Providing Preventive Oral Health Care to Infants and Young Children in Women, Infants, and Children (WIC), Early Head Start, and Primary Care Settings

This report focuses on seven oral health programs that provide preventive oral health care to young children (infants, toddlers, and children up to 5 years old) in Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), Early Head Start (EHS), and primary care settings. All of the programs strive to increase access to preventive oral health care by integrating dental services into primary care settings, WIC clinics, or EHS centers. These programs also rely on primary care providers (physicians, nurses, medical assistants, etc.) or new types of dental hygienists who can practice in community settings to deliver preventive oral health services. Two additional reports in this series describe the remaining programs that provide care in non-dental settings and programs designed to specifically address socioeconomic, cultural, and geographic barriers to preventive oral health care.The findings from the EAs of these programs are synthesized to highlight diverse and innovative strategies that are utilized to provide preventive oral health care in primary care settings, WIC clinics, or EHS centers. These strategies have potential for rigorous evaluation and could emerge as best practices. If proven effective, these innovative program elements could then be disseminated and replicated to increase access for populations in need of preventive oral health care

Decreasing Maternal Breastfeeding Dissatisfaction During the Night Shift Related to Lactation Support

Abstract Problem This paper will discuss the Clinical Nurse Leader (CNL) project\u27s specific aim: to decrease maternal dissatisfaction during the night shift related to lactation support in a high-risk maternal department. Context Research has shown that adding lactation support improves the decision to exclusively breastfeed and increases the duration. Breastfeeding for all infants starting at birth and continuing until at least 6 months of age has been recommended by the World Health Organization, UNICEF, and the American Academy of Pediatrics. Many studies about lactation support have demonstrated the health benefits to mothers and their infants. Interventions A baseline survey will be given to exclusively breastfeeding mothers with either vaginal or c-section deliveries with singleton or multiple infant births. Based on results, a six-week-night shift lactation pilot program will add 24-hour lactation support for mothers who decide to breastfeed exclusively. A baseline survey highlights the need to ensure that postpartum breastfeeding support provided by lactation consultants is perceived as positive by new mothers. Post survey will identify the success of the six-week pilot. Devoted lactation consultants provide education and support for new mothers desiring to breastfeed to improve breastfeeding outcomes. Measures The project\u27s process measure will be to implement lactation consultant coverage on the night shift. Each measure in the project will lead to a goal to increase maternal satisfaction. This project\u27s global aim will be to increase exclusive breastfeeding rates from 69% to 75%, by results monitored in an in-house STATIT tracking report. The specific aim of decreasing maternal dissatisfaction during the night shift related to lactation support will be documented by 24 respondents completing a seven-question baseline and post-pilot survey. Conclusion The objective of this review was to assess if providing night shift lactation education or support using lactation consultants would improve patient satisfaction and increase exclusive breastfeeding rates. Evidence suggests that developing and improving lactation support increases breastfeeding initiation and improves breastfeeding experiences in an atmosphere of well-being

Barriers and facilitators in the integration of oral health into primary care: a scoping review

Objective This scoping study has been conducted to map the literature and provide a descriptive synthesis on the barriers and facilitators of the integration of oral health into primary care. Methods Grounded in the Rainbow conceptual model and using the Levac et al six-stage framework, we performed a systematic search of electronic databases, organisational websites and grey literature from 1978 to April 2016. All publications with a focus on the integration of oral health into primary care were included except commentaries and editorials. Thematic analyses were performed to synthesise the results. Results From a total of 1619 citations, 58 publications were included in the review. Barrier-related themes included: lack of political leadership and healthcare policies; implementation challenges; discipline-oriented education; lack of continuity of care and services and patients’ oral healthcare needs. The facilitators of integration were supportive policies and resources allocation, interdisciplinary education, collaborative practices between dental and other healthcare professionals, presence of local strategic leaders and geographical proximity. Discussion and public health implications This work has advanced the knowledge on the barriers and facilitators at each integration domain and level, which may be helpful if the healthcare organisations decide to integrate oral health and dental services into primary care. The scoping review findings could be useful for both dental and medical workforce and allied primary healthcare providers. They could also guide the development of healthcare policies that support collaborative practices and patient-centred care in the field of primary care

Development and implementation of a mobile device-based pediatric electronic decision support tool as part of a national practice standardization project

