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Lauren Destino, MD

  • Lauren A Destino

Trabajo y Educación

Formación Profesional

Northwestern University Feinberg School of Medicine, Chicago, IL, 2004

Residencia

Medical College of Wisconsin, Milwaukee, WI, 2007

Certificaciones Médicas

Pediatrics, American Board of Pediatrics

Todo Publicaciones

Inpatient Hospital Factors and Resident Time With Patients and Families PEDIATRICS Destino, L. A., Valentine, M., Sheikhi, F. H., Starmer, A. J., Landrigan, C. P., Sanders, L. 2017; 139 (5)

Abstract

To define hospital factors associated with proportion of time spent by pediatric residents in direct patient care.We assessed 6222 hours of time-motion observations from a representative sample of 483 pediatric-resident physicians delivering inpatient care across 9 pediatric institutions. The primary outcome was percentage of direct patient care time (DPCT) during a single observation session (710 sessions). We used one-way analysis of variance to assess a significant difference in the mean percentage of DPCT between hospitals. We used the intraclass correlation coefficient analysis to determine within- versus between-hospital variations. We compared hospital characteristics of observation sessions with 12% DPCT to characteristics of sessions with <12% DPCT (12% is the DPCT in recent resident trainee time-motion studies). We conducted mixed-effects regression analysis to allow for clustering of sessions within hospitals and accounted for correlation of responses across hospital.Mean proportion of physician DPCT was 13.2% (SD = 8.6; range, 0.2%-49.5%). DPCT was significantly different between hospitals (P < .001). The intraclass correlation coefficient was 0.25, indicating more within-hospital than between-hospital variation. Observation sessions with 12% DPCT were more likely to occur at hospitals with Magnet designation (odds ratio [OR] = 3.45, P = .006), lower medical complexity (OR = 2.57, P = .04), and higher patient-to-trainee ratios (OR = 2.48, P = .05).On average, trainees spend <8 minutes per hour in DPCT. Variation exists in DPCT between hospitals. A less complex case mix, increased patient volume, and Magnet designation were independently associated with increased DPCT.

View details for DOI 10.1542/peds.2016-3011

View details for Web of Science ID 000400371500022

View details for PubMedID 28557735

Respiratory Scores as a Tool to Reduce Bronchodilator Use in Children Hospitalized With Acute Viral Bronchiolitis. Hospital pediatrics Mussman, G. M., Sahay, R. D., Destino, L., Lossius, M., Shadman, K. A., Walley, S. C. 2017; 7 (5): 279-286

Abstract

Adoption of clinical respiratory scoring as a quality improvement (QI) tool in bronchiolitis has been temporally associated with decreased bronchodilator usage. We sought to determine whether documented use of a clinical respiratory score at the patient level was associated with a decrease in either the physician prescription of any dose of bronchodilator or the number of doses, if prescribed, in a multisite QI collaborative.We performed a secondary analysis of data from a QI collaborative involving 22 hospitals. The project enrolled patients aged 1 month to 2 years with a primary diagnosis of acute viral bronchiolitis and excluded those with prematurity, other significant comorbid diseases, and those needing intensive care. We assessed for an association between documentation of any respiratory score use during an episode of care, as well as the method in which scores were used, and physician prescribing of any bronchodilator and number of doses. Covariates considered were phase of the collaborative, hospital length of stay, steroid use, and presence of household smokers.A total of 1876 subjects were included. There was no association between documentation of a respiratory score and the likelihood of physician prescribing of any bronchodilator. Score use was associated with fewer doses of bronchodilators if one was prescribed (P = .05), but this association disappeared with multivariable analysis (P = .73).We found no clear association between clinical respiratory score use and physician prescribing of bronchodilators in a multicenter QI collaborative.

