Evaluating Interventions to Increase Influenza Vaccination Rates among Pediatric Inpatients.

INTRODUCTION: Hospitalization provides an ideal opportunity for influenza vaccination, and strategies can enhance existing tools within the electronic medical record (EMR). The objectives of the study were to introduce and evaluate the effectiveness of provider and family-directed interventions to increase influenza vaccination ordering among inpatients. METHODS: We conducted a quality improvement initiative for children aged older than 6 months on medical inpatient teams at a large pediatric tertiary care hospital from September 2014 to March 2015, comprising 2 intervention groups (provider reminders and family education) and 1 control group for comparison, using EMR prompts alone. The provider reminder interventions comprised weekly e-mails indicating inpatient immunization status; vaccination reports; and visual reminders. The family education group intervention consisted of handouts regarding the benefits and safety of influenza vaccination. We measured vaccine ordering rates for each group among eligible children and overall vaccination rates. Data were analyzed using Statistical Process Control Charts and Chi-square tests. RESULTS: Among 2,552 patients aged older than 6 months hospitalized during the study period, 1,657 were unimmunized. During the intervention period, the provider group ordered 213/409 (52%) influenza vaccines, the family education group ordered 138/460 (30%) and the control group ordered 71/279 (25%) (P < 0.0001). The provider group had higher influenza immunization status than the control group (61% versus 53%; P = 0.0017). Exposure to the intervention did not impact the length of stay/discharge time. CONCLUSIONS: Provider reminders including e-mails, visual reminders, and vaccination reports are effective ways of increasing inpatient influenza vaccination rates and are more effective than family education, or EMR prompts alone.

Insertion characteristics of intrauterine devices in adolescents and young women: success, ancillary measures, and complications.

OBJECTIVE: The objective of the study was to evaluate success and safety of intrauterine device (IUD) placement in a large cohort of adolescents. STUDY DESIGN: We examined the medical records of patients aged 13-24 years at the Children's Hospital Colorado Adolescent Family Planning Clinic with at least 1 attempt at IUD placement. We abstracted demographic, reproductive, and procedural variables. The primary outcome was successful placement at first IUD insertion visit. We compared nulliparous with parous adolescents and patients younger than 18 years with those 18 years of age and older. RESULTS: Between April 2009 and December 2011, 1177 adolescent women aged 13-24 years (mean age 20.8 ± 2.5 years) had an attempted IUD placement, 1012 (86%) of which were with an advanced practice clinician. The first attempt was successful for 1132 women (96.2%). The first-attempt success rate was 95.8% for nulliparous women and 96.7% for parous women (P = .45). The first-attempt success rate was 95.5% (n = 169) for women aged 13-17 years compared with 96.3% (n = 963) for women aged 18-24 years (P = .6). Only 1.8% (n = 21) of all first-attempt successful insertions required ancillary measures. Of the 45 patients with a failed first insertion attempt, 40% (n = 18) had a second attempt with a physician, of which 78% (n = 14) were successful. Within the first 6 months of IUD placement, no perforations were identified and 24 patients (3.0%) expelled the IUD. Insertion failures and IUD expulsions were not related to IUD type, age, or parity. CONCLUSION: Intrauterine devices can be inserted in nulliparous adolescents of any age with similar success to parous adolescents, by both physicians and advanced practice clinicians. Inability to provide ancillary measures such as paracervical block or cervical dilation should not limit access to this first-line contraceptive method.

A quality improvement study to improve inpatient problem list use.

BACKGROUND: The problem list is a meaningful use incentivized criterion, and >80% of patients should have 1 problem entered as structured data. OBJECTIVE: The aim of the present study was to use a series of interventions to increase the use of the problem list for inpatients to >80% as measured by at least 1 hospital problem at discharge. METHODS: This study was a quasi-experimental time series quality improvement trial. The primary outcome was 80% of medical and psychiatric inpatients with a problem added to the problem list before discharge. Control charts of percentage (p charts) of medical and psychiatric patients with an inpatient problem list at discharge were constructed with three-σ control limits. Control limits were revised after evidence of improvement. The charts were annotated with interventions, including increasing awareness, focused education, and timely feedback in the form of performance graphs e-mailed to providers. RESULTS: For medical inpatients, use rose from 31% to 97% at its peak in April 2011 and continues to maintain above the goal of 80%. In psychiatry, problem list use rose from 2% initially to an average of 72% after the interventions. CONCLUSIONS: Significant gains were made with inpatient problem list usage by the medical and psychiatric teams. Our goal ascribed by meaningful use for >80% of inpatients to have a problem at discharge was met after initiation of our series of interventions.

Patient health questionnaire-9 as an effective tool for screening of depression among Indian adolescents.