OBJECTIVE: Implementing evidence-based practices requires a multi-faceted approach. Electronic clinical decision support (ECDS) tools may encourage evidence-based practice adoption. However, data regarding the role of mobile ECDS tools in pediatrics is scant. Our objective is to describe the development, distribution, and usage patterns of a smartphone-based ECDS tool within a national practice standardization project. MATERIALS AND METHODS: We developed a smartphone-based ECDS tool for use in the American Academy of Pediatrics, Value in Inpatient Pediatrics Network project entitled Reducing Excessive Variation in the Infant Sepsis Evaluation (REVISE). The mobile application (app), PedsGuide, was developed using evidence-based recommendations created by an interdisciplinary panel. App workflow and content were aligned with clinical benchmarks; app interface was adjusted after usability heuristic review. Usage patterns were measured using Google Analytics. RESULTS: Overall, 3805 users across the United States downloaded PedsGuide from December 1, 2016, to July 31, 2017, leading to 14 256 use sessions (average 3.75 sessions per user). Users engaged in 60 442 screen views, including 37 424 (61.8%) screen views that displayed content related to the REVISE clinical practice benchmarks, including hospital admission appropriateness (26.8%), length of hospitalization (14.6%), and diagnostic testing recommendations (17.0%). Median user touch depth was 5 [IQR 5]. DISCUSSION: We observed rapid dissemination and in-depth engagement with PedsGuide, demonstrating feasibility for using smartphone-based ECDS tools within national practice improvement projects. CONCLUSIONS: ECDS tools may prove valuable in future national practice standardization initiatives. Work should next focus on developing robust analytics to determine ECDS tools\u27 impact on medical decision making, clinical practice, and health outcomes

Refining Clinician Workflow as a Means to Improving Catheter Quality Measures

Objective This study aimed to improve the quality measure performance for indwelling urinary catheter (IUC) duration, central venous catheter (CVC) duration, and telemetry duration by redesigning clinical decision support (CDS) tools within the documentation process and order workflow. Methods The effectiveness of the redesign was evaluated using system standard quality reporting methodology to observe device duration, central-line-associated bloodstream infection (CLABSI) rate, and catheter-associated urinary tract infection (CAUTI) rate preintervention (FY2017) and postintervention (FY2018). Electronic health record (EHR) reporting tools were used to evaluate CDS alert data both preintervention and postintervention. Results Total device duration and line days per patient days were reduced for CVC (12.8% [0.305–0.266]) and IUC (4.68% [0.171–0.163]). Mean telemetry duration was reduced by 16.94% (3.72–3.09 days), and CDS alert volume decreased 18.6% from a preintervention mean of 1.18 alerts per patient per day (81,190 total alerts) to a postintervention mean of 0.96 alerts per patient per day (61,899 total alerts). Both CLABSI (2.8% [1.07–1.04]) and CAUTI (8.1% [1.61–1.48]) rates were reduced, resulting in approximately $926,000 in savings. Conclusion In this novel model, the redesigned CDS tools improved clinician response to CDS alerts, prompting providers to take action on relevant orders that automatically updated the clinical documentation to reflect their actions. The study demonstrated that effective redesign of CDS tools within the documentation process and order workflow can reduce device duration, improve patient outcomes, and decrease CDS alert volume

Introducing Screening for Family Risks in Young Children in Primary Care

Background: One in four children in the United States under the age of five is at risk for developmental, behavioral or social delay. Genetics and environment, including exposure to adversity, play a major role in healthy neurological development. The Survey of Well-being of Young Children (SWYC) as a screening instrument was developed to address perceived barriers and standardize physiological, psychosocial and family risks screening in primary care to identify those who would benefit most from early intervention. Methods: This quality improvement project involved an information session for providers and staff at a Federally-Qualified Health Center in Western Massachusetts to introduce standardized adversity screening in the pediatric population. A workflow was developed for regular screening and the SWYC was incorporated into all preventative health exams for children under age 5 ½. Results: The SWYC forms are now a part of the electronic medical record for use by all providers in this clinic. Developmental and behavioral screening with the SWYC effectively identifies those children at risk for delay, provides a valuable longitudinal snapshot of their development over time, and referrals to early intervention services has increased upon implementation. Limitations include increased work for support staff, a consensus that caregivers are not forthcoming in their answers about family risks and a paucity of trauma-informed medical professionals in the area able to support positive adversity findings. Conclusion: Standardizing screening for family risks allows providers to assess the impact of home environment on their patient’s future health while addressing many of the perceived barriers that have prevented childhood adversity screening in the past. Evidence-based, easily accessible mental health care needs to be more readily available for screening to be effective. Keywords: Childhood adversity, Survey of Well-being for Young Childre

The Promise of Health Information Technology: Ensuring that Florida's Children Benefit

Substantial policy interest in supporting the adoption of Health Information Technology (HIT) by the public and private sectors over the last 5 -- 7 years, was spurred in particular by the release of multiple Institute of Medicine reports documenting the widespread occurrence of medical errors and poor quality of care (Institute of Medicine, 1999 & 2001). However, efforts to focus on issues unique to children's health have been left out of many of initiatives. The purpose of this report is to identify strategies that can be taken by public and private entities to promote the use of HIT among providers who serve children in Florida

Sustainable Deimplementation of Continuous Pulse Oximetry Monitoring in Children Hospitalized with Bronchiolitis: Study Protocol for the Eliminating Monitor Overuse (EMO) Type III Effectiveness-Deimplementation Cluster-Randomized Trial

