Improving ondansetron use and oral rehydration instructions for pediatric acute gastroenteritis.

In paediatric patients with acute gastroenteritis (AGE), ondansetron use decreases the need for intravenous fluids, reduces hospitalisations and shortens illness duration. Oral rehydration is also known to have excellent outcomes for mild to moderate dehydration secondary to AGE. Although these interventions are recommended in guidelines from international professional societies, baseline data at our clinic showed that <2% of these patients were offered ondansetron, and that few patients received appropriately detailed rehydration instructions. Therefore, we engaged residents and fellows as teachers and leaders in our university clinic's quality improvement programme to promote evidence-based practice for paediatric AGE. Our gap analysis identified opportunities for interventions including educating paediatricians and paediatrics residents on the safety and utility of the medication. We created standardised oral rehydration after-visit instructions and implemented a trainee-led educational approach that encouraged appropriate medication use. We used a follow-up survey to uncover provider concerns and tailor future interventions. The process metrics included: proportion of paediatric patients appropriately treated with ondansetron (goal of 80%), and proportion of patients given appropriate oral rehydration instructions. The outcome metric was 7-day representation rates. To achieve sustainability, we restructured our process to have senior residents take ownership of teaching and data collection. Trainee-driven interventions increased ondansetron prescription rates to a median of 66.6%. Patients prescribed ondansetron were less likely to represent to care, although representation rate was low overall. Postintervention data suggests that prescription rates decreased without continued interventions and additional systems redesign may help sustain impact

Development of a Multi-Domain Assessment Tool for Quality Improvement Projects.

BackgroundImproving the quality of health care and education has become a mandate at all levels within the medical profession. While several published quality improvement (QI) assessment tools exist, all have limitations in addressing the range of QI projects undertaken by learners in undergraduate medical education, graduate medical education, and continuing medical education.ObjectiveWe developed and validated a tool to assess QI projects with learner engagement across the educational continuum.MethodsAfter reviewing existing tools, we interviewed local faculty who taught QI to understand how learners were engaged and what these faculty wanted in an ideal assessment tool. We then developed a list of competencies associated with QI, established items linked to these competencies, revised the items using an iterative process, and collected validity evidence for the tool.ResultsThe resulting Multi-Domain Assessment of Quality Improvement Projects (MAQIP) rating tool contains 9 items, with criteria that may be completely fulfilled, partially fulfilled, or not fulfilled. Interrater reliability was 0.77. Untrained local faculty were able to use the tool with minimal guidance.ConclusionsThe MAQIP is a 9-item, user-friendly tool that can be used to assess QI projects at various stages and to provide formative and summative feedback to learners at all levels

Trainee and Program Director Perspectives on Meaningful Patient Attribution and Clinical Outcomes Data

BackgroundThe Accreditation Council for Graduate Medical Education specifies that trainees must receive clinical outcomes and quality benchmark data at specific levels related to institutional patient populations. Program directors (PDs) are challenged to identify meaningful data and provide them in formats acceptable to trainees.ObjectiveWe sought to understand what types of patients, data/metrics, and data delivery systems trainees and PDs prefer for supplying trainees with clinical outcomes data.MethodsTrainees (n = 21) and PDs (n = 12) from multiple specialties participated in focus groups during academic year 2017-2018. They described key themes for providing clinical outcomes data to trainees.ResultsTrainees and PDs differed in how they identified patients for clinical outcomes data for trainees. Trainees were interested in encounters where they felt a sense of responsibility or had autonomy/independent decision-making opportunities, continuity, or learned something new; PDs used broader criteria including all patients cared for by their trainees. Both groups thought trainees should be given trainee-level metrics and consistently highlighted the importance of comparison to peers and/or benchmarks. Both groups found value in "push" and "pull" data systems, although trainees wanted both, while PDs wanted one or the other. Both groups agreed that trainees should review data with specific faculty. Trainees expressed concern about being judged based on their patients' clinical outcomes.ConclusionsTrainee and PD perspectives on which patients they would like outcomes data for differed, but they overlapped for types of metrics, formats, and review processes for the data

Improving Diversity in Pediatric Residency Selection: Using an Equity Framework to Implement Holistic Review.

