Standardized Clinical Assessment And Management Plans Research Articles

A standardized clinical assessment and management plan (SCAMP) reduces readmissions in postpartum hypertension

Postpartum hypertension is one of the most frequent reasons for emergency department (ED) visits and readmission. We aimed to evaluate the effect of a SCAMP on these metrics in the postpartum period. We conducted a prospective cohort study of patients with postpartum hypertension at a tertiary care center for 3 months before and after enacting a SCAMP. The prospective group (P) were compared with historical controls (C). Elements of the SCAMP included 1) initiation or uptitration of medication for any blood pressure (BP) >150/100 or 2 BPs >140/90 within a 24hr period with goal of achieving normotension and 2) enrollment in outpatient virtual BP monitoring with close follow-up by the study team on discharge. Primary outcome was postpartum ED visit or readmission. Secondary outcomes were medication side effects, hypotension, utilization of the BP monitoring system, and length of stay (LOS). Chi-square, t-test, and Mann-Whitney U test were used as appropriate to compare groups. IRB#14-001098. 176 patients in (P) cohort were compared to 156 historical controls (C). The primary outcome of ED visits significantly decreased from 7.69% (C) to 1.13% (P) (p=0.003), and readmission rates decreased from 7.05% (C) to 1.70% (P) (p=0.02). When combined, the rate of patients who had either an ED visit or readmission decreased from 14.74% (C) to 3.21% (P) (p< 0.001). More patients were prescribed anti-hypertensives on discharge in (P) cohort (33.0% P vs 21.8% C, p=0.02), of whom 3 (5.2%) had hypotension (BP < 100/60) and 4 (6.9%) had side effects. The (P) cohort had longer mean postpartum LOS that was statistically significant (2.4 1.0 days P vs 2.1 1.0 days C, p=0.04). Total 100 (56.8%) patients were compliant with virtual BP monitoring, with 18 (18%) medication adjustments made per protocol. Utilizing a SCAMP encompassing strict BP control in the postpartum period followed by intensive outpatient follow-up can significantly reduce postpartum ED visits and readmissions.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Controlled Study of Decision-Making Algorithms for Kidney Replacement Therapy Initiation in Acute Kidney Injury.

AKI requiring KRT is associated with high mortality and utilization. We evaluated the use of an AKI Standardized Clinical Assessment and Management Plan (SCAMP) on patient outcomes, including mortality, hospital length of stay, and intensive care unit length of stay. We conducted a 12-month controlled study in the intensive care units of a large academic tertiary medical center. We alternated use of the AKI-SCAMP with use of a "sham" control form in 4- to 6-week blocks. The primary outcome was risk of inpatient mortality. Prespecified secondary outcomes included 30- and 60-day mortality, hospital length of stay, and intensive care unit length of stay. Generalized estimating equations were used to estimate the effect of the AKI-SCAMP on mortality and length of stay. There were 122 patients in the AKI-SCAMP group and 102 patients in the control group. There was no significant difference in inpatient mortality associated with AKI-SCAMP use (41% versus 47% control). AKI-SCAMP use was associated with significantly reduced intensive care unit length of stay (mean, 8; 95% confidence interval, 8 to 9 days versus mean, 12; 95% confidence interval, 10 to 13 days; P<0.001) and hospital length of stay (mean, 25; 95% confidence interval, 22 to 29 days versus mean, 30; 95% confidence interval, 27 to 34 days; P=0.02). Patients in the AKI-SCAMP group were less likely to receive KRT in the context of physician-perceived treatment futility than those in the control group (2% versus 7%; P=0.003). Use of the AKI-SCAMP tool for AKI KRT was not significantly associated with inpatient mortality, but was associated with reduced intensive care unit length of stay, hospital length of stay, and use of KRT in cases of physician-perceived treatment futility. Acute Kidney Injury Standardized Clinical Assessment and Management Plan for Renal Replacement Initiation, NCT03368183. This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2022_02_07_CJN02060221.mp3.

Multi-Institutional Practice-Patterns in Fetal Congenital Heart Disease Following Implementation of a Standardized Clinical Assessment and Management Plan.

