First name
Robert
Middle name
M
Last name
Sutton

Title

Leveraging EHR Data to Evaluate the Association of Late Recognition of Deterioration With Outcomes.

Year of Publication

2022

Number of Pages

447-460

Date Published

05/2022

ISSN Number

2154-1671

Abstract

OBJECTIVES: Emergency transfers (ETs), deterioration events with late recognition requiring ICU interventions within 1 hour of transfer, are associated with adverse outcomes. We leveraged electronic health record (EHR) data to assess the association between ETs and outcomes. We also evaluated the association between intervention timing (urgency) and outcomes.

METHODS: We conducted a propensity-score-matched study of hospitalized children requiring ICU transfer between 2015 and 2019 at a single institution. The primary exposure was ET, automatically classified using Epic Clarity Data stored in our enterprise data warehouse endotracheal tube in lines/drains/airway flowsheet, vasopressor in medication administration record, and/or ≥60 ml/kg intravenous fluids in intake/output flowsheets recorded within 1 hour of transfer. Urgent intervention was defined as interventions within 12 hours of transfer.

RESULTS: Of 2037 index transfers, 129 (6.3%) met ET criteria. In the propensity-score-matched cohort (127 ET, 374 matched controls), ET was associated with higher in-hospital mortality (13% vs 6.1%; odds ratio, 2.47; 95% confidence interval [95% CI], 1.24-4.9, P = .01), longer ICU length of stay (subdistribution hazard ratio of ICU discharge 0.74; 95% CI, 0.61-0.91, P < .01), and longer posttransfer length of stay (SHR of hospital discharge 0.71; 95% CI, 0.56-0.90, P < .01). Increased intervention urgency was associated with increased mortality risk: 4.1% no intervention, 6.4% urgent intervention, and 10% emergent intervention.

CONCLUSIONS: An EHR measure of deterioration with late recognition is associated with increased mortality and length of stay. Mortality risk increased with intervention urgency. Leveraging EHR automation facilitates generalizability, multicenter collaboratives, and metric consistency.

DOI

10.1542/hpeds.2021-006363

Alternate Title

Hosp Pediatr

PMID

35470399

Title

Leveraging EHR Data to Evaluate the Association of Late Recognition of Deterioration With Outcomes.

Year of Publication

2022

Number of Pages

447-460

Date Published

2022 May 01

ISSN Number

2154-1671

Abstract

<p><strong>OBJECTIVES: </strong>Emergency transfers (ETs), deterioration events with late recognition requiring ICU interventions within 1 hour of transfer, are associated with adverse outcomes. We leveraged electronic health record (EHR) data to assess the association between ETs and outcomes. We also evaluated the association between intervention timing (urgency) and outcomes.</p>

<p><strong>METHODS: </strong>We conducted a propensity-score-matched study of hospitalized children requiring ICU transfer between 2015 and 2019 at a single institution. The primary exposure was ET, automatically classified using Epic Clarity Data stored in our enterprise data warehouse endotracheal tube in lines/drains/airway flowsheet, vasopressor in medication administration record, and/or ≥60 ml/kg intravenous fluids in intake/output flowsheets recorded within 1 hour of transfer. Urgent intervention was defined as interventions within 12 hours of transfer.</p>

<p><strong>RESULTS: </strong>Of 2037 index transfers, 129 (6.3%) met ET criteria. In the propensity-score-matched cohort (127 ET, 374 matched controls), ET was associated with higher in-hospital mortality (13% vs 6.1%; odds ratio, 2.47; 95% confidence interval [95% CI], 1.24-4.9, P = .01), longer ICU length of stay (subdistribution hazard ratio of ICU discharge 0.74; 95% CI, 0.61-0.91, P &lt; .01), and longer posttransfer length of stay (SHR of hospital discharge 0.71; 95% CI, 0.56-0.90, P &lt; .01). Increased intervention urgency was associated with increased mortality risk: 4.1% no intervention, 6.4% urgent intervention, and 10% emergent intervention.</p>

<p><strong>CONCLUSIONS: </strong>An EHR measure of deterioration with late recognition is associated with increased mortality and length of stay. Mortality risk increased with intervention urgency. Leveraging EHR automation facilitates generalizability, multicenter collaboratives, and metric consistency.</p>

DOI

10.1542/hpeds.2021-006363

Alternate Title

Hosp Pediatr

PMID

35470399

Title

Implementation of a Multidisciplinary Debriefing Process for Pediatric Ward Deterioration Events.

