BACKGROUND AND OBJECTIVES: The 30-day readmission rate is a common quality metric used by Medicare for adult patients. However, studies in pediatrics have shown lower readmission rates and potentially less preventability. Therefore, some question the utility of the 30-day readmission time frame in pediatrics. Our objective was to describe the characteristics of patients readmitted within 30 days of discharge over a 1-year period and determine the preventability of readmissions occurring 0 to 7 vs 8 to 30 days after discharge from a pediatric hospitalist service at an academic children's hospital. METHODS: Retrospective chart review and hospital administrative data were used to gather medical characteristics, demographics, and process-level metrics for readmitted patients between July 1, 2015, and June 30, 2016. All readmissions were reviewed by 2 senior authors and assigned a preventability category. Subgroup analysis comparing preventability in 0-to-7-and 8-to-30-day readmissions groups was performed. Qualitative thematic analysis was performed on readmissions deemed preventable. RESULTS: Of 1523 discharges that occurred during the study period, 49 patients, with 65 distinct readmission encounters, were readmitted for an overall 30-day readmission rate of 4.3% (65 of 1523). Twenty-eight percent (9 of 32) of readmissions within 7 days of discharge and 12.1% (4 of 33) occurring 8 to 30 days after discharge were deemed potentially preventable (P 5 .13). Combined, the 30-day preventable readmission rate was 20% (13 of 65). CONCLUSIONS: We identified a possible association between preventability and time to readmission. If confirmed by larger studies, the 7-day, rather than 30-day, time frame may represent a better quality metric for readmitted pediatric patients.
OBJECTIVES: To determine the incidence of refeeding syndrome in otherwise healthy children <3 years of age admitted for failure to thrive (FTT). METHODS: A multicenter retrospective cohort study was performed on patients aged ≤36 months admitted with a primary diagnosis of FTT from January 1, 2011, to December 31, 2016. The primary outcome measure was the percentage of patients with laboratory evidence of refeeding syndrome. Exclusion criteria included admission to an ICU, parenteral nutrition, history of prematurity, gastrostomy tube feeds, and any complex chronic conditions. RESULTS: Of the 179 patients meeting inclusion criteria, none had laboratory evidence of refeeding syndrome. Of these, 145 (81%) had laboratory work done at the time of admission, and 69 (39%) had laboratory work repeated after admission. A small percentage (6%) of included patients experienced an adverse event due to repeat laboratory draw. CONCLUSIONS: In otherwise healthy hospitalized patients <3 years of age with a primary diagnosis of FTT, routine laboratory monitoring for electrolyte derangements did not reveal any cases of refeeding syndrome. More robust studies are needed to determine the safety and feasibility of applying low-risk guidelines to this patient population to reduce practice variability and eliminate unnecessary laboratory evaluation and monitoring.
Adolescents are at high-risk for sexually transmitted infections and pregnancy, yet many do not receive regular preventive care. Hospitalization represents an opportunity for providing sexual and contraception counseling for this high-risk population. Our aim in this study was to assess the frequency of sexual and contraception history documentation in hospitalized adolescents and identify subgroups that may benefit from more vigilant screening. METHODS:A retrospective chart review of adolescent patients 11 years of age and older who were discharged from the pediatric hospitalist service at an urban, academic children's hospital from July 2017 to June 2018 was conducted. Patient and admission characteristics were analyzed for presence of sexual and contraception history documentation. Technology-dependent patients were analyzed separately. In addition, technology-dependent patients were assessed by chart review for developmental appropriateness for screening.RESULTS: Twenty-five percent of patients (41 of 165) had a sexual history documented, and 8.5% (14 of 165) had a contraception history documented. Among patients with any technology dependence, 0 had a sexual history documented and only 1 had a contraception history documented, whereas 31.5% (12 of 38) were deemed developmentally appropriate for screening. Female and older patients were more likely to have sexual and contraceptive histories documented than male and younger patients. Patients transferred from the PICU had lower rates of sexual history documentation compared with direct admissions. CONCLUSIONS: Hospitalized adolescents, especially those with technology dependence, did not have adequate sexual and contraception histories documented. Improving documentation of these discussions is an important step in providing adolescents with preventive medicine services while hospitalized.