BackgroundPrenatal diagnosis of congenital heart disease has been associated with early‐term delivery and cesarean delivery (CD). We implemented a multi‐institutional standardized clinical assessment and management plan (SCAMP) through the University of California Fetal‐Maternal Consortium. Our objective was to decrease early‐term (37–39 weeks) delivery and CD in pregnancies complicated by fetal congenital heart disease using a SCAMP methodology to improve practice in a high‐risk and clinically complex setting.Methods and ResultsUniversity of California Fetal‐Maternal Consortium site‐specific management decisions were queried following SCAMP implementation. This contemporary intervention group was compared with a University of California Fetal‐Maternal Consortium historical cohort. Primary outcomes were early‐term delivery and CD. A total of 496 maternal–fetal dyads with prenatally diagnosed congenital heart disease were identified, 185 and 311 in the historical and intervention cohorts, respectively. Recommendation for later delivery resulted in a later gestational age at delivery (38.9 versus 38.1 weeks, P=0.01). After adjusting for maternal age and site, historical controls were more likely to have a CD (odds ratio [OR],1.8; 95% CI, 2.1–2.8; P=0.004) and more likely (OR, 2.1; 95% CI, 1.4–3.3) to have an early‐term delivery than the intervention group. Vaginal delivery was recommended in 77% of the cohort, resulting in 61% vaginal deliveries versus 50% in the control cohort (P=0.03). Among pregnancies with major cardiac lesions (n=373), vaginal birth increased from 51% to 64% (P=0.008) and deliveries ≥39 weeks increased from 33% to 48% (P=0.004).ConclusionsImplementation of a SCAMP decreased the rate of early‐term deliveries and CD for prenatal congenital heart disease. Development of clinical pathways may help standardize care, decrease maternal risk secondary to CD, improve neonatal outcomes, and reduce healthcare costs.

Development of a Standardized Clinical Assessment and Management Plan for Pediatric Acute Respiratory Distress Syndrome.

Pediatric acute respiratory distress syndrome (PARDS) is one of the most challenging patient populations for a clinician to manage with mortality between 8 and 31%. The project was designed to identify patients with PARDS, implement management guidelines with the goal of standardizing practice. Our objectives were to describe the development and implementation of a protocolized approach to identify patients with PARDS and institute ventilator management guidelines. Patients who met criteria for moderate or severe PARDS as per the Pediatric Acute Lung Injury Consensus Conference (PALICC) definitions were identified using the best practice alert (BPA) in the electronic health record (EHR). Patients who did not meet exclusion criteria qualified for management using the Standardized Clinical Assessment and Management Plan (SCAMP), a quality improvement (QI) methodology with iterative cycles. The creation of a BPA enabled identification of patients with PARDS. With our second cycle, the number of false BPA alerts due to incorrect data decreased from 66.7 (68/102) to 29.2% (19/65; p < 0.001) and enrollment increased from 48.3 (14/29) to 73.2% (30/41; p = 0.03). Evaluation of our statistical process control chart (SPC) demonstrated a shift in the adherence with the tidal volume guideline. Overall, we found that SCAMP methodology, when used in the development of institutional PARDS management guidelines, allows for development of a process to aid identification of patients and monitor adherence to management guidelines. This should eventually allow assessment of impact of deviations from clinical practice guidelines.

617: A Standardized Clinical Assessment and Management Plan (SCAMP) reduces non-indicated cesarean deliveries in gastroschisis-affected pregnancies

617: A Standardized Clinical Assessment and Management Plan (SCAMP) reduces non-indicated cesarean deliveries in gastroschisis-affected pregnancies

The uptake of family screening in hypertrophic cardiomyopathy and an online video intervention to facilitate family communication.

