Pediatric Health Care System Research Articles

Overview of the pediatric healthcare system in Romania.

Until 1989, Romania was one of the countries of the communist bloc in Europe and its healthcare system was characterized by centralized planning and severe underfunding, with low performance and low quality healthcare. Since 1998, Romania replaced the Semashko model with a social health insurance system, highly centralized under the management of the Ministry of Health as the central administrative authority. After joining the European Union, quality of life increased in our country and there were efforts to improve the quality of healthcare, including pediatric and neonatal care. Still, Romania has the lowest share of health expenditure of gross domestic product among the European Union Member States and the lowest level of expenditure per inhabitant. The Romanian health system is organized on three levels of assistance: primary, secondary and tertiary assistance. This overview presents the organization and the characteristics of pediatric and neonatal healthcare in Romania at all levels, the infrastructure and the human resources, the educational system from medical school to pediatric residency, professional organizations, national health programs, and the child health status in Romania. Infant mortality, the most descriptive single indicator of the quality of a health system, decreased constantly for the last 30 years in Romania, but is still the highest in the European Union. Even though there were great improvements in the healthcare for children, more efforts should be made to assure a better quality of care for the future of our nation, both on the human resources (in great danger due to the brain-drain of medical professionals during the last 12 years), and on the infrastructure plan.

Child healthcare in Israel: current challenges.

The article describes and discusses several key elements of the paediatric healthcare system in Israel, including paediatric training, family and community paediatrics, hospital-based paediatric services, preventive care services, and special programs such as the “Drop of Milk” (Tipat Halav) program. Although child care in Israel has gained several notable achievements, such as a low infant mortality rate, there are several significant challenges for the coming years. These include training of enough paediatricians and periodic updating of training programs to fulfil needs and provide an adequate preventive care from fetal life through infancy, childhood, and adulthood. In addition, paediatricians in Israel should continue to be involved in national public health programs to reduce health inequities among mothers and children and reduce health disparities among certain geographic areas and various populations. Graduates of paediatric residency are expected to be able to address the new technologies, the requirements for personal medicine and on-line medicine, and to be able to deal with both pure “medical” issues, and public health, lifestyle, and environmental issues.

Children facing natural, economic and public health crisis in Europe: The risks of a predictable unpredictability.

This opening article for the volume dedicated to the diversity of paediatric healthcare systems in Europe, discusses the topic of children facing natural, economic, and public health crises in Europe. The natural and economic adversities and public health crises, which have repeatedly stormed the globe during the past twenty years, have often unveiled a low degree of self-sufficiency and a high degree of unpreparedness by European countries. It is always the case that the most vulnerable take the brunt, and these adverse events have shown their effects and a negative direct impact particularly on the population aged 0–18 years, with important implications for families and communities. The article discusses a rational approach to properly confront future public health emergencies and crises in general. The authors stress the concept that such approaches should be built on past negative experiences, in order to explore, identify, and make clear which are the priorities governing the disaster management activities at all levels in this population group. The authors conclude that safeguarding the health of children could be effectively accomplished by developing adequate, shared emergency management strategies. Improving pediatric preparedness approaches with the use of emergency measures and ongoing collaboration will facilitate a better and more efficient response, able to effectively care for the needs of children in actual crises.

Improving Bronchiolitis Care in Outpatient Settings Across a Health Care System.

