Provider perspectives on chronic kidney disease diagnosis delivery
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AIMS: Lack of clear provider communication has been suggested as a reason for low patient awareness of their chronic kidney disease (CKD) diagnosis. Using quality improvement methods, we performed one-on-one provider interviews about CKD diagnosis delivery. MATERIALS AND METHODS: Interviews were audio-recorded, transcribed, and examined using mixed methods. We used thematic analysis to code and analyze transcripts, and Fisher's exact test to examine differences comparing nephrologist and primary care provider (PCP) perspectives. RESULTS: 24 providers completed interviews (18 nephrologists, 6 PCPs). Four themes emerged (N = 260 statements): 1) perspectives informing patients about CKD diagnosis (37 statements), 2) timing of diagnosis messaging (38 statements), 3) language used to convey diagnosis (42 statements), and 4) challenges in diagnosis delivery (143 statements). Most agreed that patients should be informed of their CKD (87.5%), but only 76% believed that communication should occur early. Terminology was not unified; half of nephrology providers used the term "Chronic Kidney Disease" to explain diagnosis. No PCPs used this terminology. Challenges to CKD diagnosis delivery included: Kidney disease is perceived as difficult to explain, lack of provider time, lack of patient symptoms, patient denial of disease, and low public awareness of CKD. CONCLUSIONS: Providers' views on informing patients of their CKD diagnosis were not unified, in particular with respect to timing and terminology of diagnosis delivery. More work is needed to address barriers to efficiently and effectively convey CKD diagnosis information.
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Making Improvements in the ED: Does ED Busyness Affect Time to Antibiotics in Febrile Pediatric Oncology Patients Presenting to the Emergency Department?

OBJECTIVES: Febrile neutropenic pediatric patients are at heightened risk for serious bacterial infections, and rapid antibiotic administration (in <60 minutes) improves survival. Our objectives were to reduce the time-to-antibiotic (TTA) administration and to evaluate the effect of overall emergency department (ED) busyness on TTA. METHODS: This study was a quality improvement initiative with retrospective chart review to reduce TTA in febrile children with underlying diagnosis of cancer or hematologic immunodeficiency who visited the pediatric ED. A multidisciplinary clinical practice guideline (CPG) was implemented to improve TTA. The CPG's main focus was delivery of antibiotics before availability of laboratory data. We collected data on TTA during baseline and intervention periods. Concurrent patient arrivals to the ED per hour served as a proxy of busyness. Time to antibiotic was compared with the number of concurrent arrivals per hour. Analyses included scatter plot and regression analysis. RESULTS: There were 253 visits from October 1, 2010 to March 30, 2012. Median TTA administration dropped from 207 to 89 minutes (P < 0.001). Eight months after completing all intervention periods, the median had dropped again to 44 minutes with 70% of patients receiving antibiotics within 60 minutes of ED arrival. There was no correlation between concurrent patient arrivals and TTA administration during the historical or intervention periods. CONCLUSIONS: Implementation of a CPG and process improvements significantly reduced median TTA administration. Total patient arrivals per hour as a proxy of ED crowding did not affect TTA administration. Our data suggest that positive improvements in clinical care can be successful despite fluctuations in ED patient volume.