BackgroundIndividuals with hypertrophic cardiomyopathy (HCM), even when asymptomatic, are at‐risk for sudden cardiac death and stroke from arrhythmias, making it imperative to identify individuals affected by this familial disorder. Consensus guidelines recommend that first‐degree relatives (FDRs) of a person with HCM undergo serial cardiovascular evaluations.MethodsWe determined the uptake of family screening in patients with HCM and developed an online video intervention to facilitate family communication and screening. Family screening and genetic testing data were collected through a prospective quality improvement initiative, a standardized clinical assessment and management plan (SCAMP), utilized in an established cardiovascular genetics clinic. Patients were prescribed an online video if screening of their FDRs was incomplete and a pilot study on video utilization and family communication was conducted.ResultsTwo‐hundred and sixteen probands with HCM were enrolled in SCAMP Phase I and 190 were enrolled in SCAMP Phase II. In both phases, probands reported that 51% of FDRs had been screened (382/749 in Phase I, 258/504 in Phase II). Twenty patients participated in a pilot study on video utilization and family communication. Nine participants reported watching the video and six participants reported sharing the video with relatives; however only one participant reported sharing the video with relatives who were not yet aware of the diagnosis of HCM in the family.ConclusionDespite care in a specialized cardiovascular genetics clinic, approximately one half of FDRs of patients with HCM remained unscreened. Online interventions and videos may serve as supplemental tools for patients communicating genetic risk information to relatives.

Development and Implementation of a Surgical Quality Improvement Pathway for Pediatric Intussusception Patients.

We developed a standardized clinical assessment and management plan (SCAMP) for ileocolic intussusception to enable the discharge from the ED of successfully reduced patients meeting certain criteria with 2 planned follow-up phone calls by surgical personnel after discharge. Outcomes included incidence of complications in discharged patients, bacteremia, the success of follow-up phone calls, rates of recurrent intussusception, and return to care. Of the 118 patient encounters treated through the SCAMP in 2 pilot studies from February 2013 to December 2017, 76% met discharge criteria, of whom 88% underwent outpatient management. There were no instances of bowel perforation, necrosis, or death in the discharged group. No patients developed bacteremia despite withholding antibiotics for the indication of intussusception. Sixty-two percent and 59% of patients received 24-hour follow-up phone calls, and 28% and 55% of patients received second follow-up phone calls in pilots 1 and 2, respectively. Of those successfully discharged, 74% did not return to care, 19% returned for recurrent intussusception, and 7% returned for unrelated symptoms. Nearly all patients who returned to care did so through the ED and not the clinic. Implementation of the SCAMP demonstrated that patients meeting certain criteria could be safely discharged from the ED, avoid antibiotics, and safely undergo phone-based follow-up for concerns of recurrent intussusception.

Resource reduction in pediatric chest pain: Standardized clinical assessment and management plan.

Using a Standardized Clinical Assessment and Management Plan (SCAMP) for pediatric patients presenting to clinic with chest pain, we evaluated the cost impact associated with implementation of the care algorithm. Prior to introduction of the SCAMP, we analyzed charges for 406 patients with chest pain, seen in 2009, and predicted 21% reduction of overall charges had the SCAMP methodology been used. The SCAMP recommended an echocardiogram for history, examination, or ECG findings suggestive of a cardiac etiology for chest pain. Resource utilization was reviewed for 1517 patients (7-21 years) enrolled in the SCAMP from July 2010 to April 2014. Compared to the 2009 historic cohort, patients evaluated by the SCAMP had higher rates of exertional chest pain (45% vs 37%) and positive family history (5% vs 1%). The SCAMP cohort had fewer abnormal physical examination findings (1% vs 6%) and abnormal electrocardiograms (3% vs 5%). Echocardiogram use increased in the SCAMP cohort compared to the 2009 historic cohort (45% vs 41%), whereas all other ancillary testing was reduced: exercise stress testing (4% SCAMP vs 28% historic), Holter (4% vs 7%), event monitors (3% vs 10%), and MRI (1% vs 2%). Total charges were reduced by 22% ($822625) by use of the Chest Pain SCAMP, despite a higher percentage of patients for whom echocardiogram was recommended compared to the historic cohort. The Chest Pain SCAMP effectively streamlines cardiac testing and reduces resource utilization. Further reductions can be made by algorithm refinement regarding echocardiograms for exertional symptoms.

Impact of standardized clinical assessment and management plans on resource utilization and costs in children after the arterial switch operation.