This study aimed (1) to reduce use of ineffective testing and therapies in children with bronchiolitis across outpatient settings in a large pediatric health care system and (2) to assess the cost impact and sustainability of these initiatives. We designed a system-wide quality improvement project for patients with bronchiolitis seen in 3 emergency departments (EDs) and 5 urgent care (UC) centers. Interventions included development of a best-practice guideline and education of all clinicians (physicians, nurses, and respiratory therapists), ongoing performance feedback for physicians, and a small physician financial incentive. Measures evaluated included use of chest x-ray (CXR), albuterol, viral testing, and direct (variable) costs. Data were tracked using statistical process control charts. For 3 bronchiolitis seasons, albuterol use decreased from 54% to 16% in UC and from 45% to 16% in ED. Chest x-ray usage decreased from 29% to 9% in UC and from 21% to 12% in the ED. Viral testing in UC decreased from 18% to 2%. Cost of care was reduced by $283,384 within our system in the first 2 seasons following guideline implementation. Improvements beginning in the first bronchiolitis season were sustained and strengthened in the second and third seasons. Admissions from the ED and admissions after return to the ED within 48 hours of initial discharge did not change. A system-wide quality improvement project involving multiple outpatient care settings reduced the use of ineffective therapies and interventions in patients with bronchiolitis and resulted in significant cost savings. Improvements in care were sustained for 3 bronchiolitis seasons.

Prospective External Validation of the Pediatric Risk Assessment Score in Predicting Perioperative Mortality in Children Undergoing Noncardiac Surgery.

Early identification of children at high risk for perioperative mortality could lead to improved outcomes; however, there is a lack of well-validated risk prediction tools. The Pediatric Risk Assessment (PRAm) score is a new model to prognosticate perioperative risk of mortality in pediatric patients undergoing noncardiac surgery. It was derived from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) Pediatric database. In this study, we aimed to externally validate the PRAm score at 1 large institution. A PRAm score was prospectively assigned by the primary anesthesia team to children ≤18 years of age undergoing noncardiac surgery between July 2017 and July 2018 at a tertiary care pediatric hospital. The primary outcome was the PRAm score's ability to predict 30-day mortality. The area under the receiver operating characteristic (ROC) curve was utilized to determine discriminative ability. Sensitivity and specificity at varying cutoffs were considered. Youden J index and the gray zone approach were applied to determine the optimal PRAm cutoff for predicting 30-day mortality. Among the 13,530 cases included in the external validation cohort, the incidence of 30-day mortality was 0.21% (29/13,530). The PRAm score was found to predict 30-day mortality with an area under the curve (AUC) of 0.956 (95% confidence interval [CI], 0.938-0.974; P < .001). Youden J index determined the optimal PRAm score threshold to be ≥5 with a sensitivity of 86% and a specificity of 91%. The gray zone identified an inconclusive risk of mortality in 6.93% (938/13,530) of patients who had PRAm scores of 4 or 5 (sensitivity or specificity <90%, respectively), therefore refining the optimal cutoff point to be a PRAm score of ≥6. The incidence of mortality for patients with an American Society of Anesthesiologists Physical Status (ASA PS) ≤3 (0.06%, 8/13,530) increased 8-fold for those with an ASA PS of ≤3 and a PRAm score of ≥6. The PRAm score is a simple and objective tool that has excellent ability to predict perioperative risk of mortality in pediatric patients undergoing noncardiac surgery and can be easily used by clinicians. The application of the PRAm score could have important implications on the safety and quality of care delivered to infants and children and on the resource utilization in the pediatric health care system.

Characteristics and Workload of Pediatricians in China

Although it is widely believed that China is facing a major shortage of pediatricians, the real situation of the current national status of pediatric human resources and their working conditions has not been evaluated to date. We administered a survey to 54 214 hospitals from all 31 provinces in mainland China from 2015 to 2016. Hospital directors of all secondary and tertiary hospitals with pediatric services and a random sample (10%) of primary hospitals provided information on number of pediatricians and their educational levels, specialties, workloads, dropout rates, and other hospital characteristics. A data set of medical resources and socioeconomic information regarding each region (1997-2016) was constructed from the Chinese National Statistics Bureau. The Gini coefficient was used to describe the geographical distributions of pediatricians and hospitals. There were 135 524 pediatricians in China or ∼4 pediatricians per 10 000 children. Pediatricians' average educational level was low, with ∼32% having only 3 years of junior college training after high school. The distribution of pediatricians was extremely skewed (Gini coefficient 0.61), and the imbalance of highly educated pediatricians was even more skewed (Gini coefficient 0.68). The dropout rate of pediatricians was 12.6%. Despite an increase in the Chinese government's financial investment in health over the last decade, physicians have been burdened with a greater workload. Uneven development of the pediatric care system, inadequately trained pediatricians, low job satisfaction, and unmet demand for pediatric care are the major challenges facing China's pediatric health care system.

