Redesigning an inpatient pediatric service using <scp>L</scp>ean to improve throughput efficiency

Beck, Michael; Gosik, Kirk

doi:10.1002/jhm.2300

Cited by 41 publications

(44 citation statements)

References 13 publications

(22 reference statements)

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“…UA and urine Gram stain testing are billed at similar costs to the patient at our institution, so performing both rapid tests doubles the patient cost of rapid UTI screening with no additional impact on UTI diagnosis. Furthermore, the turnaround time of UA was 53 min faster than that for Gram stain, an important difference, as outpatient clinics and emergency departments focus on throughput efficiency (17,18). The results of our study suggest that routine Gram stain does not add to the diagnosis of suspected UTI in children.…”

Section: Discussionmentioning

confidence: 69%

Lack of Clinical Utility of Urine Gram Stain for Suspected Urinary Tract Infection in Pediatric Patients

et al. 2015

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bUrinary tract infection (UTI) is one of the most common infections in children. Urine culture remains the gold standard for diagnosis, but the utility of urine Gram stain relative to urinalysis (UA) is unclear. We reviewed 312 pediatric patients with suspected UTI who had urine culture, UA, and urine Gram stain performed from a single urine specimen. UA was considered positive if >10 leukocytes per oil immersion field were seen or if either nitrates or leukocyte esterase testing was positive. Urine Gram stain was considered positive if any organisms were seen. Sensitivity, specificity, and positive and negative predictive values were calculated using urine culture as the gold standard. Thirty-seven (12%) patients had a culture-proven UTI. Compared to urine Gram stain, UA had equal sensitivity (97.3% versus 97.5%) and higher specificity (85% versus 74%). Empirical therapy was prescribed before the Gram stain result was known in 40 (49%) patients and after in 42 (51%) patients. The antibiotics chosen did not differ between the two groups (P ‫؍‬ 0.81), nor did they differ for patients with Gram-negative rods on urine Gram stain compared to those with Gram-positive cocci (P ‫؍‬ 0.67). From these data, we conclude that UA has excellent negative predictive value that is not enhanced by urine Gram stain and that antibiotic selection did not vary based on the urine Gram stain result. In conclusion, the clinical utility of urine Gram stain does not warrant the time or cost it requires. U rinary tract infection (UTI) is one of the most common infections in children, accounting for up to 2% of pediatric hospital admissions at an annual cost of more than half a billion dollars (1). Timely diagnosis and antibiotic therapy are necessary to reduce the risk of serious complications from UTI (2). However, due to nonspecific manifestations, UTI requires a high degree of suspicion, which in turn has contributed to both underand overdiagnosis (3, 4). The need for timely antibiotic therapy necessitates the use of rapid diagnostic tests in addition to urine culture, notably, urinalysis (UA) and urine Gram stain. However, the utility of urine Gram stain relative to UA remains controversial. Previous studies have supported the use of urine Gram stain, urinalysis, or both as a screening test (5-8). However, the most recent American Academy of Pediatrics guidelines for the management of UTI in children 2 to 24 months of age does not include Gram stain as part of the diagnosis (9). Furthermore, significant resources are required to perform urine Gram stain in a timely manner, including microbiology technician time. The objectives of our study were to identify the sensitivity and specificity of UA and urine Gram stain and to determine whether urine Gram stain has utility in diagnosis or optimal antimicrobial prescribing for pediatric UTI. MATERIALS AND METHODS Patient cohort.We retrospectively included all patients aged Յ19 years of age who had a urine culture, urinalysis, and urine Gram stain ordered on a single urine specimen between 28...