Standardized Clinical Assessment and Management Plans (SCAMPs) are a quality improvement initiative designed to reduce unnecessary utilization, decrease practice variation, and improve patient outcomes. We created a novel methodology, the SCAMP managed episode of care (SMEOC), which encompasses multiple encounters to assess the impact of the arterial switch operation (ASO) SCAMP on total costs. All ASO SCAMP patients (dates March 2009 to July 2015) were compared to a control group of ASO patients (January 2001 to February 2009). Patients were divided into "younger" (<2 years) and "older" (2-18 years) subgroups. Utilization included all cardiology visits, tests, and procedures. Standardized costs were applied to each unit of utilization. There were 100 historical and 63 SCAMP patients in the younger subgroup, and 163 historical and 165 SCAMP patients in the older subgroup. In the younger subgroup, the SCAMP had a 28% reduction in outpatient clinic visits (P < .001), a 52% reduction in chest radiographs (P < .001), a 21% reduction in electrocardiograms (P < .001), and a 30% total reduction in costs. In the older subgroup, the SCAMP had a 21% reduction in outpatient clinic visits (P < .001), a 20% reduction in chest radiographs (P = .05), a 10% reduction in echocardiograms (P = .05), a 25% reduction in exercise stress tests (P = .01), and a 14% total reduction in costs. The total cost savings of the ASO SCAMP was $216 649 in the first 6 years of the SCAMP. There was no difference in clinical outcomes between the historical and SCAMP cohorts. SCAMPs can improve resource utilization and reduce costs after the ASO operation while maintaining quality of care.

SCAMPs for Multimodal Post-Operative Analgesia: A Concept to Standardize and Individualize Care.

We discuss the challenges and strategies in delivering post-operative pain relief that is both standardized and individualized as appropriate. Post-operative pain remains under-treated and is frequently complicated by side effects. Guidelines for multimodal analgesia report varying strengths of evidence. Additionally, there are particular evidence gaps in establishing how individual and population subgroups responses vary, due to pharmacogenetic, metabolic, and psychological variation. In cases where evidence is scarce or low quality, Standardized Clinical Assessment and Management Plans (SCAMPs) are an innovative method for healthcare practitioners to integrate available evidence resources and avoid unplanned variations in the quality of care delivered. Implementation of SCAMPs can be facilitated by the sheer volume of relevant information for drug prescribing and monitoring, drug-drug interactions, laboratory tests of organ function, drug metabolism and excretion data, electronic medical record data, and individual pharmacogenetic profile data. Standardization of care using algorithms or computer-assisted prescribing is emerging as a useful tool to raise compliance where guidance does exist. Individualizing care may require computational analysis of vast quantities of individual and population data to support or lead clinician decision-making. Such technology is used widely across diverse fields ranging from meteorology and commerce to agriculture and gene sequencing, but there are particular applications and challenges within medicine. To maximize benefit and reduce harm from post-operative analgesia, standardization and individualization, such as SCAMPs must be balanced and employed as appropriate.

Implementation of a Risk Stratification and Management Pathway for Acute Chest Pain in the Emergency Department.

Chest pain is a common complaint in the emergency department, and a small but important minority represents an acute coronary syndrome (ACS). Variation in diagnostic workup, risk stratification, and management may result in underuse, misuse, and/or overuse of resources. From July to October 2014, we conducted a prospective cohort study in an academic medical center by implementing a Standardized Clinical Assessment and Management Plan (SCAMP) for chest pain based on the HEART score. In addition to capturing adherence to the SCAMP algorithm and reasons for any deviations, we measured troponin sample timing; rates of stress test utilization; length of stay (LOS); and 30-day rates of revascularization, ACS, and death. We identified 239 patients during the enrollment period who were eligible to enter the SCAMP, of whom 97 patients were entered into the pathway. Patients were risk stratified into one of 3 risk tiers: high (n = 3), intermediate (n = 40), and low (n = 54). Among low-risk patients, recommendations for troponin testing were not followed in 56%, and 11% received stress tests contrary to the SCAMP recommendation. None of the low-risk patients had elevated troponin measurements, and none had an abnormal stress test. Mean LOS in low-risk patients managed with discordant plans was 22:26 h/min, compared with 9:13 h/min in concordant patients (P < 0.001). Mean LOS in intermediate-risk patients with stress testing was 25:53 h/min, compared with 7:55 h/min for those without (P < 0.001). At 30 days, 10% of intermediate-risk patients and 0% of low-risk patients experienced an ACS event (risk difference 10% [0.7%-19%]); none experienced revascularization or death. The most frequently cited reason for deviation from the SCAMP was lack of confidence in the tool. Compliance with SCAMP recommendations for low- and intermediate-risk patients was poor, largely due to lack of confidence in the tool. However, in our study population, outcomes suggest that deviation from the SCAMP yielded no additional clinical benefit while significantly prolonging emergency department LOS.