BackgroundMany programs struggle to recruit, select, and match a diverse class of residents, and the most effective strategies for holistic review of applications to enhance diversity are not clear.ObjectiveWe determined if holistic pediatric residency application review guided by frameworks that assess for bias along structural, interpersonal, and individual levels would increase the number of matched residents from racial and ethnic groups that are underrepresented in medicine (UiM).MethodsBetween 2017 and 2020, University of California San Francisco Pediatrics Department identified structural, interpersonal, and individual biases in existing selection processes and developed mitigation strategies in each area. Interventions included creating a shared mental model of desirable qualities in residents, employing a new scoring rubric, intentional inclusion of UiM faculty and trainees in the selection process, and requiring anti-bias training for everyone involved with recruitment and selection.ResultsSince implementing these changes, the percentage of entering interns who self-identify as UIM increased from 11% in 2015 to 45% (OR 6.8, P = .008) in 2019 and to 35% (OR 4.6, P = .035) in 2020.ConclusionsUsing an equity framework to guide implementation of a pediatric residency program's holistic review of applications increased the numbers of matched UiM residents over a 3-year period

National patterns of codeine prescriptions for children in the emergency department.

Background and objectivesNational guidelines have recommended against codeine use in children, but little is known about prescribing patterns in the United States. Our objectives were to assess changes over time in pediatric codeine prescription rates in emergency departments nationally and to determine factors associated with codeine prescription.MethodsWe performed a serial cross-sectional analysis (2001-2010) of emergency department visits for patients ages 3 to 17 years in the nationally representative National Hospital Ambulatory Medical Care Survey. We determined survey-weighted annual rates of codeine prescriptions and tested for linear trends over time. We used multivariate logistic regression to identify characteristics associated with codeine prescription and interrupted time-series analysis to assess changes in prescriptions for upper respiratory infection (URI) or cough associated with two 2006 national guidelines recommending against its use for these indications.ResultsThe proportion of visits (N = 189 million) with codeine prescription decreased from 3.7% to 2.9% during the study period (P = .008). Odds of codeine prescription were higher for children ages 8 to 12 years (odds ratio [OR], 1.42; 95% confidence interval [1.21-1.67]) and among providers outside the northeast. Odds were lower for children who were non-Hispanic black (OR, 0.67 [0.56-0.8]) or with Medicaid (OR, 0.84 [0.71-0.98]). The 2006 guidelines were not associated with a decline in codeine prescriptions for cough or URI visits.ConclusionsAlthough there was a small decline in codeine prescription over 10 years, use for cough or URI did not decline after national guidelines recommending against its use. More effective interventions are needed to prevent codeine prescription to children

Association between Adaptations to ACGME Duty Hour Requirements, Length of Stay, and Costs

Study objectiveTo determine whether adaptations to comply with Accreditation Council for Graduate Medical Education (ACGME) duty hour requirements are associated with changes in total cost and length of stay.DesignRetrospective, interrupted time-series cohort study using concurrent control patients.SettingUCSF Benioff Children's Hospital, San Francisco, CA.PatientsInpatients newborn to 18 y on the primary pediatrics medical-surgical unit. Medical patients were studied before and after an intervention, and surgical patients served as a concurrent control group.InterventionPediatrics trainees' work schedules were changed from those that relied on prolonged call shifts to those primarily based on shorter day shifts and night shifts.ResultsWe detected significant relative reductions in length of stay but not in total cost. When the analysis was limited to the subset of patients who did not receive intensive care unit care, length of stay decreased by 18% and total cost decreased by 10%. We did not detect similar changes in the control group.ConclusionsA trainee staffing model that included shorter shifts as consistent with current ACGME duty hour requirements was associated with reduced length of stay and total costs for patients not in the intensive care unit