Characteristics of Pediatric Rapid Response Systems: Results From a Survey of PRIS Hospitals.

2021

144-152

02/2021

2154-1671

BACKGROUND: Many hospitals use rapid response systems (RRSs) to identify and intervene on hospitalized children at risk for deterioration.

OBJECTIVES: To describe RRS characteristics across hospitals in the Pediatric Research in Inpatient Settings (PRIS) network.

METHODS: We developed the survey through a series of prospective respondent, expert, and cognitive interviews. One institutional expert per PRIS hospital ( = 109) was asked to complete the web survey. We summarized responses using descriptive statistics with a secondary analysis of univariate associations between RRS characteristics and perceived effectiveness.

RESULTS: The response rate was 72% (79 of 109). Respondents represented diverse hospital types and were primarily physicians (97%) with leadership roles in care escalation. Many hospitals used an early warning score (77%) for identification with variable characteristics (46% automated versus 54% full or partially manual calculation; inputs included vital signs [98%], physical examination findings [88%], diagnoses [23%], medications [19%], and diagnostic tests [14%]). Few incorporated a validated prediction model (9%). Similarly, many RRSs used a rapid response team for intervention (93%) with variable team composition (respiratory therapists [94%], ICU nurses [93%], ICU providers [67%], and pharmacists [27%]). Some used the early warning score to trigger the rapid response team (50%). Only a few staffed a clinician to proactively surveil hospitalized children for risk of deterioration (18%), and these tended to be larger hospitals (annual admissions 12 000 vs 6000, = .007). Most responding experts stated their RRSs improved patient outcomes (92%).

CONCLUSIONS: RRS characteristics varied across PRIS hospitals.

10.1542/hpeds.2020-002659

Hosp Pediatr

33495251

Sustainable deimplementation of continuous pulse oximetry monitoring in children hospitalized with bronchiolitis: study protocol for the Eliminating Monitor Overuse (EMO) type III effectiveness-deimplementation cluster-randomized trial.

2022

72

10/2022

1748-5908

BACKGROUND: Methods of sustaining the deimplementation of overused medical practices (i.e., practices not supported by evidence) are understudied. In pediatric hospital medicine, continuous pulse oximetry monitoring of children with the common viral respiratory illness bronchiolitis is recommended only under specific circumstances. Three national guidelines discourage its use for children who are not receiving supplemental oxygen, but guideline-discordant practice (i.e., overuse) remains prevalent. A 6-hospital pilot of educational outreach with audit and feedback resulted in immediate reductions in overuse; however, the best strategies to optimize sustainment of deimplementation success are unknown.

METHODS: The Eliminating Monitor Overuse (EMO) trial will compare two deimplementation strategies in a hybrid type III effectiveness-deimplementation trial. This longitudinal cluster-randomized design will be conducted in Pediatric Research in Inpatient Settings (PRIS) Network hospitals and will include baseline measurement, active deimplementation, and sustainment phases. After a baseline measurement period, 16-19 hospitals will be randomized to a deimplementation strategy that targets unlearning (educational outreach with audit and feedback), and the other 16-19 will be randomized to a strategy that targets unlearning and substitution (adding an EHR-integrated clinical pathway decision support tool). The primary outcome is the sustainment of deimplementation in bronchiolitis patients who are not receiving any supplemental oxygen, analyzed as a longitudinal difference-in-differences comparison of overuse rates across study arms. Secondary outcomes include equity of deimplementation and the fidelity to, and cost of, each deimplementation strategy. To understand how the deimplementation strategies work, we will test hypothesized mechanisms of routinization (clinicians developing new routines supporting practice change) and institutionalization (embedding of practice change into existing organizational systems).

DISCUSSION: The EMO trial will advance the science of deimplementation by providing new insights into the processes, mechanisms, costs, and likelihood of sustained practice change using rigorously designed deimplementation strategies. The trial will also advance care for a high-incidence, costly pediatric lung disease.

TRIAL REGISTRATION: ClinicalTrials.gov, NCT05132322 . Registered on November 10, 2021.

10.1186/s13012-022-01246-z

Implement Sci

36271399

Evaluation of an Educational Outreach and Audit and Feedback Program to Reduce Continuous Pulse Oximetry Use in Hospitalized Infants With Stable Bronchiolitis: A Nonrandomized Clinical Trial.