Year of Publication

2021

Number of Pages

454-461

Date Published

2021 May

ISSN Number

2154-1671

Abstract

<p><strong>OBJECTIVES: </strong>Event debriefing has established benefit, but its adoption is poorly characterized among pediatric ward providers. To improve patient safety, our hospital restructured its debriefing process for ward deterioration events culminating in ICU transfer. The aim of this study was to describe this process' implementation.</p>

<p><strong>METHODS: </strong>In the restructured process, multidisciplinary ward providers are expected to debrief all ICU transfers. We conducted a multimethod analysis using facilitative guides completed by debriefing participants. Monthly debriefing completion served as an adoption metric.</p>

<p><strong>RESULTS: </strong>Between March 2019 and February 2020, providers across 9 wards performed debriefing for 134 of 312 PICU transfers (43%). Bedside nurses participated most frequently (117 debriefings [87%]). There was no significant difference in debriefing by unit, acuity, season, or nurse staffing. Compared with units fully staffed by rotational frontline clinicians (FLCs; eg, resident physicians), units with dedicated FLCs whose responsibilities are primarily limited to that unit (eg, oncology hospitalists) completed significantly more monthly debriefings (average [SD] 57% [30%] vs 33% [28%] of PICU transfers; = .004). FLC participation was also higher on these units (50% of debriefings [37%] vs 24% [37%]; = .014). Through qualitative analysis, we identified distinct debriefing themes, with teaming activities such as communication cited most often.</p>

<p><strong>CONCLUSIONS: </strong>Implementation of a multidisciplinary debriefing process for ward deterioration events culminating in ICU transfer was associated with differential adoption across providers and FLC staffing models but not acuity or nurse staffing. Teaming activities were a debriefing priority. Future study will assess patient safety outcomes.</p>

DOI

10.1542/hpeds.2020-002014

Alternate Title

Hosp Pediatr

PMID

33858988

Title

Providing Early Attending Physician Expertise via Telemedicine to Improve Rapid Response Team Evaluations.

Year of Publication

2020

Date Published

2020 Mar 04

ISSN Number

1529-7535

Abstract

<p><strong>OBJECTIVES: </strong>To evaluate the effect of providing early attending physician involvement via telemedicine to improve the decision process of rapid response teams.</p>

<p><strong>DESIGN: </strong>Quasi-experimental; three pairs of control/intervention months: June/July; August/October; November/December.</p>

<p><strong>SETTING: </strong>Single-center, urban, quaternary academic children's hospital with three-member rapid response team: critical care fellow or nurse practitioner, nurse, respiratory therapist. Baseline practice: rapid response team leader reviewed each evaluation with an ICU attending physician within 2 hours after return to ICU.</p>

<p><strong>SUBJECTS: </strong>1) Patients evaluated by rapid response team, 2) rapid response team members.</p>

<p><strong>INTERVENTIONS: </strong>Implementation of a smartphone-based telemedicine platform to facilitate early co-assessment and disposition planning between the rapid response team at the patient's bedside and the attending in the ICU.</p>

<p><strong>MEASUREMENTS AND MAIN RESULTS: </strong>As a marker of efficiency, the primary provider outcome was time the rapid response team spent per patient encounter outside the ICU prior to disposition determination. The primary patient outcome was percentage of patients requiring intubation or vasopressors within 60 minutes of ICU transfer. There were three pairs of intervention/removal months. In the first 2 pairs, the intervention was associated with the rapid response team spending less time on rapid response team calls (June/July: point estimate -5.24 min per call; p &lt; 0.01; August/October: point estimate -3.34 min per call; p &lt; 0.01). During the first of the three pairs, patients were significantly less likely to require intubation or vasopressors within 60 minutes of ICU transfer (adjusted odds ratio, 0.66; 95 CI, 0.51-0.84; p &lt; 0.01).</p>

<p><strong>CONCLUSIONS: </strong>Early in the study, more rapid ICU attending involvement via telemedicine was associated with rapid response team providers spending less time outside the ICU, and among patients transferred to the ICU, a significant decrease in likelihood of patients requiring vasopressors or intubation within the first 60 minutes of transfer. These findings provide evidence that early ICU attending involvement via telemedicine can improve efficiency of rapid response team evaluations.</p>

DOI

10.1097/PCC.0000000000002256

Alternate Title

Pediatr Crit Care Med

PMID

32142012

Title

Performance of a Clinical Decision Support Tool to Identify PICU Patients at High Risk for Clinical Deterioration.

Year of Publication

2019

Date Published

2019 Oct 02

ISSN Number

1529-7535

Abstract

<p><strong>OBJECTIVES: </strong>To evaluate the translation of a paper high-risk checklist for PICU patients at risk of clinical deterioration to an automated clinical decision support tool.</p>

<p><strong>DESIGN: </strong>Retrospective, observational cohort study of an automated clinical decision support tool, the PICU Warning Tool, adapted from a paper checklist to predict clinical deterioration events in PICU patients within 24 hours.</p>

<p><strong>SETTING: </strong>Two quaternary care medical-surgical PICUs-The Children's Hospital of Philadelphia and Cincinnati Children's Hospital Medical Center.</p>

<p><strong>PATIENTS: </strong>The study included all patients admitted from July 1, 2014, to June 30, 2015, the year prior to the initiation of any focused situational awareness work at either institution.</p>