A Multidisciplinary Transition Consult Service: Patient Referral Characteristics

PurposeChildren's hospitals must provide developmentally appropriate care to increasing numbers of young adults with complex healthcare needs as they transition to adult-oriented care. This article describes the patients, service, and short-term outcomes of an interprofessional healthcare transition (HCT) consult team comprised of nurses, social workers, a community health worker, and physicians. Design and methodsThe Adult Consult Team's tiered population framework stratifies patients by medical complexity. The team coordinates HCT services for patients with the highest complexity. Patients at least 18 years old are eligible if they have at least two specialists or an intellectual or developmental disability (IDD). Through a comprehensive medical and psychosocial assessment, the team prepares patients/families for adult-oriented healthcare. ResultsThe Adult Consult Team received 197 referrals from July 2017 to June 2018. Patients had at least two specialists (73%), IDD (71%), technology dependence (e.g., gastrostomy tube, 37%) and Medicaid insurance (57%). The team assisted patients seen in its outpatient clinic with navigating mental health services (39%), insurance issues (13%), IDD services (15%), and the guardianship process (37%) and creating comprehensive care plans. ConclusionsThe Adult Consult Team transferred 30 patients with medical complexity to adult primary and specialty care, significantly improving pediatric inpatient and outpatient capacity for pediatric-aged patients. A broad range of young adult medical, psychosocial, legal, educational, and vocational needs were addressed. Practice implicationsAn interprofessional team approach can help large pediatric healthcare systems address the multi-faceted needs of patients who are medically and psychosocially complex as they enter adulthood.

Experience of follow-up, quality of life, and transition from pediatric to adult healthcare of patients with tuberous sclerosis complex

IntroductionTuberous sclerosis complex (TSC) is a multisystemic genetic disease with high clinical variability and age-related manifestations. These characteristics add to the complexity of transition to adulthood. This study aimed to explore the perception of medical follow-up and transition experience in a large group of patients with TSC who presented epilepsy in childhood. MethodThis multicenter French study included patients with TSC aged 18 years or older who developed epilepsy before the age of 16 years. A questionnaire specifically designed for the study explored patients' opinion through 270 questions covering different aspects of their social, familial, professional, and medical courses. ResultsThe questionnaire was sent to 72 patients, and 60 patients were included in the study (83% response rate) with a mean age of 32 years (18–55 years). Cognitive impairment was present in 80% of patients, and half of questionnaires were completed by the family. Pediatric care was coordinated by the child neurologist and was more regular and multidisciplinary than adult care. Epilepsy had the best follow-up followed by renal issues. Unmet needs were identified for psychiatric and behavioral disorders, both in children and adults. Respondents considered the help in achieving autonomy better in adult care. Only 50% of patients with a normal intellectual development had clear knowledge about their disease and the need for a regular monitoring. Two-thirds of respondents estimated that they had a transition experience between 16.5 and 21-year-old, considered as good in 60% of them. Seventy percent felt continuity between pediatric and adult care, and only 3% of respondents felt that their care would have been better if they were still followed in pediatric healthcare system. The change of care structure and/or caregivers was the most stressful factor during transition and transfer. ConclusionThis study highlights persistent issues in the regularity and coordination of the follow-up of patients with TSC despite established international guidelines. Although most patients had a positive transition experience, there is still an urgent need to optimize transition programs. This would be essential to maintain care continuity between pediatric and adult health systems, especially for patients with TSC with epilepsy and high rate of cognitive and psychiatric impairments.