2021

e2122826

2021 Sep 01

2574-3805

<p><strong>Importance: </strong>National guidelines recommend against continuous pulse oximetry use for hospitalized children with bronchiolitis who are not receiving supplemental oxygen, yet guideline-discordant use remains high.</p>

<p><strong>Objectives: </strong>To evaluate deimplementation outcomes of educational outreach and audit and feedback strategies aiming to reduce guideline-discordant continuous pulse oximetry use in children hospitalized with bronchiolitis who are not receiving supplemental oxygen.</p>

<p><strong>Design, Setting, and Participants: </strong>A nonrandomized clinical single-group deimplementation trial was conducted in 14 non-intensive care units in 5 freestanding children's hospitals and 1 community hospital from December 1, 2019, through March 14, 2020, among 847 nurses and physicians caring for hospitalized children with bronchiolitis who were not receiving supplemental oxygen.</p>

<p><strong>Interventions: </strong>Educational outreach focused on communicating details of the existing guidelines and evidence. Audit and feedback strategies included 2 formats: (1) weekly aggregate data feedback to multidisciplinary teams with review of unit-level and hospital-level use of continuous pulse oximetry, and (2) real-time 1:1 feedback to clinicians when guideline-discordant continuous pulse oximetry use was discovered during in-person data audits.</p>

<p><strong>Main Outcomes and Measures: </strong>Clinician ratings of acceptability, appropriateness, feasibility, and perceived safety were assessed using a questionnaire. Guideline-discordant continuous pulse oximetry use in hospitalized children was measured using direct observation of a convenience sample of patients with bronchiolitis who were not receiving supplemental oxygen.</p>

<p><strong>Results: </strong>A total of 847 of 1193 eligible clinicians (695 women [82.1%]) responded to a Likert scale-based questionnaire (71% response rate). Most respondents rated the deimplementation strategies of education and audit and feedback as acceptable (education, 435 of 474 [92%]; audit and feedback, 615 of 664 [93%]), appropriate (education, 457 of 474 [96%]; audit and feedback, 622 of 664 [94%]), feasible (education, 424 of 474 [89%]; audit and feedback, 557 of 664 [84%]), and safe (803 of 847 [95%]). Sites collected 1051 audit observations (range, 47-403 per site) on 709 unique patient admissions (range, 31-251 per site) during a 3.5-month period of continuous pulse oximetry use in children with bronchiolitis not receiving supplemental oxygen, which were compared with 579 observations (range, 57-154 per site) from the same hospitals during the baseline 4-month period (prior season) to determine whether the strategies were associated with a reduction in use. Sites conducted 148 in-person educational outreach and aggregate data feedback sessions and provided real-time 1:1 feedback 171 of 236 times (72% of the time when guideline-discordant monitoring was identified). Adjusted for age, gestational age, time since weaning from supplemental oxygen, and other characteristics, guideline-discordant continuous pulse oximetry use decreased from 53% (95% CI, 49%-57%) to 23% (95% CI, 20%-25%) (P &lt; .001) during the intervention period. There were no adverse events attributable to reduced monitoring.</p>

<p><strong>Conclusions and Relevance: </strong>In this nonrandomized clinical trial, educational outreach and audit and feedback deimplementation strategies for guideline-discordant continuous pulse oximetry use among hospitalized children with bronchiolitis who were not receiving supplemental oxygen were positively associated with clinician perceptions of feasibility, acceptability, appropriateness, and safety. Evaluating the sustainability of deimplementation beyond the intervention period is an essential next step.</p>

<p><strong>Trial Registration: </strong>ClinicalTrials.gov Identifier: NCT04178941.</p>

10.1001/jamanetworkopen.2021.22826

JAMA Netw Open

34473258

Validity of Continuous Pulse Oximetry Orders for Identification of Actual Monitoring Status in Bronchiolitis.

2020

665-668

2020 11

1553-5606

<p>The accuracy of pulse oximetry monitor orders for identifying infants with bronchiolitis who are being continuously monitored is unknown. In this 56-hospital repeated cross-sectional study, investigators used direct bedside observation to determine continuous pulse oximetry monitor use and then assessed if an active continuous monitoring order was present in the electronic health record. Investigators completed 3,612 observations of infants aged 8 weeks to 23 months hospitalized with bronchiolitis and on room air. Most monitored infants did not have an active monitoring order (sensitivity 49% [95% CI, 41-57]). The positive predictive value of a monitoring order was 77% (95% CI, 72-82), and the negative predictive value was 69% (95% CI, 61-77). Teams intending to measure continuous pulse oximetry use should understand the limitations of using electronic health record orders as a stand-alone measure.</p>

10.12788/jhm.3443

J Hosp Med

33147128

Characteristics of Pediatric Rapid Response Systems: Results From a Survey of PRIS Hospitals.