Decreasing Resource Utilization Using Standardized Clinical Assessment and Management Plans (SCAMPs).

Standardized clinical assessment and management plans (SCAMPs) are a novel quality improvement initiative shown to improve patient care, diminish practice variation, and reduce resource utilization. Unlike clinical practice guidelines, a SCAMP is a flexible algorithm that undergoes iterative updates based on periodic data collection and review. We recently implemented a SCAMP for the closed treatment of pediatric torus fractures. The purpose of this study is to analyze the effect of SCAMP implementation on resource utilization, practice variability, cost of care, and outcomes. This study was a retrospective review of prospectively collected data on 273 patients with pediatric torus fractures. The pre-SCAMP cohort included 116 subjects from 2008 to 2010. The SCAMP cohort included 157 subjects from 2011 to 2013. The pre-SCAMP cohort was treated according to the judgment of attending fellowship-trained pediatric orthopaedic surgeons. The SCAMP cohort was treated with a standardized algorithm including radiographs and splint application at initial presentation, with a single follow-up at 3 weeks. Patient demographics were analyzed to verify comparability between cohorts. Follow-up data including clinic visits, x-rays and practice variability was recorded. Costing analysis was conducted using time-derived activity-based costing methodology. Outcomes were compared using Poisson regression analysis. Incident rate ratios (IRR) with 95% confidence limits were estimated. No differences in clinical results were observed between the pre-SCAMP and SCAMP cohorts, and all patients demonstrated return to baseline activity at final follow-up. Patient demographics were comparable across cohorts. The SCAMP cohort had a 48% reduction in clinic visits [IRR, 0.52; 95% confidence interval (CI), 0.44-0.60; P<0.001], 60% reduction in x-rays (IRR, 0.40; CI, 0.33-0.47; P<0.001), and a 23% reduction in x-rays per clinic visit (IRR, 0.77; 95% CI, 0.65-0.91; P<0.001). Furthermore, SCAMP implementation resulted in a 49% reduction in the overall cost of care. SCAMPs provide a novel alternative to CPGs to implement cost effective changes in Orthopaedic practice. For pediatric torus fractures, SCAMP implementation resulted in decreased practice variability, resource utilization, and overall cost of care while maintaining clinical outcomes. Level 3.

Implementation of a Standardized Clinical Assessment and Management Plan (SCAMP) for Food Challenges

Oral food challenges (OFCs) are routinely used to confirm ongoing food allergy. Serum-specific IgE (sIgE) and skin prick testing (SPT) are imperfect predictors of which patients will pass OFCs. The objective of this study was to describe the design and implementation of a Standardized Clinical Assessment and Management Plan (SCAMP) to study and iteratively improve sIgE and SPT thresholds to determine when and where to conduct OFCs for patients. Allergists consulted recommended sIgE and SPT thresholds when ordering challenges although diversions were permitted. Criteria were iteratively improved after periodic analyses of challenge outcome and diversions. Over 3 years, allergists ordered 2368 food challenges for 1580 patients with histories of IgE-mediated reactions to food: 1386 in an outpatient clinic and 945 in a higher resource infusion center. Reactions to challenge were observed in 13% of clinic and 23% of infusion center challenges. Six patients challenged in clinic required treatment with epinephrine compared with 22 in the infusion center. The need for epinephrine was more common in patients with asthma-5% of asthmatic patients required epinephrine compared with 1% of nonasthmatic patients (P < .01). Recommended sIgE and SPT thresholds were incrementally changed and, using the control chart methodology, a significant decrease was noted in the proportion of challenges ordered in the higher resource location. By setting and continually refining sIgE and SPT recommendations using the SCAMP method, allergists can better determine the risk of severe reaction and triage patients to the appropriate setting for an OFC.

Needles in Hay II: Detecting Cardiac Pathology by the Pediatric Chest Pain Standardized Clinical Assessment and Management Plan.