Lost in the system? Transfer to adult congenital heart disease care-Challenges and solutions.

Transfer of congenital heart disease care from the pediatric to adult setting has been identified as a priority and is associated with better outcomes. Our objective is to determine what percentage of patients with congenital heart disease transferred to adult congenital cardiac care. A retrospective cohort study. Referrals to a tertiary referral center for adult congenital heart disease patients from its pediatric referral base. This resulted in 1514 patients age 16-30, seen at least once in three pediatric Georgia health care systems during 2008-2010. We analyzed for protective factors associated with age-appropriate care, including distance from referral center, age, timing of transfer, gender, severity of adult congenital heart disease, and comorbidities. We analyzed initial care by age among patients under pediatric care from 2008 to 2010 and if patients under pediatric care subsequently transferred to an adult congenital cardiologist in this separate pediatric and adult health system during 2008-2015. Among 1514 initial patients (39% severe complexity), 24% were beyond the recommended transfer age of 21years. Overall, only 12.1% transferred care to the referral affiliated adult hospital. 90% of these adults that successfully transferred were seen by an adult congenital cardiologist, with an average of 33.9months between last pediatric visit and first adult visit. Distance to referral center contributed to delayed transfer to adult care. Those with severe congenital heart disease were more likely to transfer (18.7% vs 6.2% for not severe). Patients with severe disease are more likely to transfer to adult congenital heart disease care than nonsevere disease. Most congenital heart disease patients do not transfer to adult congenital cardiology care with distance to referral center being a contributing factor. Both pediatric and adult care providers need to understand and address barriers in order to improve successful transfer.

Evaluating the Acceptability and Validity of Assessing Pain and Posttraumatic Stress Symptoms in an Adaptable eHealth System for School-Age Children.

To provide initial evaluation of the acceptability of a new eHealth system incorporating personalized self-report assessment of multiple health domains in school age children, and assess convergent validity of two brief measures presented via this system. Ill or injured children (N=167) age 6 to 14 recruited in two pediatric health care systems used the prototype eScreen interface on a mobile device to select an avatar and complete brief assessments of pain and posttraumatic stress symptoms (PTSS). Children rated technology acceptability and completed validated measures for pain and PTSS. Children's ratings indicated they found the eScreen interface easy to use (mean rating 4.4 on a 1-5 scale), potentially useful in helping them recover (mean=3.7), and would use / recommend it (mean=4.0). Among children age 6 to 8, mean ratings were: easy to use (3.7), usefulness (3.3), would use/recommend (3.4). Acceptability was largely consistent across child gender, family income, or usual access to mobile devices. eScreen measures showed strong convergent validity with established measures. The eScreen Pain Screener was highly correlated (r =.86 - .92) with, and evidenced strong agreement with, two validated pain measures. eScreen PTSS scores were strongly correlated with a validated PTSS measure (r=.67); a positive PTSS screen was associated with significantly higher PTSS severity. Study results support the acceptability (ease of use, intention to use/recommend, perceived usefulness) of these tools for older school age children, and provide strong initial evidence for the validity of two brief measures presented in a novel digital modality.

Standardized documentation workflow within an electronic health record to track pharmacists’ interventions in pediatric ambulatory care clinics

