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

Developing an Interfacility Transfer Handoff Intervention: Applying the Person-Based Approach Method

ObjectiveTo develop an interfacility transfer handoff intervention by applying the person-based approach method.MethodsWe conducted a qualitative study that used nominal group technique (NGT) and focus groups to apply the person-based approach for intervention development. NGT methods were used to determine prioritized pediatric transfer handoff elements to design the initial intervention prototype. Five focus group sessions were then held to solicit feedback on the intervention, perceptions on implementing the intervention, and outcomes for evaluating the intervention. Data were analyzed by using content analysis. Iterative improvements were made to the intervention prototype as data emerged.ResultsForty-two clinical providers in total participated in NGT and focus group sessions, including physicians, advanced practitioners, nurses, and a respiratory therapist. The initial intervention prototype was a handoff mnemonic tool, "SHARING" (short introduction, how the patient appeared, action taken, responses and results, interpretation, next steps, gather documents). Perceived benefits of the intervention included clarifying handoff expectations, reducing handoff deficits, supporting less experienced clinical providers, and setting the stage for ongoing effective communication. Outcomes perceived to be meaningful were related to triage appropriateness, workflow and use, and communication and information sharing. The final version of the intervention consisted of a SHARING reference card and a SHARING electronic medical record note template.ConclusionsUsing qualitative methods to apply the person-based approach to intervention development, we developed a transfer handoff intervention. Future research is needed to examine impacts of this tool; outcomes can include those identified as meaningful by participants in our present study

Impact of a Parent Video Viewing Program in the Neonatal Intensive Care Unit.

Purpose: Video visits, or televisits, have become increasingly popular across various medical subspecialties. Within the University of California, Davis, Neonatal Intensive Care Unit, a video visitation program known as FamilyLink allows families to remotely view their babies when they are otherwise unable to visit. This study aimed to explore parents' perceived effects of video camera use as well as the relationship of video visit use with rates of breast milk feedings at hospital discharge. Materials and Methods: Families enrolled in this study completed a series of two identical surveys that gathered self-reported data on their experiences during their infant's hospitalization. Comparisons were made considering whether the FamilyLink program was utilized during the admission as well as changes in self-reported experiences over the time course of the hospital admission. The type of enteral feeding at discharge was recorded and reviewed for each baby. Results: Of 100 families enrolled in the study, 30 were found to have used FamilyLink to visit with their baby. The use of FamilyLink was associated with survey findings of sustained intention to breastfeed or provide breast milk to the baby, as well as increased perceived parental involvement in the baby's care. Improved rates of breast milk feedings at the time of discharge were also found among babies whose families conducted televisits using FamilyLink. Conclusions: Video viewing in the NICU has effected a positive impact on breast milk feedings and parents' feelings of involvement during the admission, with the potential to further improve on families' experiences with a hospitalized baby

Home Visits for Children and Adolescents with Uncontrolled Type 1 Diabetes

Background: Home-based video visits were provided over one year as a supplement to in-person care for pediatric type 1 diabetes (T1D) patients with suboptimal glycemic control. We hypothesized that the intervention would be feasible and satisfactory for the target population and would significantly improve hemoglobin A1c (HbA1c) levels and completion of recommended quarterly diabetes clinic visits. Methods: This was a nonrandomized clinical trial. Fifty-seven patients aged 3-17 years with known T1D and HbA1c ≥8% (64 mmol/mol) were recruited to receive the intervention. The study population was 49% adolescent (13-17 years old) and 58% publicly insured patients. Video visits were scheduled every 4, 6, or 8 weeks depending on the HbA1c level. HbA1c levels as well as frequencies of clinic visits and of diabetes-related emergency department (ED) and hospital encounters were compared before and after the study. Results: Thirty participants completed 12 months of video visits. The study cohort demonstrated significant improvement in mean HbA1c in both intention-to-treat (N = 57) analysis (10.8% [95 mmol/mol] to 10.0% [86 mmol/mol], P = 0.01) and per-protocol (N = 30) analysis (10.8% [95 mmol/mol] to 9.6% [81 mmol/mol], P = 0.004). Completion of ≥4 annual diabetes clinic visits improved significantly from 21% at baseline to 83% during the study period for the entire cohort, P < 0.0001. The frequency of diabetes-related ED and hospital encounters did not change significantly. Conclusions: Home-based video visits are a feasible supplement to in-person care for children and adolescents with T1D and suboptimal glycemic control and can successfully improve HbA1c levels and adherence to recommended frequency of care in this high-risk clinical population

Testing Pediatric Emergency Telemedicine Implementation Strategies Using Quality Improvement Methods.

Background: Despite the recognized benefits of telemedicine use for pediatric emergency consultations, there are barriers to the widespread uptake of this technology. Quality improvement methods can be used to rapidly test implementation strategies. Our objective was to test telemedicine implementation strategies in real-world application using quality improvement methods. Our quality improvement aim was to achieve high rates of telemedicine use for pediatric transfer consultations. Methods: A multidisciplinary multisite improvement team identified that key drivers of increasing telemedicine use included telemedicine resource awareness, streamlined telemedicine workflow, provider buy-in, and data transparency. Interventions focused on telemedicine trainings, disseminating telemedicine uptake data, telemedicine reminders, telemedicine test calls, and preparing for telemedicine use for every transfer consultation. The outcome measure was percentage of pediatric emergency transfer consultations that used telemedicine. The balancing measure was time (minutes) from the initial transfer center call to completion of the consultation. Results: Multiple plan-do-study-act cycles were associated with special cause variation, with an upward shift in mean percentage of telemedicine use from 5% to 22%. Time from initial call to consultation completion remained unchanged. Conclusion: Our study supports the use of quality improvement methods to test telemedicine implementation strategies for pediatric telemedicine emergency consultations