View details for DOI 10.1542/hpeds.2016-0090

View details for PubMedID 28442541

Families as Partners in Hospital Error and Adverse Event Surveillance. JAMA pediatrics Khan, A., Coffey, M., Litterer, K. P., Baird, J. D., Furtak, S. L., Garcia, B. M., Ashland, M. A., Calaman, S., Kuzma, N. C., O'Toole, J. K., Patel, A., Rosenbluth, G., Destino, L. A., Everhart, J. L., Good, B. P., Hepps, J. H., Dalal, A. K., Lipsitz, S. R., Yoon, C. S., Zigmont, K. R., Srivastava, R., Starmer, A. J., Sectish, T. C., Spector, N. D., West, D. C., Landrigan, C. P., Allair, B. K., Alminde, C., Alvarado-Little, W., Atsatt, M., Aylor, M. E., Bale, J. F., Balmer, D., Barton, K. T., Beck, C., Bismilla, Z., Blankenberg, R. L., Chandler, D., Choudhary, A., Christensen, E., Coghlan-McDonald, S., Cole, F. S., Corless, E., Cray, S., Da Silva, R., Dahale, D., Dreyer, B., Growdon, A. S., Gubler, L., Guiot, A., Harris, R., Haskell, H., Kocolas, I., Kruvand, E., Lane, M. M., Langrish, K., Ledford, C. J., Lewis, K., Lopreiato, J. O., Maloney, C. G., Mangan, A., Markle, P., Mendoza, F., Micalizzi, D. A., Mittal, V., Obermeyer, M., O'Donnell, K. A., Ottolini, M., Patel, S. J., Pickler, R., Rogers, J. E., Sanders, L. M., Sauder, K., Shah, S. S., Sharma, M., Simpkin, A., Subramony, A., Thompson, E. D., Trueman, L., Trujillo, T., Turmelle, M. P., Warnick, C., Welch, C., White, A. J., Wien, M. F., Winn, A. S., Wintch, S., Wolf, M., Yin, H. S., Yu, C. E. 2017

Abstract

Medical errors and adverse events (AEs) are common among hospitalized children. While clinician reports are the foundation of operational hospital safety surveillance and a key component of multifaceted research surveillance, patient and family reports are not routinely gathered. We hypothesized that a novel family-reporting mechanism would improve incident detection.To compare error and AE rates (1) gathered systematically with vs without family reporting, (2) reported by families vs clinicians, and (3) reported by families vs hospital incident reports.We conducted a prospective cohort study including the parents/caregivers of 989 hospitalized patients 17 years and younger (total 3902 patient-days) and their clinicians from December 2014 to July 2015 in 4 US pediatric centers. Clinician abstractors identified potential errors and AEs by reviewing medical records, hospital incident reports, and clinician reports as well as weekly and discharge Family Safety Interviews (FSIs). Two physicians reviewed and independently categorized all incidents, rating severity and preventability (agreement, 68%-90%; , 0.50-0.68). Discordant categorizations were reconciled. Rates were generated using Poisson regression estimated via generalized estimating equations to account for repeated measures on the same patient.Error and AE rates.Overall, 746 parents/caregivers consented for the study. Of these, 717 completed FSIs. Their median (interquartile range) age was 32.5 (26-40) years; 380 (53.0%) were nonwhite, 566 (78.9%) were female, 603 (84.1%) were English speaking, and 380 (53.0%) had attended college. Of 717 parents/caregivers completing FSIs, 185 (25.8%) reported a total of 255 incidents, which were classified as 132 safety concerns (51.8%), 102 nonsafety-related quality concerns (40.0%), and 21 other concerns (8.2%). These included 22 preventable AEs (8.6%), 17 nonharmful medical errors (6.7%), and 11 nonpreventable AEs (4.3%) on the study unit. In total, 179 errors and 113 AEs were identified from all sources. Family reports included 8 otherwise unidentified AEs, including 7 preventable AEs. Error rates with family reporting (45.9 per 1000 patient-days) were 1.2-fold (95% CI, 1.1-1.2) higher than rates without family reporting (39.7 per 1000 patient-days). Adverse event rates with family reporting (28.7 per 1000 patient-days) were 1.1-fold (95% CI, 1.0-1.2; P=.006) higher than rates without (26.1 per 1000 patient-days). Families and clinicians reported similar rates of errors (10.0 vs 12.8 per 1000 patient-days; relative rate, 0.8; 95% CI, .5-1.2) and AEs (8.5 vs 6.2 per 1000 patient-days; relative rate, 1.4; 95% CI, 0.8-2.2). Family-reported error rates were 5.0-fold (95% CI, 1.9-13.0) higher and AE rates 2.9-fold (95% CI, 1.2-6.7) higher than hospital incident report rates.Families provide unique information about hospital safety and should be included in hospital safety surveillance in order to facilitate better design and assessment of interventions to improve safety.