ObjectivesTo describe the implementation of a standardized documentation workflow within an electronic health record (EHR) and to track pharmacists’ interventions in pediatric ambulatory care clinics. SettingAmbulatory care clinics and a transitions-of-care (TOC) service within a pediatric health care system in central Ohio. Practice descriptionAmbulatory clinical pharmacists work as integrated members of the health care team in 7 pediatric ambulatory care clinics and a TOC service to achieve the best medication-related outcomes for patients. Practice innovationA standardized documentation workflow was established among ambulatory clinical pharmacists to document the interventions made in their practice settings with the use of a tool in the EHR. A weekly report from the EHR was run by a technician to gather intervention data, identify reimbursable opportunities, and document and bill via a separate Internet-based medication therapy management platform. EvaluationThe success of the new documentation workflow was evaluated, and continuous feedback was gathered from the pharmacists and the billing technician. Updates were provided to the ambulatory clinical pharmacist at monthly staff meetings and workflow changes implemented as needed. ResultsA total of 5210 interventions were documented by the pharmacists in various intervention categories. The 3 most common intervention categories included patient and medication education (1765), medication reconciliations (1170), and compliance assessments (795). ConclusionA standardized documentation workflow allowed for consistent tracking of interventions across ambulatory care clinics and a TOC service. Key elements to the successful implementation of this new documentation workflow included proper training and continuous feedback to the ambulatory clinical pharmacists, assistance from a billing technician, and consistent documentation by the ambulatory clinical pharmacists.

Patient Characteristics Associated With Completion of 24-hour Urine Analyses Among Children and Adolescents With Nephrolithiasis

ObjectiveTo inform the development of strategies to improve adherence to guidelines, we sought to identify characteristics of pediatric patients with nephrolithiasis associated with completing 24-hour urine analyses. Materials and MethodsWe performed a retrospective cohort study of patients with nephrolithiasis aged 3-18years treated in a large pediatric healthcare system from May 2012 to May 2017. Multivariable Cox models were fit to estimate the association between patient characteristics and completion of a 24-hour urine analysis. ResultsAmong 623 patients, 317 (50.9%) completed a 24-hour urine collection. Median age was 14.4years (interquartile range [IQR] 10.5, 16.3). In adjusted analyses, age at diagnosis (hazard ratio [HR] 1.03; 95% confidence interval [CI] 1.01-1.07), renal colic on presentation (HR 1.72; 95% CI 1.15-2.58), and family history of nephrolithiasis (HR 1.50; 95% CI 1.17-1.93) were associated with an increased likelihood of completion of a 24-hour urine. Public/government assistance insurance (HR 0.68; 95% CI 0.48-0.96) was associated with decreased likelihood of completing a 24-hour urine. ConclusionPatients who had prior painful experiences with stones (renal colic), and potential better understanding of nephrolithiasis (family history, older age on presentation) were more likely to complete a 24-hour urine. Those patients with public insurance/government assistance were less likely to complete a 24-hour urine. These results can be used to develop strategies to improve pediatric patients’ adherence to completing 24-hour urine collections.

Poor adherence to early childhood blood pressure measurement guidelines in a large pediatric healthcare system.

Children who were born prematurely, those with a very low birthweight, or who have survived the neonatal intensive care unit (NICU) are at risk for the development of hypertension and chronic kidney disease (CKD), and thus require blood pressure screening less than 3years of age, per American Academy of Pediatrics (AAP) 2004 and 2017 guidelines. We reviewed the practice patterns of a large pediatric health care system and assessed adherence to the AAP clinical practice guidelines on blood pressure measurements in children less than 3years of age for hypertension and CKD with the following risk factors: prematurity, very low birthweight, and a neonatal intensive care setting encounter. This retrospective chart review included a total of 9965 patients with a median gestational age of 34weeks. Overall, 38% of patients had at least one blood pressure measured less than 3years of age. Primary care accounted for 41% of all outpatient encounters and 4% of all blood pressure measurements. Surgical specialties (i.e., ophthalmology, otolaryngology, and orthopedics) accounted for many non-primary care visits and were less likely than medical specialties (i.e., cardiology and nephrology) to obtain a blood pressure measurement (p < 0.0001). This study of a large healthcare system's practice revealed a lack of basic screening for hypertension in a population known to be at risk for hypertension and CKD.

