Home-based video visits for pediatric patients with poorly controlled type 1 diabetes

IntroductionManagement of type 1 diabetes (T1D) is labor-intensive, requiring multiple daily blood glucose measurements and insulin injections. Patients are seen quarterly by providers, but evidence suggests more frequent contact is beneficial. Current technology allows secure, remote sharing of diabetes data and video-conferencing between providers and patients in their home settings.MethodsHome-based video visits were provided for six months to pediatric T1D patients with poor glycemic control, indicated by a hemoglobin A1c (HbA1c) ≥8% at enrollment. Video visits were conducted every 4-8 weeks in addition to regularly scheduled clinic visits. Dates of clinic visits and HbA1c values were abstracted from the medical record at baseline and six months. Patients were surveyed at video visits regarding technical issues, and after six months a standardized survey was administered to assess satisfaction with video-based care.ResultsA total of 57 patients enrolled and 36 completed six months of video visits. Patients completing six months averaged 4.0 video visits (SD 1.1). Their frequency of in-person care also increased from 3.2 clinic visits/year at baseline to 3.7 clinic visits/year during the study (P = 0.04). Mean HbA1c reduction among patients completing six months was 0.8% (95% CI 0.2-1.4%); 94% of these patients were "very satisfied" while 6% were "somewhat satisfied" with the experience.DiscussionThis study demonstrates that home-based video visits are feasible and satisfactory for pediatric patients with poorly controlled T1D. Furthermore, use of video visits can improve frequency of subspecialty care and resulting glycemic control in this population

Parent and Physician Qualitative Perspectives on Reasons for Pediatric Hospital Readmissions

ObjectivesOne in 5 parents report a problem in their child's hospital-to-home transition, leading to adverse events, dissatisfaction, and readmissions. Although researchers in several studies have explored parent insights into discharge needs, few have explored perceptions of causes for pediatric readmissions. We sought to investigate factors contributing to pediatric readmissions, from both parent and physician perspectives.MethodsWe conducted a qualitative study using semistructured interviews with parents, discharging and readmitting physicians, and subspecialist consultants of children readmitted within 30 days of initial discharge from the pediatric ward at an urban nonfreestanding children's hospital. Participants were interviewed during the readmission and asked about care transition experiences during the initial admission and potential causes and preventability of readmission. Data were analyzed iteratively by using a constant-comparative approach. We identified major themes, solicited feedback, and inferred relationships between themes to develop a conceptual model for preventing readmissions.ResultsWe conducted 53 interviews from 20 patient readmissions, including 20 parents, 20 readmitting physicians, 11 discharging physicians, and 3 consulting subspecialists. Major themes included the following: (1) unclear roles cause lack of ownership in patient care tasks, (2) lack of collaborative communication leads to discordant understanding of care plans, and (3) incomplete hospital-to-home transitions result in ongoing reliance on the hospital.ConclusionsClear definition of team member roles, improved communication among care team members and between care teams and families, and enhanced care coordination to facilitate the hospital-to-home transition were perceived as potential interventions that may help prevent readmissions

Disconnection in Information Exchange During Pediatric Trauma Transfers: A Qualitative Study.

Pediatric patients experiencing an emergency department (ED) visit for a traumatic injury often transfer from the referring ED to a pediatric trauma center. This qualitative study sought to evaluate the experience of information exchange during pediatric trauma visits to referring EDs from the perspectives of parents and referring and accepting clinicians through semi-structured interviews. Twenty-five interviews were conducted (10 parents and 15 clinicians) and analyzed through qualitative thematic analysis. A 4-person team collaboratively identified codes, wrote memos, developed major themes, and discussed theoretical concepts. Three interdependent themes emerged: (1) Parents' and clinicians' distinct experiences result in a disconnect of information exchange needs; (2) systems factors inhibit effective information exchange and amplify the disconnect; and (3) situational context disrupts the flow of information contributing to the disconnect. Individual-, situational-, and systems-level factors contribute to disconnects in the information exchanged between parents and clinicians. Understanding how these factors' influence information disconnect may offer avenues for improving patient-clinician communication in trauma transfers

Virtual Family-Centered Rounds in the Neonatal Intensive Care Unit: A Randomized Controlled Pilot Trial