2021

2021 Jan 25

2154-1671

<p><strong>BACKGROUND: </strong>Many hospitals use rapid response systems (RRSs) to identify and intervene on hospitalized children at risk for deterioration.</p>

<p><strong>OBJECTIVES: </strong>To describe RRS characteristics across hospitals in the Pediatric Research in Inpatient Settings (PRIS) network.</p>

<p><strong>METHODS: </strong>We developed the survey through a series of prospective respondent, expert, and cognitive interviews. One institutional expert per PRIS hospital ( = 109) was asked to complete the web survey. We summarized responses using descriptive statistics with a secondary analysis of univariate associations between RRS characteristics and perceived effectiveness.</p>

<p><strong>RESULTS: </strong>The response rate was 72% (79 of 109). Respondents represented diverse hospital types and were primarily physicians (97%) with leadership roles in care escalation. Many hospitals used an early warning score (77%) for identification with variable characteristics (46% automated versus 54% full or partially manual calculation; inputs included vital signs [98%], physical examination findings [88%], diagnoses [23%], medications [19%], and diagnostic tests [14%]). Few incorporated a validated prediction model (9%). Similarly, many RRSs used a rapid response team for intervention (93%) with variable team composition (respiratory therapists [94%], ICU nurses [93%], ICU providers [67%], and pharmacists [27%]). Some used the early warning score to trigger the rapid response team (50%). Only a few staffed a clinician to proactively surveil hospitalized children for risk of deterioration (18%), and these tended to be larger hospitals (annual admissions 12 000 vs 6000, = .007). Most responding experts stated their RRSs improved patient outcomes (92%).</p>

<p><strong>CONCLUSIONS: </strong>RRS characteristics varied across PRIS hospitals.</p>

10.1542/hpeds.2020-002659

Hosp Pediatr

33495251

Barriers and Facilitators to Guideline-Adherent Pulse Oximetry Use in Bronchiolitis.

2021

23-30

2021 Jan

1553-5606

<p><strong>OBJECTIVE: </strong>Continuous pulse oximetry monitoring (cSpO) in children with bronchiolitis does not improve clinical outcomes and has been associated with increased resource use and alarm fatigue. It is critical to understand the factors that contribute to cSpO overuse in order to reduce overuse and its associated harms.</p>

<p><strong>METHODS: </strong>This multicenter qualitative study took place in the context of the Eliminating Monitor Overuse (EMO) SpO study, a cross-sectional study to establish rates of cSpO in bronchiolitis. We conducted semistructured interviews, informed by the Consolidated Framework for Implementation Research, with a purposive sample of stakeholders at sites with high and low cSpO use rates to identify barriers and facilitators to addressing cSpO overuse. Interviews were audio recorded and transcribed. Analyses were conducted using an integrated approach.</p>

<p><strong>RESULTS: </strong>Participants (n = 56) included EMO study site principal investigators (n = 12), hospital administrators (n = 8), physicians (n = 15), nurses (n = 12), and respiratory therapists (n = 9) from 12 hospitals. Results suggest that leadership buy-in, clear authoritative guidelines for SpO use incorporated into electronic order sets, regular education about cSpO in bronchiolitis, and visual reminders may be needed to reduce cSpO utilization. Parental perceptions and individual clinician comfort affect cSpO practice.</p>

<p><strong>CONCLUSION: </strong>We identified barriers and facilitators to deimplementation of cSpO for stable patients with bronchiolitis across children's hospitals with high- and low-cSpO use. Based on these data, future deimplementation efforts should focus on clear protocols for cSpO, EHR changes, and education for hospital staff on bronchiolitis features and rationale for reducing cSpO.</p>

10.12788/jhm.3535

J Hosp Med

33357326

Cardiorespiratory and Pulse Oximetry Monitoring in Hospitalized Children: A Delphi Process.

2020

2020 Jul 17

1098-4275

<p><strong>OBJECTIVES: </strong>Cardiorespiratory and pulse oximetry monitoring in children who are hospitalized should balance benefits of detecting deterioration with potential harms of alarm fatigue. We developed recommendations for monitoring outside the ICU on the basis of available evidence and expert opinion.</p>

<p><strong>METHODS: </strong>We conducted a comprehensive literature search for studies addressing the utility of cardiorespiratory and pulse oximetry monitoring in common pediatric conditions and drafted candidate monitoring recommendations based on our findings. We convened a panel of nominees from national professional organizations with diverse expertise: nursing, medicine, respiratory therapy, biomedical engineering, and family advocacy. Using the RAND/University of California, Los Angeles Appropriateness Method, panelists rated recommendations for appropriateness and necessity in 3 sequential rating sessions and a moderated meeting.</p>

<p><strong>RESULTS: </strong>The panel evaluated 56 recommendations for intermittent and continuous monitoring for children hospitalized outside the ICU with 7 common conditions (eg, asthma, croup) and/or receiving common therapies (eg, supplemental oxygen, intravenous opioids). The panel reached agreement on the appropriateness of monitoring recommendations for 55 of 56 indications and on necessity of monitoring for 52. For mild or moderate asthma, croup, pneumonia, and bronchiolitis, the panel recommended intermittent vital sign or oximetry measurement only. The panel recommended continuous monitoring for severe disease in each respiratory condition as well as for a new or increased dose of intravenous opiate or benzodiazepine.</p>

<p><strong>CONCLUSIONS: </strong>Expert panel members agreed that intermittent vital sign assessment, rather than continuous monitoring, is appropriate management for a set of specific conditions of mild or moderate severity that require hospitalization.</p>

10.1542/peds.2019-3336

Pediatrics

32680879

Prevalence of Continuous Pulse Oximetry Monitoring in Hospitalized Children With Bronchiolitis Not Requiring Supplemental Oxygen.