VARIATION IN COMPREHENSIBILITY BETWEEN SPANISH AND ENGLISH-LANGUAGE ASTHMA ACTION PLANS

Introduction An EMR-generated individualized Spanish-language Asthma Action Plan (Sp-AAP) had been developed for use throughout a large pediatric health care system. This study completed the first quality assessment review of the Sp-AAP by comparing measures of Sp-AAP comprehensibility and user valuation to the comparator English-language AAP (E-AAP). Methods 53 caregivers (35 English, 18 Spanish-speaking) of children < 12 years old with a previous provider-confirmed diagnosis of persistent asthma completed an anonymous survey in their preferred language at an asthma & allergy specialty clinic. Survey questions interrogated utilization pattern, comprehension and valuation of the AAP. Five questions about typical asthma management scenarios requiring reference to a mock demonstration AAP measured objective comprehension via percent correct. Project exempted by IRB. Results Both objective (English: 60.0% range 0-100%, Spanish: 32.5% range 0-80%, p = 0.009) and subjective AAP comprehension (p = 0.03) differed significantly between English and Spanish-language respondents. Sp-AAP users reported taking longer to answer questions using the AAP compared to E-AAP users (p < 0.0001). The significance of these differences was lost at lower educational levels (p > 0.05) but maintained at higher educational levels. There was no significant difference in caregiver valuation of the Sp-AAP (9.2) vs. E-AAP (8.9) (p=0.50) and valuation did not associate with objective comprehension (p = 0.86). Conclusions Differences in comprehensibility between Sp-AAP and E-AAP appear to exist but this study is limited by the differences in educational level between groups. Comprehensibility of the AAP irrespective of language was lower than expected. Valuation occurs independent of objective comprehension. An EMR-generated individualized Spanish-language Asthma Action Plan (Sp-AAP) had been developed for use throughout a large pediatric health care system. This study completed the first quality assessment review of the Sp-AAP by comparing measures of Sp-AAP comprehensibility and user valuation to the comparator English-language AAP (E-AAP). 53 caregivers (35 English, 18 Spanish-speaking) of children < 12 years old with a previous provider-confirmed diagnosis of persistent asthma completed an anonymous survey in their preferred language at an asthma & allergy specialty clinic. Survey questions interrogated utilization pattern, comprehension and valuation of the AAP. Five questions about typical asthma management scenarios requiring reference to a mock demonstration AAP measured objective comprehension via percent correct. Project exempted by IRB. Both objective (English: 60.0% range 0-100%, Spanish: 32.5% range 0-80%, p = 0.009) and subjective AAP comprehension (p = 0.03) differed significantly between English and Spanish-language respondents. Sp-AAP users reported taking longer to answer questions using the AAP compared to E-AAP users (p < 0.0001). The significance of these differences was lost at lower educational levels (p > 0.05) but maintained at higher educational levels. There was no significant difference in caregiver valuation of the Sp-AAP (9.2) vs. E-AAP (8.9) (p=0.50) and valuation did not associate with objective comprehension (p = 0.86). Differences in comprehensibility between Sp-AAP and E-AAP appear to exist but this study is limited by the differences in educational level between groups. Comprehensibility of the AAP irrespective of language was lower than expected. Valuation occurs independent of objective comprehension.