ObjectivesTo measure the feasibility, reach, and potential impact of a virtual family-centered rounds (FCR) intervention in the neonatal intensive care unit.MethodsWe conducted a randomized controlled pilot trial with a 2:1 intervention-to-control arm allocation ratio. Caregivers of intervention arm neonates were invited to participate in virtual FCR plus standard of care. We specified 5 feasibility objectives. We profiled intervention usage by neonatal and maternal characteristics. Exploratory outcomes included FCR caregiver attendance, length of stay, breast milk feeding at discharge, caregiver experience, and medical errors. We performed descriptive analyses to calculate proportions, means, and rates with 95% confidence intervals (CI).ResultsWe included 74 intervention and 36 control subjects. Three of the five feasibility objectives were met based on the point estimates. The recruitment and intervention uptake objectives were not achieved. Among intervention arm subjects, recruitment of a caregiver occurred for 47 (63.5%, 95% CI 51.5%-74.4%) neonates. Caregiver use of the intervention occurred for 36 (48.6%, 95% CI 36.8%-60.6%) neonates in the intervention arm. Feasibility objectives assessing technical issues, burden, and data collection were achieved. Among the attempted virtual encounters, 95.0% (95% CI 91.5%-97.3%) had no technical issues. The survey response rate was 87.5% (95% CI 78.2%-93.8%). Intervention arm neonates had 3.36 (95% CI 2.66%-4.23) times the FCR caregiver attendance rate of subjects in the control arm.ConclusionsA randomized trial to compare virtual FCR to standard of care in neonatal subjects is feasible and has potential to improve patient and caregiver outcomes

Improving Pediatric Resident Safety Event Reporting Using Quality Improvement Methods

Background and objectivesSafety event reporting systems facilitate identification of system-level targets to improve patient safety. Resident physicians report few safety events despite their role as frontline providers and the frequent occurrence of events. The objective of this study is to increase the number of pediatric resident safety event submissions from <1 to 4 submissions per 14-day period within 12 months.MethodsWe conducted an iterative quality improvement process with 39 pediatric residents at a children's hospital. Interventions focused on 4 key drivers: user-friendly event submission process, resident buy-in, nonpunitive safety culture, and data transparency. The primary outcome measure of number of pediatric resident event submissions was analyzed by using statistical process control. Balancing measures included time from submission to feedback, duplicate submissions, and nonevent submissions. As a control, the primary outcome measure was monitored for nonpediatric residents during the same period.ResultsThe mean number of pediatric resident event submissions increased from 0.9 to 5.7 submissions per 14 days. Impactful interventions included a designated space in the resident workroom to list safety events to submit, monthly project updates, and an interresident competition. There were no duplicate submissions or nonevent submissions in the postintervention period. Time to feedback in the postintervention period had both upward and downward shifts, with >8 consecutive points above and below the baseline period's centerline. The control group showed no sustained change in event submissions.ConclusionsOur improvement process was associated with significant increase in pediatric resident safety event submissions without an increase in the number of submissions categorized as duplicates or nonevents

Using a Distance-Based Partnership to Start a Hospital Medicine Program and a Quality Improvement Education Program

Distance-based partnerships are being increasingly used in health care and have previously been described to facilitate the training of nurses, researchers, and occupational therapists.1–6 In 2013, the Society of Hospital Medicine’s newly published guidelines for pediatric hospital medicine (PHM) programs indicated that strong leadership is critically important to a program’s success. Many smaller children’s hospitals have very few dedicated pediatric hospitalists, and these hospitalists might not have formal leadership or quality improvement (QI) training, resources, or dedicated time for QI work because of their clinical responsibilities. Similarly, pediatric residency programs at smaller institutions might lack robust inpatient QI experiences for their trainees. Leaders at Cincinnati Children’s Hospital Medical Center (Cincinnati) were approached by leaders at Niswonger Children’s Hospital (Niswonger) to complete a needs assessment of Niswonger’s inpatient program. Niswonger is a 69-bed children’s hospital colocated with Johnson City Medical Center, an adult hospital. These hospitals are located in a suburban area with a large rural catchment area. Both the adult and children’s hospitals are part of a larger health system, Mountain States Health Alliance. Niswonger is affiliated with East Tennessee State University (ETSU) Department of Pediatrics, which provided the majority of physician staffing. The needs assessment, completed in 2012, consisted of several site visits, observation of inpatient rounds, interviews with Niswonger faculty and staff, evaluation of available historical data, and collection of new data. Two main gaps in clinical care and training at Niswonger were identified. The first was the need for a dedicated hospitalist program with providers who did not have competing clinical responsibilities. The general pediatric inpatient unit was historically staffed by several ETSU faculty members, all of whom had primary responsibilities in other areas such as intensive care, outpatient primary care, and infectious disease and none of whom were dedicated pediatric hospitalists. These physicians would typically conduct inpatient teaching rounds in the morning and then resume other clinical responsibilities. The second was the need for QI training for the 19 residents in the ETSU pediatric residency program, an Accreditation Council for Graduate Medical Education requirement