Background: Methods of sustaining the deimplementation of overused medical practices (i.e., practices not supported by evidence) are understudied. In pediatric hospital medicine, continuous pulse oximetry monitoring of children with the common viral respiratory illness bronchiolitis is recommended only under specific circumstances. Three national guidelines discourage its use for children who are not receiving supplemental oxygen, but guideline-discordant practice (i.e., overuse) remains prevalent. A 6-hospital pilot of educational outreach with audit and feedback resulted in immediate reductions in overuse; however, the best strategies to optimize sustainment of deimplementation success are unknown. Methods: The Eliminating Monitor Overuse (EMO) trial will compare two deimplementation strategies in a hybrid type III effectiveness-deimplementation trial. This longitudinal cluster-randomized design will be conducted in Pediatric Research in Inpatient Settings (PRIS) Network hospitals and will include baseline measurement, active deimplementation, and sustainment phases. After a baseline measurement period, 16–19 hospitals will be randomized to a deimplementation strategy that targets unlearning (educational outreach with audit and feedback), and the other 16–19 will be randomized to a strategy that targets unlearning and substitution (adding an EHR-integrated clinical pathway decision support tool). The primary outcome is the sustainment of deimplementation in bronchiolitis patients who are not receiving any supplemental oxygen, analyzed as a longitudinal difference-in-differences comparison of overuse rates across study arms. Secondary outcomes include equity of deimplementation and the fidelity to, and cost of, each deimplementation strategy. To understand how the deimplementation strategies work, we will test hypothesized mechanisms of routinization (clinicians developing new routines supporting practice change) and institutionalization (embedding of practice change into existing organizational systems). Discussion: The EMO trial will advance the science of deimplementation by providing new insights into the processes, mechanisms, costs, and likelihood of sustained practice change using rigorously designed deimplementation strategies. The trial will also advance care for a high-incidence, costly pediatric lung disease. Trial registration: ClinicalTrials.gov,NCT05132322. Registered on November 10, 2021

A systematic review of outcomes reported inpediatric perioperative research: A report from the Pediatric Perioperative Outcomes Group

The Pediatric Perioperative Outcomes Group (PPOG) is an international collaborative of clinical investigators and clinicians within the subspecialty of pediatric anesthesiology and perioperative care which aims to use COMET (Core Outcomes Measures in Effectiveness Trials) methodology to develop core outcome sets for infants, children, and young people that are tailored to the priorities of the pediatric surgical population. Focusing on four age‐dependent patient subpopulations determined a priori for core outcome set development: (a) neonates and former preterm infants (up to 60 weeks postmenstrual age); (b) infants (>60 weeks postmenstrual age—1‐13‐<18 years), we conducted a systematic review of outcomes reported in perioperative studies that include participants within age‐dependent pediatric subpopulations. Our review of pediatric perioperative controlled trials published from 2008 to 2018 identified 724 articles reporting 3192 outcome measures. The proportion of published trials and the most frequently reported outcomes varied across predetermined age‐groups. Outcomes related to patient comfort, particularly pain and analgesic requirement, were the most frequent domain for infants, children, and adolescents. Clinical indicators, particularly cardiorespiratory or medication‐related adverse events, were the most common outcomes for neonates and infants <60 weeks and were the second most frequent domain at all other ages. Neonates and infants <60 weeks of age were significantly under‐represented in perioperative trials. Patient‐centered outcomes, healthcare utilization, and bleeding/transfusion‐related outcomes were less often reported. In most studies, outcomes were measured in the immediate perioperative period, with the duration often restricted to the postanesthesia care unit or the first 24 postoperative hours. The outcomes identified with this systematic review will be combined with patient‐centered outcomes identified through a subsequent stakeholder engagement study to arrive at a core outcome set for each age‐specific group

Information Systems and Healthcare XXXIV: Clinical Knowledge Management Systems—Literature Review and Research Issues for Information Systems

Knowledge Management (KM) has emerged as a possible solution to many of the challenges facing U.S. and international healthcare systems. These challenges include concerns regarding the safety and quality of patient care, critical inefficiency, disparate technologies and information standards, rapidly rising costs and clinical information overload. In this paper, we focus on clinical knowledge management systems (CKMS) research. The objectives of the paper are to evaluate the current state of knowledge management systems diffusion in the clinical setting, assess the present status and focus of CKMS research efforts, and identify research gaps and opportunities for future work across the medical informatics and information systems disciplines. The study analyzes the literature along two dimensions: (1) the knowledge management processes of creation, capture, transfer, and application, and (2) the clinical processes of diagnosis, treatment, monitoring and prognosis. The study reveals that the vast majority of CKMS research has been conducted by the medical and health informatics communities. Information systems (IS) researchers have played a limited role in past CKMS research. Overall, the results indicate that there is considerable potential for IS researchers to contribute their expertise to the improvement of clinical process through technology-based KM approaches