CARING FOR THE CAREGIVER: EXPLORING THE EXPERIENCE OF CAREGIVING FOR A CHID WITH MEDICAL COMPLEXITY

Abstract BACKGROUND Children with medical complexity (CMC) represent a growing population in the paediatric healthcare system. CMCs’ multiple health needs, illness severity, and fragility lead to a high degree of caregiver burnout, parental employment loss, and other social and financial consequences. Healthcare providers must consider a holistic view of the family, including consideration of social determinants of health [SDOH]: socio-economic status, employment, quality of housing, availability of social support, and access to healthcare services. This study addresses a gap in current research by exploring how caring for a CMC exacerbates social inequalities, and how these challenges may be mitigated. OBJECTIVES 1. What are the SDOH impacting CMC and their families? 2. How do families report the impact of their child’s medical complexity on their social circumstances? DESIGN/METHODS A qualitative description approach was used to enable rich data collection through semi-structured interviews until thematic saturation was reached. Nine interviews were conducted with CMC caregivers who were chosen by purposeful sampling. The interview guide was developed by expert consultation and iteratively refined. Ethics approval and written consent were obtained. Interviews were recorded and transcribed verbatim. Three team members independently coded the interviews for recurrent themes to inform qualitative content analysis. RESULTS Caregiving for a CMC is all-consuming, requiring parents to take on roles including planner, medical professional, medical educator, and advocate. Parents of CMC report three major areas negatively impacted by caregiving: 1) physical and mental health; 2) personal relationships; and 3) finances. Additionally, three themes emerged describing enablers for resiliency: 1) the CMC’s health status when well or stable in hospital; 2) acceptance of one’s limitations as a caregiver and of the family’s ‘new normal’; and 3) broad supports including medical, personal, financial, and educational. CONCLUSION The wellbeing of CMC families is impacted by medical and social factors. An interdisciplinary model of care may offset some of the caregiver’s advocacy and medical educator responsibilities. Paediatricians can support families of CMC by providing comprehensive care for all components of the child’s health status, and by including routine assessment of the family’s SDOH. Finally, explicit discussion about parental expectations and caregiver burnout helps foster a positive therapeutic relationship with the family.

Variations in Mechanisms of Injury for Children with Concussion

To assess the distribution of injury mechanisms and activities among children with concussions in a large pediatric healthcare system. All patients, age 0-17 years, who had at least 1 clinical encounter with an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis of concussion in the Children's Hospital of Philadelphia's electronic health record system from July 1, 2012 to June 30, 2014, were selected (N = 8233) and their initial concussion-related visit identified. Approximately, 20% of the patients (n = 1625) were randomly selected for manual record review to examine injury mechanisms and activities. Overall, 70% of concussions were sports related; however, this proportion varied by age. Only 18% of concussions sustained by children aged 0-4 were sports related, compared with greater proportions for older children (67% for age 5-11, 77% for age 12-14, and 73% for age 15-17). When the concussion was not sports related, the primary mechanisms of injury were struck by an object (30%) and falls (30%). Sports-related injuries in children older than 6 years of age contributed to the majority of concussions in this cohort; however, it is important to note that approximately one-third of concussions were from non-sports-related activities. Although there is increased participation in community and organized sports activities among children, a focus on prevention efforts in other activities where concussions occur is needed.

10,000 Good Catches: Increasing Safety Event Reporting In A Pediatric Health Care System.

Background:In 2014, Children’s National Health System’s executive leadership team challenged the organization to double the number of voluntary safety event reports submitted over a 3-year period; the intent was to increase reliability and promote our safety culture by hardwiring employee event reporting.Methods:Following a Donabedian quality improvement framework of structure, process, and outcomes, a multidisciplinary team was formed and areas for improvement were identified. The multidisciplinary team focused on 3 major areas: the perceived ease of reporting (ie, how difficult is it to report an event?); the perceived safety of reporting (ie, will I get in trouble for reporting?); and the perceived impact of reporting (ie, does my report make a difference?) technology, making it safe to report, and how reporting makes a difference. The team developed a key driver diagram and implemented interventions designed to impact the key drivers and to increase reporting.Results:Children’s National increased the number of safety event reports from 4,668 in fiscal year 2014 to 10,971 safety event reports in fiscal year 2017. Median event report submission time was decreased by nearly 30%, anonymous reporting decreased by 69%, the number of submitting departments increased by 94%, and the number of reports submitted as “other” decreased from a baseline of 6% to 2%.Conclusions:Children’s National Health System’s focus on increasing safety event reporting resulted in increased organizational engagement and attention. This initiative served as a tangible step to improve organizational reliability and the culture of safety and is readily generalizable to other hospitals.