PURPOSE: Detection of depression among adolescents in the primary care setting is of paramount importance, especially in resource-constrained countries such as India. This article discusses the diagnostic accuracy, reliability, and validity of the Patient Health Questionnaire-9 (PHQ-9) when pediatricians use it among Indian adolescents. METHODS: Pediatricians administered the PHQ-9 to 233 adolescent students aged 14-18 years, along with the Beck Depression Inventory. Our psychologist clinically diagnosed depression based on an International Classification of Diseases, 10th Revision, interview of participants. One month later, the PHQ-9 was readministered among students. We conducted appropriate analyses for validity and diagnostic accuracy. RESULTS: A total of 31 students (13.3%) had a form of depression on psychiatric interview. A PHQ-9 score of ≥5 was ideal for screening (sensitivity, 87.1%; specificity, 79.7%). In addition to good content validity, PHQ-9 had good 1-month test-retest reliability (r = .875) and internal consistency (Cronbach's α = .835). There was high convergent validity with the Beck Depression Inventory (r = .76; p = .001). The concordance rate between the PHQ-9 threshold score of ≥10 and the International Classification of Diseases, 10th Revision based diagnosis was good (Cohen's κ = .62). The area under the receiver operating characteristic curve for PHQ-9 was .939. CONCLUSIONS: The PHQ-9 is a psychometrically sound screening tool for use by pediatricians in a primary care setting in India. Because it is a short, simple, easy to administer questionnaire, the PHQ-9 has tremendous potential in helping to tackle the growing problem of depression among adolescents in developing countries.

Clinical tracking of severely obese children: a new growth chart.

The 2000 Centers for Disease Control and Prevention growth charts are unable to accurately define and display BMI percentiles beyond the 97th percentile. At Children's Hospital Colorado, we created new growth charts that allow clinicians to track and visualize BMI values in severely obese children. This growth chart defines a child's BMI as a "percentage of the 95th percentile." It has the potential to allow clinicians to define subgroups of severe obesity, monitor trends in obese children, and measure treatment success or failure.

The use of patient pictures and verification screens to reduce computerized provider order entry errors.

OBJECTIVE: To determine whether an order verification screen, including a patient photograph, is an effective strategy for reducing the risk that providers will place orders in an unintended patient's electronic medical record (EMR). METHODS: We describe several changes to the EMR/provider interface and ordering workflow that were implemented as one part of a hospital-wide quality improvement effort to improve patient identification and verification practices. We measured the impact by comparing the number of reported incidents of care being provided to any patient other than for whom it was intended before the intervention, and directly after the intervention. RESULTS: For the year before the interventions described herein, placement of orders in the incorrect patient's chart was the second most common cause of care being provided to the wrong patient, comprising 24% of the reported errors. In the 15 months after the implementation of an order verification screen with the patient's photo centrally placed on the screen, no patient whose picture was in the EMR was reported to have received unintended care based on erroneous order placement in his or her chart. CONCLUSIONS: The incorporation of patient pictures within a computerized order entry verification process is an effective strategy for reducing the risk that erroneous placement of orders in a patient's EMR will result in unintended care being provided to an incorrect patient.

Adolescent medicine training in pediatric residency programs.

OBJECTIVES: The aim of this study was to provide an assessment of pediatric residency training in adolescent medicine. METHODS: We conducted 2 national surveys: 1 of pediatric residency program directors and the other of faculty who are responsible for the adolescent medicine block rotation for pediatric residents to elicit descriptive and qualitative information concerning the nature of residents' ambulatory care training experience in adolescent medicine and the workforce issues that affect the experience. RESULTS: Required adolescent medicine topics that are well covered pertain to normal development, interviewing, and sexual issues. Those least well covered concern the effects of violence, motor vehicle safety, sports medicine, and chronic illness. Shortages of adolescent medicine specialists, addictions counselors, psychiatrists, and other health professionals who are knowledgeable about adolescents frequently limit pediatric residency training in adolescent medicine. Considerable variation exists in the timing of the mandatory adolescent medicine block rotation, the clinic sites used for ambulatory care training, and the range of services offered at the predominant training sites. In addition, residents' continuity clinic experience often does not include adolescent patients; thus, pediatric residents do not have opportunities to establish ongoing therapeutic relationships with adolescents over time. Both program and rotation directors had similar opinions about adolescent medicine training. CONCLUSIONS: Significant variation and gaps exist in adolescent medicine ambulatory care training in pediatric residency programs throughout the United States. For addressing the shortcomings in many programs, the quality of the block rotation should be improved and efforts should be made to teach adolescent medicine in continuity, general pediatric, and specialty clinics. In addition, renewed attention should be given to articulating the core competencies needed to care for adolescents.

Reproductive health in school-based health centers: findings from the 1998-99 census of school-based health centers.