2020

1467-1477

2020 Apr 21

1538-3598

<p><strong>Importance: </strong>US national guidelines discourage the use of continuous pulse oximetry monitoring in hospitalized children with bronchiolitis who do not require supplemental oxygen.</p>

<p><strong>Objective: </strong>Measure continuous pulse oximetry use in children with bronchiolitis.</p>

<p><strong>Design, Setting, and Participants: </strong>A multicenter cross-sectional study was performed in pediatric wards in 56 US and Canadian hospitals in the Pediatric Research in Inpatient Settings Network from December 1, 2018, through March 31, 2019. Participants included a convenience sample of patients aged 8 weeks through 23 months with bronchiolitis who were not receiving active supplemental oxygen administration. Patients with extreme prematurity, cyanotic congenital heart disease, pulmonary hypertension, home respiratory support, neuromuscular disease, immunodeficiency, or cancer were excluded.</p>

<p><strong>Exposures: </strong>Hospitalization with bronchiolitis without active supplemental oxygen administration.</p>

<p><strong>Main Outcomes and Measures: </strong>The primary outcome, receipt of continuous pulse oximetry, was measured using direct observation. Continuous pulse oximetry use percentages were risk standardized using the following variables: nighttime (11 pm to 7 am), age combined with preterm birth, time after weaning from supplemental oxygen or flow, apnea or cyanosis during the present illness, neurologic impairment, and presence of an enteral feeding tube.</p>

<p><strong>Results: </strong>The sample included 3612 patient observations in 33 freestanding children's hospitals, 14 children's hospitals within hospitals, and 9 community hospitals. In the sample, 59% were male, 56% were white, and 15% were black; 48% were aged 8 weeks through 5 months, 28% were aged 6 through 11 months, 16% were aged 12 through 17 months, and 9% were aged 18 through 23 months. The overall continuous pulse oximetry monitoring use percentage in these patients, none of whom were receiving any supplemental oxygen or nasal cannula flow, was 46% (95% CI, 40%-53%). Hospital-level unadjusted continuous pulse oximetry use ranged from 2% to 92%. After risk standardization, use ranged from 6% to 82%. Intraclass correlation coefficient suggested that 27% (95% CI, 19%-36%) of observed variation was attributable to unmeasured hospital-level factors.</p>

<p><strong>Conclusions and Relevance: </strong>In a convenience sample of children hospitalized with bronchiolitis who were not receiving active supplemental oxygen administration, monitoring with continuous pulse oximetry was frequent and varied widely among hospitals. Because of the apparent absence of a guideline- or evidence-based indication for continuous monitoring in this population, this practice may represent overuse.</p>

10.1001/jama.2020.2998

JAMA

32315058

A National Approach to Pediatric Sepsis Surveillance.

2019

2019 Nov 27

1098-4275

<p>Pediatric sepsis is a major public health concern, and robust surveillance tools are needed to characterize its incidence, outcomes, and trends. The increasing use of electronic health records (EHRs) in the United States creates an opportunity to conduct reliable, pragmatic, and generalizable population-level surveillance using routinely collected clinical data rather than administrative claims or resource-intensive chart review. In 2015, the US Centers for Disease Control and Prevention recruited sepsis investigators and representatives of key professional societies to develop an approach to adult sepsis surveillance using clinical data recorded in EHRs. This led to the creation of the adult sepsis event definition, which was used to estimate the national burden of sepsis in adults and has been adapted into a tool kit to facilitate widespread implementation by hospitals. In July 2018, the Centers for Disease Control and Prevention convened a new multidisciplinary pediatric working group to tailor an EHR-based national sepsis surveillance approach to infants and children. Here, we describe the challenges specific to pediatric sepsis surveillance, including evolving clinical definitions of sepsis, accommodation of age-dependent physiologic differences, identifying appropriate EHR markers of infection and organ dysfunction among infants and children, and the need to account for children with medical complexity and the growing regionalization of pediatric care. We propose a preliminary pediatric sepsis event surveillance definition and outline next steps for refining and validating these criteria so that they may be used to estimate the national burden of pediatric sepsis and support site-specific surveillance to complement ongoing initiatives to improve sepsis prevention, recognition, and treatment.</p>

10.1542/peds.2019-1790

Pediatrics

31776196

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

2019

2019 Oct 02

1529-7535

<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>

10.1097/PCC.0000000000002106

Pediatr Crit Care Med

31577691