Background There is increasing emphasis on resident involvement in quality improvement (QI) efforts, yet resident engagement in QI has remained low for many reasons. Although QI methods are classically applied to clinical processes, there are many opportunities to incorporate QI principles into curricular design and implementation. Objective Demonstrate the utility of QI methods when applied to curricular design and the implementation of a novel point-of-care ultrasound portfolio development and quality assurance program at a large internal medicine residency program. Methods We applied foundational QI methods, including process mapping, plan–do–study–act (PDSA) cycles, time-trap identification, run-chart analysis, and qualitative interviews throughout the curricular design and implementation phases to rapidly identify areas for improvement and perform timely tests of change. Results Fifty-one interns participated in the curriculum, submitting 731 images in the first trimester. Process mapping and submission review revealed that 29% of images were saved to the incorrect digital archive. Resident–reviewer interpretation concordance was present in 80.7% of submissions. In 95.2% of completed quality assurance cards, the same information was provided in the commentary feedback and the evaluator’s checklists, representing a time trap. Interventions included restricting access to image archives and removing redundant fields from quality assurance cards. The time to feedback fell from 69.5 to 6.5 days, demonstrating nonrandom variation via run-chart analysis. Conclusion This pilot study demonstrates the successful application of QI methods to a novel point-of-care ultrasound curriculum. The systematic use of these methodologies in curricular design and implementation allows expeditious curricular improvement. Emphasizing the relevance of QI methods to subject matter beyond clinical processes may increase resident engagement in QI efforts.
We developed a pilot elective to enhance the critical care training experience for medical students through integration of didactic, simulation, and experiential learning with the goal to increase student confidence in caring for patients with critical illness and advance knowledge and competencies within core critical care topics. Approach:We created and piloted a 4-week critical care elective for fourthyear medical students pairing clinical experience with didactic and simulationbased training. Students completed two 2-week intensive care unit (ICU) rotations in both medical and surgical ICUs. Students received 6 half-days of didactics focusing on: respiratory failure, ventilator management, shock, acid/ base, and discussions at the end of life. Didactic sessions were coupled with simulation-based training to reinforce content through application and provide opportunity to build procedural skills. Medical knowledge was assessed via multiple-choice questions delivered before and after course completion. Course grades were determined through clinical evaluations by faculty/residents, written examination, and simulation assessment. Pre-and postknowledge assessment performance was compared between students enrolled in the pilot and traditional curricula. The traditional curriculum involved clinical experience without formal didactics or simulation opportunities, and course grades were determined by evaluations only.
Introduction: Adolescents seek routine healthcare, including immunizations, less frequently than any other age group. Hospitalizations are an opportunity to provide immunizations to this vulnerable population. The aims of this study were to assess the accuracy of provider documentation of immunization status and evaluate the prevalence of delayed immunization status in this population. Methods: A retrospective chart review of adolescents discharged from July 2017 to June 2018 from the pediatric hospitalist service of a tertiary care academic childrens hospital was conducted. Provider documentation of immunization status was compared to the immunization registry ALERT Immunization Information System (ALERT IIS) linked to the electronic medical record using descriptive statistics. Results: Provider documentation of up-to-date on all immunizations had a sensitivity of 60% and specificity of 55%, with 84% of patients needing at least one immunization despite 48% of patients being documented as up-to-date by providers. Provider documentation of the immunization status for the HPV, MCV and Tdap immunizations displayed a low sensitivity (10-11%) but a high specificity (97-100%) while documentation of the influenza immunization was associated with high sensitivity (86%) and low specificity (26%). Provider documentation of immunization status for the HPV, MCV, Tdap and influenza immunizations had positive likelihood ratios of 3.5, 8.5, infinity, and 1.2 with negative likelihood ratios of 0.9, 0.9, 0.9 and 0.53, respectively. Conclusions: Providers inaccurately documented the immunization status for adolescent patients in the inpatient setting. Hospitalizations may provide opportunities to improve immunization rates in adolescents, especially when using state immunization registries.
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