To determine if patients evaluated using the pediatric chest pain standardized clinical assessment and management plan (SCAMP) in cardiology clinic were later diagnosed with unrecognized cardiac pathology, and to determine if other patients with cardiac pathology not enrolled in the SCAMP would have been identified using the algorithm. Patients 7-21 years of age, newly diagnosed with hypertrophic or dilated cardiomyopathy, coronary anomalies, pulmonary embolus, pulmonary hypertension, pericarditis, or myocarditis were identified from the Boston Children's Hospital (BCH) cardiac database between July 1, 2010 and December 31, 2012. Patients were cross-referenced to the SCAMP database or retrospectively assessed with the SCAMP algorithm. Among 98 patients with cardiac pathology, 34 (35%) reported chest pain, of whom 10 were diagnosed as outpatients. None of these patients were enrolled in the SCAMP because of alternate chief complaints (n = 4) or referral to BCH for management of the new diagnosis (n = 6). Each of these patients would have had an echocardiogram recommended by retrospective application of the SCAMP algorithm. Two other patients with cardiac pathology were among the 1124 patients assessed by the SCAMP. One patient initially diagnosed with noncardiac chest pain presented 18 months later and was diagnosed with myocarditis as an inpatient. One patient seen initially in the emergency department was subsequently diagnosed with pericarditis as an outpatient. Patients assessed by the chest pain SCAMP at BCH were not later diagnosed with cardiac pathology that was missed at the initial encounter. Nonenrolled outpatients with cardiac pathology and chest pain would have been successfully identified with the SCAMP algorithm.

Regional Implementation of a Pediatric Cardiology Syncope Algorithm Using Standardized Clinical Assessment and Management Plans (SCAMPS) Methodology.

BackgroundPediatric syncope is common. Cardiac causes are rarely found. We describe and assess a pragmatic approach to these patients first seen by a pediatric cardiologist in the New England region, using Standardized Clinical Assessment and Management Plans (SCAMPs).Methods and ResultsAmbulatory patients aged 7 to 21 years initially seen for syncope at participating New England Congenital Cardiology Association practices over a 2.5‐year period were evaluated using a SCAMP. Findings were iteratively analyzed and the care pathway was revised. The vast majority (85%) of the 1254 patients had typical syncope. A minority had exercise‐related or more problematic symptoms. Guideline‐defined testing identified one patient with cardiac syncope. Syncope Severity Scores correlated well between physician and patient perceived symptoms. Orthostatic vital signs were of limited use. Largely incidental findings were seen in 10% of ECGs and 11% of echocardiograms. The 10% returning for follow‐up, by design, reported more significant symptoms, but did not have newly recognized cardiac disease. Iterative analysis helped refine the approach.Conclusions SCAMP methodology confirmed that the vast majority of children referred to the outpatient pediatric cardiology setting had typical low‐severity neurally mediated syncope that could be effectively evaluated in a single visit using minimal resources. A simple scoring system can help triage patients into treatment categories. Prespecified criteria permitted the effective diagnosis of the single patient with a clear cardiac etiology. Patients with higher syncope scores still have a very low risk of cardiac disease, but may warrant attention.

Implementation of a Standardized Clinical Assessment and Management Plan (SCAMP) for Food Challenges

Implementation of a Standardized Clinical Assessment and Management Plan (SCAMP) for Food Challenges

Abstract 15309: Resource Reduction by Use of Pediatric Chest Pain Standardized Clinical Assessment and Management Plan

Using a Standardized Clinical Assessment and Management Plan (SCAMP) for pediatric patients presenting to clinic with chest pain, we evaluated the cost impact associated with implementation of the care algorithm. Previously, we analyzed charges for 406 patients (7-21 yrs) with chest pain seen in 2009, prior to introduction of the SCAMP, and predicted 21% reduction of overall charges had the SCAMP methodology been used. The SCAMP recommended an echocardiogram for history, exam, or ECG findings suggestive of a cardiac etiology for chest pain. Resource utilization for 1520 patients evaluated by the SCAMP from 12/11-4/14 was reviewed in this study. Compared to the 2009 cohort, patients evaluated in the SCAMP presented with similar rates of exertional chest pain (33%, SCAMP vs. 37%, 2009) and significant past medical history (1% vs. 1%). The SCAMP cohort had fewer abnormal physical exam findings (1% vs. 4%) and ECG abnormalities (3% vs. 6%), and more pertinent family history (4% vs. 1%). Echocardiograms were additionally recommended by the SCAMP for exertional syncope (1%), pain worse by supine position, or radiation to the back, jaw, or left arm (5%). Ancillary testing for concurrent symptoms was reduced compared to the 2009 cohort (Figure 1) and compared to predicted: Holter (4% vs. 6%), event monitors (3% vs. 8%), MRI (&lt;1% vs. 1%). Stress testing was not recommended though 4% underwent evaluation. Adherence to SCAMP guidelines for recommended testing approached 80%; slightly fewer echocardiograms were actually performed than recommended. Total testing charges were reduced by an estimated 30% ($740,000) despite a small increase in echocardiogram utilization, and overall charges were reduced by 17% by use of the Chest Pain SCAMP. Given the low incidence of cardiac disease historically as well as detected by the SCAMP algorithm (&lt;1%), further modifications to the algorithm should refine indications for echocardiography, particularly related to exertional symptoms.

