video visits within an Adolescent Medicine subspecialty clinic in May-July 2020. Proportions of AYA and caregivers who rated telehealth as noninferior were compared using chi-squared tests. Feasibility was assessed via items measuring technical difficulties. Deductive thematic analysis using the Institute of Medicine dimensions of health care quality was used to code open-ended question responses. RESULTS: Survey response rates were 20.5% (55/268) for AYA and 21.8% (123/563) for caregivers. The majority of the respondents were White cisgender females. Most AYA and caregivers rated telehealth as noninferior to in-person visits with respect to confidentiality, communication, medication management, and mental health care. A higher proportion of AYA compared to caregivers found telehealth inferior with respect to confidentiality (11/51, 22% vs 3/118, 2.5%, P<.001). One-quarter (14/55) of the AYA patients and 31.7% (39/123) of the caregivers reported technical difficulties. The dominant themes in the qualitative data included advantages of telehealth for efficiency and equity of health care delivery. However, respondents' concerns included reduced safety and effectiveness of care, particularly for patients with eating disorders, owing to lack of hands-on examinations, collection of vital signs, and laboratory testing. CONCLUSIONS: Telehealth was highly acceptable among AYA and caregivers. Future optimization should include improving privacy, ameliorating technical difficulties, and standardizing at-home methods of obtaining patient data to assure patient safety.

Improving Compliance with a Rounding Checklist through Low- and High-technology Interventions: A Quality Improvement Initiative.

INTRODUCTION: Checklists aid in ensuring consistency and completeness in medical care delivery. However, using an improvement and safety checklist during rounds was variable in our neonatology intensive care unit (NICU), and completion was not tracked sustainably. This quality improvement (QI) initiative's primary aim was to increase compliance with checklist completion from 31% to >75% within 1 year. METHODS: A multidisciplinary QI team identified barriers to checklist completion and implemented a human factors-focused low-technology intervention (redesign of a hard-copy checklist) and later a high-technology clinical decision support tool within the electronic health record. The primary outcome measure was percent compliance with the use of the checklist. Process metrics included the duration of checklist completion. Balancing measures included staff perceptions of work burden and question relevance. RESULTS: Major barriers to checklist utilization were inability to remember, rounding interruptions, and perceived lack of question relevance to patients. Average biweekly checklist compliance improved from 31% before interventions to 80% after interventions. Average checklist completion time decreased from 46 to 11 seconds. Follow-up surveys demonstrated more respondents found questions "completely relevant" (34% pre versus 43% post) but perceived increased work burden (26% pre versus 31% post). CONCLUSIONS: Using QI methodology, human factors-based interventions, and a novel clinical decision support tool, we significantly improved efficiency and checklist compliance and created an automated, sustainable method for monitoring completion and responses. This foundational project provides an infrastructure broadly applicable to QI work in other healthcare settings.

Pediatric Telehealth in the COVID-19 Pandemic Era and Beyond.

The coronavirus disease 2019 (COVID-19) pandemic led to an unprecedented demand for health care at a distance, and telehealth (the delivery of patient care using telecommunications technology) became more widespread. Since our 2018 state-of-the-art review assessing the pediatric telehealth landscape, there have been many changes in technology, policy, payment, and physician and patient acceptance of this care model. Clinical best practices in telehealth, on the other hand, have remained unchanged during this time, with the primary difference being the need to implement them at scale.Because of the pandemic, underlying health system weaknesses that have previously challenged telehealth adoption (including inequitable access to care, unsustainable costs in a fee-for-service system, and a lack of quality metrics for novel care delivery modalities) were simultaneously exacerbated. Higher volume use has provided a new appreciation of how patients from underrepresented backgrounds can benefit from or be disadvantaged by the shift toward virtual care. Moving forward, it will be critical to assess which COVID-19 telehealth changes should remain in place or be developed further to ensure children have equitable access to high-quality care.With this review, we aim to (1) depict today's pediatric telehealth practice in an era of digital disruption; (2) describe the people, training, processes, and tools needed for its successful implementation and sustainability; (3) examine health equity implications; and (4) critically review current telehealth policy as well as future policy needs. The American Academy of Pediatrics (AAP) is continuing to develop policy, specific practice tips, training modules, checklists, and other detailed resources, which will be available later in 2021.