PURPOSE: To describe the state of reproductive health services, including access to contraception and health center policies, among school-based health centers (SBHCs) serving adolescents in the United States METHODS: We examined questionnaire data on provision of reproductive health services from the 1998-99 Census of School-Based Health Centers (response rate 70%). We examined 551 SBHCs in schools with high or middle school grades. We used logistic regression to define factors independently associated with services and policies. RESULTS: Most SBHCs (76%) were open full-time; over one-half (51%) of centers had opened in the past 4 years. Services provided, either on-site or by referral, included gynecological examinations (95%), pregnancy testing (96%), sexually transmitted disease (STD) diagnosis and treatment (95%), Human Immunodeficiency Virus (HIV) counseling (94%), HIV testing (93%), oral contraceptive pills (89%), condoms (88%), Depo-Provera (88%), Norplant (78%), and emergency contraception (77%). Counseling, screening, pregnancy testing, and STD/HIV services were often provided on-site (range 55%-82%); contraception was often provided only by referral (on-site availability = 3%-28%). SBHCs with more provider staffing were more likely to provide services on-site; rural SBHCs and those serving younger grades were less likely to provide these services on-site. Over three-quarters (76%) of SBHCs reported prohibitions about providing contraceptive services on-site; the sources of these prohibitions included school district policy (74%), school policy (30%), state law (13%), and health center policy (12%). While SBHCs generally required parental permission for general health services, many allowed adolescents to access care independently for certain services including STD care (48%) and family planning (40%). Older SBHCs were more likely to allow independent access. CONCLUSIONS: SBHCs provide a broad range of reproductive health services directly or via referral; however, they often face institutional and logistical barriers to providing recommended reproductive health care.

Manual de pediatria / Handbook of pediatrics

Este livro oferece uma fonte adequada e atual de informações práticas sobre os cuidados com a criança, desde a primeira infância até a adolescência. Princípios fisiológicos e farmacológicos dão substancial apoio às variadas informações clínicas contidas neste texto. Satisfaz às necessidades de todos os profissionais de saúde envolvidos nos cuidados do dia-a-dia de pacientes pediátricos. Os estudantes de medicina e os residentes que trabalham em hospitais ou em ambulatórios irão apreciar a descrição concisa das doenças e a acessibilidade das informações aqui apresentadas. As enfermeiras e os médicos práticos, particularmente os de cuidados primários, encontrarão uma rápida referência oferecendo largo espectro de informações: são incluídos capítulos sobre dermatologia, cardiologia, otorrinolaringologia, além de outras importantes especialidades pediátricas. O livro proporciona uma síntese atualizada dos conhecimentos pediátricos. A equipe de editores e de colaboradores continuou a revisar, a reorganizar e modernizar os assuntos para facilitar sua utilização na prática diária. São incluídos os mais recentes avanços médicos e recomendações terapêuticas. Os editores continuam a esforçar-se para apresentar o máximo possível de dados sob a forma de quadros e figuras, tornando o texto mais compreensível. Foi dada nova disposição aos capítulos de modo a oferecer uma apresentação mais fluente. No final do livro foram agrupados capítulos sob Terapia medicamentosa e Formulário, Emergências pediátricas, Procedimentos pediátricos e o Apêndice contendo os valores laboratoriais normais. Os novos capítulos incluíram os seguintes tópicos: Medicina desportiva; Pediatria comportamental, picossocial e psiquiátrica; Genética; Cuidados com o recém-nascido; O recém-nascido: doenças e distúrbios. Muitos capítulos sofreram importante revisão. Incluindo amplas alterações nos: Fluídos e eletrólitos; Distúrbios neurológicos e musculares

Manual de pediatria / Handbook of pediatrics

Este livro oferece uma fonte adequada e atual de informações práticas sobre os cuidados com a criança, desde a primeira infância até a adolescência. Princípios fisiológicos e farmacológicos dão substancial apoio às variadas informações clínicas contidas neste texto. Satisfaz às necessidades de todos os profissionais de saúde envolvidos nos cuidados do dia-a-dia de pacientes pediátricos. Os estudantes de medicina e os residentes que trabalham em hospitais ou em ambulatórios irão apreciar a descrição concisa das doenças e a acessibilidade das informações aqui apresentadas. As enfermeiras e os médicos práticos, particularmente os de cuidados primários, encontrarão uma rápida referência oferecendo largo espectro de informações: são incluídos capítulos sobre dermatologia, cardiologia, otorrinolaringologia, além de outras importantes especialidades pediátricas. O livro proporciona uma síntese atualizada dos conhecimentos pediátricos. A equipe de editores e de colaboradores continuou a revisar, a reorganizar e modernizar os assuntos para facilitar sua utilização na prática diária. São incluídos os mais recentes avanços médicos e recomendações terapêuticas. Os editores continuam a esforçar-se para apresentar o máximo possível de dados sob a forma de quadros e figuras, tornando o texto mais compreensível. Foi dada nova disposição aos capítulos de modo a oferecer uma apresentação mais fluente. No final do livro foram agrupados capítulos sob Terapia medicamentosa e Formulário, Emergências pediátricas, Procedimentos pediátricos e o Apêndice contendo os valores laboratoriais normais. Os novos capítulos incluíram os seguintes tópicos: Medicina desportiva; Pediatria comportamental, picossocial e psiquiátrica; Genética; Cuidados com o recém-nascido; O recém-nascido: doenças e distúrbios. Muitos capítulos sofreram importante revisão. Incluindo amplas alterações nos: Fluídos e eletrólitos; Distúrbios neurológicos e musculares.