From Strangers in a Foreign Land to Active, Engaged Citizens.

* Abbreviation: CSHCN — : children with special health care needs Despite many successes in patient- and family-centered care, including efforts to address cultural competency, much work remains to be done to fully understand and implement effective strategies for patient engagement. The Affordable Care Act and some state legislation have mandated programs and provided incentives that promote engagement and partnerships with patients and caregivers because patient activation and engagement have been shown to improve the quality of care and lower health care costs.1 There are 3 key participants in the use, experience, and costs of health services: the provider, the payer, and the consumer. According to the tenets of health care reform, for quality to improve consumers must be empowered to make informed decisions.2 Therefore, continuing progress and establishing a practice of engagement in patient care across the nation is critical to the survival of health care reform in the United States. One way to look at this engagement is to examine individual relationships between health care teams and patients and families. In pediatrics, an informative paradigm is in the care of children with special health care needs (CSHCN), with whom the highest degree of interaction occurs. This article was jointly written by a parent of CSHCN and a primary care physician to offer a perspective on the evolution of family partnerships as parents and other caregivers gain experience working with the health care system. While pediatric health care systems transform to become more family centered, parents are often … Address correspondence to Christopher J. Stille, MD, MPH, Section of General Academic Pediatrics, University of Colorado School of Medicine/Children’s Hospital Colorado, 13123 East 16th Ave B032, Aurora, CO 80045. E-mail: christopher.stille{at}childrenscolorado.org

Adult Chest Pain in the Pediatric Emergency Department: Treatment and Timeliness From Door In To Door Out.

The American College of Cardiology Foundation/American Heart Association guidelines for acute coronary syndrome (ACS) recommend immediate aspirin (ASA) administration, an electrocardiogram (ECG) in less than 10 minutes, and a door-in to door-out (DIDO) time less than 30 minutes for interfacility transfer. We sought to determine if compliance is hindered when adults with suspected ACS present to pediatric facilities. Visits to the 2 tertiary care emergency departments of a pediatric healthcare system using an adult chest pain protocol were examined from October 2006 to September 2012. Patients older than 18 years with a diagnosis suggestive of ACS and an initial ECG interpretation were identified. Proportions of patients receiving ASA were calculated as well as median times to ECG and DIDO. Bivariate analysis of ECG and DIDO time and the proportion of the patients receiving ASA was conducted for ECG findings positive and negative for ACS. One hundred thirteen patients were identified. Aspirin was administered in 69% of eligible cases. Electrocardiogram and DIDO times met recommended intervals in 42% (median, 12 minutes) and 5% (median, 59 minutes) of the patients, respectively. No significant differences between positive (22% of total) and negative (78% of total) ECG findings groups were detected in median DIDO time (57 vs 59 minutes, P = 0.99), time to ECG (14 vs 12 minutes, P = 0.45), or the proportion receiving ASA (84% vs 64%, P = 0.08). Despite the use of an emergency department protocol, compliance with the American College of Cardiology Foundation/American Heart Association guidelines for adults with suspected ACS remained challenging at this pediatric center. The ECG findings did not seem to impact ASA administration, ECG time, or DIDO time.

The Daily Operational Brief: Fostering Daily Readiness, Care Coordination, and Problem-Solving Accountability in a Large Pediatric Health Care System

At a pediatric health system, the Daily Operational Brief (DOB) was updated in 2015 after three years of operation. Quality and safety metrics, the patient volume and staffing assessment, and the readiness assessment are all presented. In addition, in the problem-solving accountability system, problematic issues are categorized as Quick Hits or Complex Issues. Walk-the-Wall, a biweekly meeting attended by hospital senior administrative leadership and quality and safety leaders, is conducted to chart current progress on Complex Issues. The DOB provides a daily standardized approach to evaluate readiness to provide care to current patients and improvement in the care to be provided for future patients.