<p><strong>INTERVENTIONS: </strong>We replicated the predictions of the real-time PICU Warning Tool by retrospectively querying the institutional data warehouse to identify all patients that would have flagged as high-risk by the PICU Warning Tool for their index deterioration.</p>

<p><strong>MEASUREMENTS AND MAIN RESULTS: </strong>The primary exposure of interest was determination of high-risk status during PICU admission via the PICU Warning Tool. The primary outcome of interest was clinical deterioration event within 24 hours of a positive screen. The date and time of the deterioration event was used as the index time point. We evaluated the sensitivity, specificity, positive predictive value, and negative predictive value of the performance of the PICU Warning Tool. There were 6,233 patients evaluated with 233 clinical deterioration events experienced by 154 individual patients. The positive predictive value of the PICU Warning Tool was 7.1% with a number needed to screen of 14 patients for each index clinical deterioration event. The most predictive of the individual criteria were elevated lactic acidosis, high mean airway pressure, and profound acidosis.</p>

<p><strong>CONCLUSIONS: </strong>Performance of a clinical decision support translation of a paper-based tool showed inferior test characteristics. Improved feasibility of identification of high-risk patients using automated tools must be balanced with performance.</p>

DOI

10.1097/PCC.0000000000002106

Alternate Title

Pediatr Crit Care Med

PMID

31577691

Title

Focused Training for the Handover of Critical Patient Information During Simulated Pediatric Emergencies.

Year of Publication

2018

Number of Pages

227-31

Date Published

2018 Apr

ISSN Number

2154-1663

Abstract

<p><strong>OBJECTIVES: </strong>Miscommunication has been implicated as a leading cause of medical errors, and standardized handover programs have been associated with improved patient outcomes. However, the role of structured handovers in pediatric emergencies remains unclear. We sought to determine if training with an airway, breathing, circulation, situation, background, assessment, recommendation handover tool could improve the transmission of essential patient information during multidisciplinary simulations of critically ill children.</p>

<p><strong>METHODS: </strong>We conducted a prospective, randomized, intervention study with first-year pediatric residents at a quaternary academic children's hospital. Baseline and second handovers were recorded for residents in the intervention group (12) and residents in the control group (= 8) during multidisciplinary simulations throughout the academic year. The intervention group received handover education after baseline handover observation and a cognitive aid before second handover observation. Audio-recorded handovers were scored by using a Delphi-developed assessment tool by a blinded rater.</p>

<p><strong>RESULTS: </strong>There was no difference in baseline handover scores between groups (= .69), but second handover scores were significantly higher in the intervention group (median 12.5 [interquartile range 12-13] versus median 7.5 [interquartile range 6-8] in the control group;&lt; .01). Trained residents were more likely to include a reason for the call (&lt; .01), focused history (= .02), and summative assessment (= .03). Neither timing of the second observation in the academic year nor duration between first and second observation were associated with the second handover scores (both&gt; .5).</p>

<p><strong>CONCLUSIONS: </strong>Structured handover training and provision of a cognitive aid may improve the inclusion of essential patient information in the handover of simulated critically ill children.</p>

DOI

10.1542/hpeds.2017-0173

Alternate Title

Hosp Pediatr

PMID

29514852

Title

A pragmatic checklist to identify pediatric ICU patients at risk for cardiac arrest or code bell activation.

Year of Publication

2016

Number of Pages

33-7

Date Published

2016 Feb

ISSN Number

1873-1570

Abstract

<p><strong>BACKGROUND: </strong>In-hospital cardiac arrest is a rare event associated with significant morbidity and mortality. The ability to identify the ICU patients at risk for cardiac arrest could allow the clinical team to prepare staff and equipment in anticipation.</p>

<p><strong>METHODS: </strong>This pilot study was completed at a large tertiary care pediatric intensive care unit to determine the feasibility of a simple checklist of clinical variables to predict deterioration. The daily checklist assessed patient risk for critical deterioration defined as cardiac arrest or code bell activation within 24h of the checklist screen. The Phase I checklist was developed by expert consensus and evaluated to determine standard diagnostic test performance. A modified Phase II checklist was developed to prospectively test the feasibility and bedside provider "number needed to train".</p>

<p><strong>RESULTS: </strong>For identifying patients requiring code bell activation, both checklists demonstrated a sensitivity of 100% with specificity of 76.0% during Phase I and 97.7% during Phase II. The positive likelihood ratio improved from 4.2 to 43.7. For identifying patients that had a cardiac arrest within 24h, the Phase I and II checklists demonstrated a sensitivity of 100% with specificity again improving from 75.7% to 97.6%. There was an improved positive likelihood ratio from 4.1 in Phase I to 41.9 in Phase II, with improvement of "number needed to train" from 149 to 7.4 providers.</p>

<p><strong>CONCLUSIONS: </strong>A novel high-risk clinical indicators checklist is feasible and provides timely and accurate identification of the ICU patients at risk for cardiac arrest or code bell activation.</p>

DOI

10.1016/j.resuscitation.2015.11.017

Alternate Title

Resuscitation

PMID

26703460

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