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A B S T R A C TBACKGROUND: Asthma exacerbations are a leading cause of hospitalization among children.Despite the existence of national pediatric asthma guidelines, significant variation in care persists. At Duke Children's Hospital, we determined that our average length of stay (ALOS) and cost for pediatric asthma admissions exceeded that of our peers. Our aim was to reduce the ALOS of pediatric patients hospitalized with asthma from 2.9 days to 2.6 days within 12 months by implementing an asthma pathway within our new electronic health record. METHODS:We convened a multidisciplinary committee charged with reducing variability in practice, ALOS, and cost of inpatient pediatric asthma care, while adhering to evidence-based guidelines. Interventions were tested through multiple "plan-do-study-act" cycles. Control charts of the ALOS were constructed and annotated with interventions, including testing of an asthma score, implementation of order sets, use of a respiratory therapy-driven albuterol treatment protocol, and provision of targeted education. Order set usage was audited as a process measure. Readmission rates were monitored as a balancing measure. RESULTS:The ALOS of pediatric patients hospitalized with asthma decreased significantly from 2.9 days to 2.3 days. Comparing baseline with intervention variable direct cost data revealed a savings of $1543 per case. Improvements occurred in the context of high compliance with the asthma pathway order sets. Readmission rates remained stable throughout the study period.CONCLUSIONS: Implementation of an asthma care pathway based on the electronic health record improved the efficiency and variable direct costs of hospital care, reduced variability in practice, and ensured adherence to high-quality national guidelines.

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Purpose Entrustment has become a popular assessment framework in recent years. Most research in this area has focused on how frontline assessors determine when a learner can be entrusted. However, less work has focused on how these entrustment decisions are made. The authors sought to understand the key factors that pediatric residency program clinical competency committee (CCC) members consider when recommending residents to a supervisory role. Method CCC members at 14 pediatric residency programs recommended residents to one of five progressive supervisory roles (from not serving as a supervisory resident to serving as a supervisory resident in all settings). They then responded to a free-text prompt, describing the key factors that led them to that decision. The authors analyzed these responses, by role recommendation, using a thematic analysis. Results Of the 155 CCC members at the participating programs, 84 completed 769 supervisory role recommendations during the 2015–2016 academic year. Four themes emerged from the thematic analysis: (1) Determining supervisory ability follows from demonstrated trustworthiness; (2) demonstrated performance matters, but so does experience; (3) ability to lead a team is considered; and (4) contextual considerations external to the resident are at play. Conclusions CCC members considered resident and environmental factors in their summative entrustment decision making. The interplay between these factors should be considered as CCC processes are optimized and studied further.

BACKGROUND: Asthma is a common reason for admissions to the pediatric intensive care unit (PICU). Since June 2014, our institution has used a pediatric asthma clinical pathway for all patients, including those in PICU. The pathway promotes respiratory therapist-driven bronchodilator weaning based on the Modified Pulmonary Index Score (MPIS). This pathway was associated with decreased hospital length of stay (LOS) for all pediatric asthma patients; however, the effect on PICU patients was unclear. We hypothesized that the implementation of a pediatric asthma pathway would reduce hospital LOS for asthmatic patients admitted to the PICU. METHODS: We retrospectively reviewed the medical records of all pediatric asthma subjects 2-17 y old admitted to our PICU before and after pathway initiation. Primary outcome was hospital LOS. Secondary outcomes were PICU LOS and time on continuous albuterol. Data were analyzed using the chi-square test for categorical data, the t test for normally distributed data, and the Mann-Whitney test for nonparametric data. RESULTS: A total of 203 eligible subjects (49 in the pre-pathway group, 154 in the post group) were enrolled. There were no differences between groups for age, weight, gender, home medications, cause of exacerbation, medical history, or route of admission. There were significant decreases in median (interquartile range) hospital LOS (4.4 [2.9 -6.6] d vs 2. 7 [1.6 -4.0] d, P < .001), median PICU LOS (2.1 [1.3-4.0] d vs 1.6 [0.8 -2.4] d, P ‫؍‬ .003), and median time on continuous albuterol (39 [25-85] h vs 27 [13-42] h, P ‫؍‬ .001). Significantly more subjects in the post-pathway group were placed on high-flow nasal cannula (32% vs 6%, P ‫؍‬ .001) or noninvasive ventilation (10% vs 4%, P ‫؍‬ .02). CONCLUSION: The implementation of an asthma pathway was associated with decreased hospital LOS, PICU LOS, and time on continuous albuterol. There was also an increase in the use of high-flow nasal cannula and noninvasive ventilation after the implementation of this clinical pathway.

Identifying residents with performance concerns is important for their education and the care they provide. This study delineates strategies used by CCC members across several programs for identifying these residents, which may be helpful for other CCCs to consider in their efforts.

Background The Pediatrics Milestone Project uses behavioral anchors, narrative descriptions of observable behaviors, to describe learner progression through the Accreditation Council for Graduate Medical Education competencies. Starting June 2014, pediatrics programs were required to submit milestone reports for their trainees semiannually. Likert-type scale assessment tools were not designed to inform milestone reporting, creating a challenge for Clinical Competency Committees. Objective To determine if milestone-based assessments better stratify trainees by training level compared to Likert-type assessments. Methods We compared assessment results for 3 subcompetencies after changing from a 5-point Likert scale to milestone-based behavioral anchors in July 2013. Program leadership evaluated the new system by (1) comparing PGY-1 mean scores on Likert-type versus milestone-based assessments; and (2) comparing mean scores on the Likert-type versus milestone-based assessments across PGY levels. Results Mean scores for PGY-1 residents were significantly higher on the prior year's Likert-type assessments than milestone-based assessments for all 3 subcompetencies (P &lt; .01). Stratification by PGY level was not observed with Likert-type assessments (eg, interpersonal and communication skills 1 [ICS1] mean score for PGY-1, 3.99 versus PGY-3, 3.98; P  =  .98). In contrast, milestone-based assessments demonstrated stratification by PGY level (eg, the ICS1 mean score was 3.06 for PGY-1, 3.83 for PGY-2, and 3.99 for PGY-3; P &lt; .01 for PGY-1 versus PGY-3). Significantly different means by trainee level were noted across 21 subcompetencies on milestone-based assessments (P &lt; .01 for PGY-1 versus PGY-3). Conclusions Initial results indicate milestone-based assessments stratify trainee performance by level better than Likert-type assessments. Average PGY-level scores from milestone-based assessments may ultimately provide guidance for determining whether trainees are progressing at the expected pace.