View details for DOI 10.1001/jamapediatrics.2016.4812

View details for PubMedID 28241211

Improving Communication with Primary Care Physicians at the Time of Hospital Discharge. Joint Commission journal on quality and patient safety Destino, L. A., Dixit, A., Pantaleoni, J. L., Wood, M. S., Pageler, N. M., Kim, J., Platchek, T. S. 2017; 43 (2): 80-88

Abstract

Communication with primary care physicians (PCPs) at the time of a patient's hospital discharge is important to safely transition care to home. The goal of this quality improvement initiative was to increase discharge communication to PCPs at an academic children's hospital.A multidisciplinary team at Lucile Packard Children's Hospital Stanford used Lean A3 problem solving methodology to address the problem of inadequate discharge communication with PCPs. Emphasis was placed on frontline provider (resident physicians) involvement in the improvement process, creating standards, and error proofing. Root cause analysis identified several key drivers of the problem, and successive countermeasures were implemented beginning in August 2013 aimed at achieving the target of 80% attempted verbal communication within seven days before or after (usually 24-48 hours) on the pediatric medical services. Run charts were generated tracking the outcome of PCP communication.On the pediatric medical services, the goal of 80% communication was met and sustained during a seven-month period starting October 2013, a statistically significant improvement. In the eight months prior to October 2013, hospitalwide PCP communication prior to discharge averaged 59.1% (n=5,397) and improved to 76.7% (n=4,870) in the seven months after (p<0.001). Fifteen of 19 specialty services had a significant increase in discharge communication after October 2013.Lean improvement methodology (including structured problem solving using A3 thinking), intensive frontline provider involvement, and process-oriented electronic health record work flow redesign led to increased verbal PCP communication at around the time of a patient's discharge.

View details for DOI 10.1016/j.jcjq.2016.11.005

View details for PubMedID 28334566

Integrating Research, Quality Improvement, and Medical Education for Better Handoffs and Safer Care: Disseminating, Adapting, and Implementing the I-PASS Program. Joint Commission journal on quality and patient safety Starmer, A. J., Spector, N. D., West, D. C., Srivastava, R., Sectish, T. C., Landrigan, C. P. 2017; 43 (7): 31929

Abstract

In 2009 the I-PASS Study Group was formed by patient safety, medical education, health services research, and clinical experts from multiple institutions in the United States and Canada. When the I-PASS Handoff Program, which was developed by the I-PASS Study Group, was implemented in nine hospitals, it was associated with a 30% reduction in injuries due to medical errors and significant improvements in handoff processes, without any adverse effects on provider work flow.To effectively disseminate and adapt I-PASS for use across specialties and disciplines, a series of federally and privately funded dissemination and implementation projects were carried out following the publication of the initial study. The results of these efforts have informed ongoing initiatives intended to continue adapting and scaling the program.As of this writing, I-PASS Study Group members have directly worked with more than 50 hospitals to facilitate implementation of I-PASS. To further disseminate I-PASS, Study Group members delivered hundreds of academic presentations, including plenaries at scientific meetings, workshops, and institutional Grand Rounds. Some 3,563 individuals, representing more than 500 institutions in the 50 states in the United States, the District of Columbia, Puerto Rico, and 57 other countries, have requested access to I-PASS materials. Most recently, the I-PASS(SM) Patient Safety Institute has developed a virtual immersion training platform, mobile handoff observational tools, and processes to facilitate further spread of I-PASS.Implementation of I-PASS has been associated with substantial improvements in patient safety and can be applied to a variety of disciplines and types of patient handoffs. Widespread implementation of I-PASS has the potential to substantially improve patient safety in the United States and beyond.

View details for DOI 10.1016/j.jcjq.2017.04.001

View details for PubMedID 28648217

Expanding the phenotype of hawkinsinuria: new insights from response to N-acetyl-L-cysteine. Journal of inherited metabolic disease Gomez-Ospina, N., Scott, A. I., Oh, G. J., Potter, D., Goel, V. V., Destino, L., Baugh, N., Enns, G. M., Niemi, A., Cowan, T. M. 2016; 39 (6): 821-829

Abstract

Hawkinsinuria is a rare disorder of tyrosine metabolism that can manifest with metabolic acidosis and growth arrest around the time of weaning off breast milk, typically followed by spontaneous resolution of symptoms around 1 year of age. The urinary metabolites hawkinsin, quinolacetic acid, and pyroglutamic acid can aid in identifying this condition, although their relationship to the clinical manifestations is not known. Herein we describe clinical and laboratory findings in two fraternal twins with hawkinsinuria who presented with failure to thrive and metabolic acidosis. Close clinical follow-up and laboratory testing revealed previously unrecognized hypoglycemia, hypophosphatemia, combined hyperlipidemia, and anemia, along with the characteristic urinary metabolites, including massive pyroglutamic aciduria. Treatment with N-acetyl-L-cysteine (NAC) restored normal growth and normalized or improved most biochemical parameters. The dramatic response to NAC therapy supports the idea that glutathione depletion plays a key role in the pathogenesis of hawkinsinuria.