Development of Standardized Clinical Assessment and Management Plans (SCAMPs) in Plastic and Reconstructive Surgery

Background:With rising cost of healthcare, there is an urgent need for developing effective and economical streamlined care. In clinical situations with limited data or conflicting evidence-based data, there is significant institutional and individual practice variation. Quality improvement with the use of Standardized Clinical Assessment and Management Plans (SCAMPs) might be beneficial in such scenarios. The SCAMPs method has never before been reported to be utilized in plastic surgery.Methods:The topic of immediate breast reconstruction was identified as a possible SCAMPs project. The initial stages of SCAMPs development, including planning and implementation, were entered. The SCAMP Champion, along with the SCAMPs support team, developed targeted data statements. The SCAMP was then written and a decision-tree algorithm was built. Buy-in was obtained from the Division of Plastic Surgery and a SCAMPs data form was generated to collect data.Results:Decisions pertaining to “immediate implant-based breast reconstruction” were approved as an acceptable topic for SCAMPs development. Nine targeted data statements were made based on the clinical decision points within the SCAMP. The SCAMP algorithm, and the SDF, required multiple revisions. Ultimately, the SCAMP was effectively implemented with multiple iterations in data collection.Conclusions:Full execution of the SCAMP may allow better-defined selection criteria for this complex patient population. Deviations from the SCAMP may allow for improvement of the SCAMP and facilitate consensus within the Division. Iterative and adaptive quality improvement utilizing SCAMPs creates an opportunity to reduce cost by improving knowledge about best practice.

Value in Pediatric Orthopaedic Surgery Health Care: the Role of Time-driven Activity-based Cost Accounting (TDABC) and Standardized Clinical Assessment and Management Plans (SCAMPs).

The continuing increases in health care expenditures as well as the importance of providing safe, effective, timely, patient-centered care has brought government and commercial payer pressure on hospitals and providers to document the value of the care they deliver. This article introduces work at Boston Children's Hospital on time-driven activity-based accounting to determine cost of care delivery; combined with Systemic Clinical Assessment and Management Plans to reduce variation and improve outcomes. The focus so far has been on distal radius fracture care for children and adolescents.

Commentary: Launch of a Quality Improvement Network for Evidence-Based Management of Uncommon Pediatric Endocrine Disorders: Turner Syndrome as a Prototype

Traditional, hypothesis-oriented research approaches have thus far failed to generate sufficient evidence to achieve consensus about the management of children with many endocrine disorders, partly because of the rarity of these disorders and because of regulatory burdens unique to research in children. The Pediatric Endocrine Society is launching a quality improvement network in spring 2015 for the management of pediatric endocrine disorders that are relatively uncommon in any single practice and/or for which there is no consensus on management. The first of the quality improvement programs to be implemented seeks to improve the care of 11- to 17-year-old girls with Turner syndrome who require initiation of estrogen replacement therapy by providing a standardized clinical assessment and management plan (SCAMP) for transdermal estradiol treatment to induce pubertal development. The SCAMP algorithm represents a starting point within current best practice that is meant to undergo refinement through an iterative process of analysis of deidentified data collected in the course of clinical care by a network of pediatric endocrinologists. It is anticipated that this program will not only improve care, but will also result in actionable data that will generate new research hypotheses and changes in management of pediatric endocrine disorders.