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Section: Discussionmentioning

confidence: 69%

Lack of Clinical Utility of Urine Gram Stain for Suspected Urinary Tract Infection in Pediatric Patients

et al. 2015

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“…Modeling has suggested that EDCs could also improve ED flow, 7 but studies implementing EDC have not necessarily assessed this outcome. [10][11][12][13][14][15] One study retrospectively evaluated ED boarding times in the context of an EDC improvement effort and found a decrease in boarding times. 21 This decrease is important as ED boarders may be at a higher risk for adverse events, a longer LOS, and more readmissions.…”

Section: Discussionmentioning

confidence: 99%

“…[7][8][9] A number of recent im-provement efforts directed at moving discharges earlier in the day have been published. [10][11][12][13][14][15] However, these improvements are often targeted at specific units or teams within a larger hospital setting and only one is in the pediatric setting.…”

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confidence: 99%

Improving Patient Flow: Analysis of an Initiative to Improve Early Discharge

Destino

Bennett

Wood

et al. 2019

Journal of Hospital Medicine

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BACKGROUND: Discharge delays adversely affect hospital bed availability and thus patient flow. OBJECTIVE: We aimed to increase the percentage of early discharges (EDCs; before 11 am). We hypothesized that obtaining at least 25% EDCs would decrease emergency department (ED) and postanesthesia care unit (PACU) hospital bed wait times. DESIGN: This study used a pre/postintervention retrospective analysis. SETTING: All acute care units in a quaternary care academic children's hospital were included in this study.

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“…2 Interestingly, our model improved all of these. 5 Essentially, "one size does not fit all." All health systems function differently as a result of varying organizational microsystems, missions and goals, resources, culture, and reward structure.…”

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confidence: 99%

The Authors Reply “Redesigning an inpatient pediatric service using lean to improve throughput efficiency”

Beck

2015

Journal of Hospital Medicine

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We thank Dr. Cakir for reading our article and taking the time to raise important issues, all of which we agree with. Her query of what is the best patient/hospitalist ratio and can/should our study results be generalized to community hospitalist programs are important. We believe the intervention we conducted, like many others conducted in academic centers, is not entirely generalizable, but the concepts are.Our article did not set out to determine what the optimum patient/physician ratio should be for any particular academic or community-based hospital setting. Dr. Cakir's question regarding the "centerspecific 'right' patient/hospitalist ratio" is the million dollar question. We believe that to better address this concern, it is important to include quality and value in the discussion. As defined by the Institute of Medicine, quality has the following subsets: timeliness, safety, effectiveness, efficiency, personalized, and equitable. 1 In terms of safety, data support that if a census exceeds 15 patients/provider, the frequency of rapid response team activations, readmission rates, or hospital mortality rates are not negatively impacted. 2,3 However, higher hospitalist workloads were associated with significant inefficiencies, and many of these inefficiencies negatively impact the organizational value chain. 2 As payment reform shifts from volume to value, it will become increasingly important for hospitalists to reframe their identity from relative value unit generators to value generators and use the following equations: quality 5 outcomes/waste (inefficiencies), and value 5 quality/cost. Therefore, whether we are academic or community-based hospitalists, one of the most impactful things we can do is to identify elements in our processes that are wasteful, and eliminate them. This means we need to routinely evaluate workloads of attending physicians. 4 If we believe in quality and value, we should do so in a way that seeks to maximize our efficiency, not just productivity. Programs should analyze local data to see what their workload versus outcome curves look like. 2 The right census will be the one in a given setting that maximizes patient outcomes, efficiency, and satisfaction of patients and clinicians. 2 Interestingly, our model improved all of these. 5 Essentially, "one size does not fit all." All health systems function differently as a result of varying organizational microsystems, missions and goals, resources, culture, and reward structure. 6 To be successful and sustainable, any proposed intervention must take into account these 5 elements and maintain their alignment. As either a pediatric or an internal medicine hospitalist, in a community or academic setting, we all function within a system that has models or processes, with functionalities that either enhance or reduce the effectiveness and/or efficiency of the services we render.The impetus that inspired our project was the organizational pain point of excess patient boarding time in the emergency department (ED) and lost referrals. Like man...

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Redesigning an inpatient pediatric service using Lean to improve throughput efficiency

Cited by 41 publications

References 13 publications

Lack of Clinical Utility of Urine Gram Stain for Suspected Urinary Tract Infection in Pediatric Patients

Lack of Clinical Utility of Urine Gram Stain for Suspected Urinary Tract Infection in Pediatric Patients

Improving Patient Flow: Analysis of an Initiative to Improve Early Discharge

The Authors Reply “Redesigning an inpatient pediatric service using lean to improve throughput efficiency”

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