View details for PubMedID 27488560

Engaging Pediatric Resident Physicians in Quality Improvement Through Resident-Led Morbidity and Mortality Conferences. Joint Commission journal on quality and patient safety / Joint Commission Resources Destino, L. A., Kahana, M., Patel, S. J. 2016; 42 (3): 99-106

Abstract

Increasingly, medical disciplines have used morbidity and mortality conferences (MMCs) to address quality improvement and patient safety (QI/PS), as well as teach systems-based improvement to graduate trainees. The goal of this educational intervention was to establish a pediatric resident physicianled MMC that not only focused on QI/PS principles but also engaged resident physicians in QI/ PS endeavors in their clinical learning environments.Following a needs assessment, pediatric resident physicians at the Stanford University School of Medicine (Stanford, California) established a new MMC model in February 2010 as part of a required QI rotation. Cases were identified, explored, analyzed, and presented by resident physicians using the Johns Hopkins Learning from Defects tool. Discussions during the MMCs were resident physician directed and systems-based, and resulted in projects to address care delivery. Faculty advisors assessed resident physician comprehension of QI/PS. Conferences were evaluated through the end of the 20122013 academic year and outcomes tracked through the 20132014 academic year to determine trainee involvement in systems change resulting from the MMCs.The MMC was well received and the number of MMCs increased over time. By the end of the 20132014 academic year, resident physicians were involved in address ing 14 systems-based issues resulting from 25 MMCs. Examples of the resident physicianinitiated improvement work included increasing use of the rapid response team, institution of a gastrostomy (g)-tube order set, and establishing a face-to-face provider handoff for pediatric ICUto-acute-care-floor transfers.A resident physicianrun MMC exposes resident physicians to QI/PS concepts and principles, enables direct faculty assessment of QI/PS knowledge, and can propel resident physicians into real-time engagement in the culture of safety in a complex hospital environment.

View details for PubMedID 26892704

Intern and Resident Workflow Patterns on Pediatric Inpatient Units: A Multicenter Time-Motion Study JAMA PEDIATRICS Starmer, A. J., Destino, L., Yoon, C. S., Landrigan, C. P. 2015; 169 (12): 1175-1177
Variation in printed handoff documents: Results and recommendations from a multicenter needs assessment JOURNAL OF HOSPITAL MEDICINE Rosenbluth, G., Bale, J. F., Starmer, A. J., Spector, N. D., Srivastava, R., West, D. C., Sectish, T. C., Landrigan, C. P. 2015; 10 (8): 517-524

Abstract

Handoffs of patient care are a leading root cause of medical errors. Standardized techniques exist to minimize miscommunications during verbal handoffs, but studies to guide standardization of printed handoff documents are lacking.To determine whether variability exists in the content of printed handoff documents and to identify key data elements that should be uniformly included in these documents.Pediatric hospitalist services at 9 institutions in the United States and Canada.Sample handoff documents from each institution were reviewed, and structured group interviews were conducted to understand each institution's priorities for written handoffs. An expert panel reviewed all handoff documents and structured group-interview findings, and subsequently made consensus-based recommendations for data elements that were either essential or recommended, including best overall printed handoff practices.Nine sites completed structured group interviews and submitted data. We identified substantial variation in both the structure and content of printed handoff documents. Only 4 of 23 possible data elements (17%) were uniformly present in all sites' handoff documents. The expert panel recommended the following as essential for all printed handoffs: assessment of illness severity, patient summary, action items, situation awareness and contingency plans, allergies, medications, age, weight, date of admission, and patient and hospital service identifiers. Code status and several other elements were also recommended.Wide variation exists in the content of printed handoff documents. Standardizing printed handoff documents has the potential to decrease omissions of key data during patient care transitions, which may decrease the risk of downstream medical errors.

View details for DOI 10.1002/jhm.2380

View details for Web of Science ID 000358693600007

View details for PubMedID 26014471

Changes in Medical Errors after Implementation of a Handoff Program NEW ENGLAND JOURNAL OF MEDICINE Starmer, A. J., Spector, N. D., Srivastava, R., West, D. C., Rosenbluth, G., Allen, A. D., NOBLE, E. L., Tse, L. L., Dalal, A. K., Keohane, C. A., Lipsitz, S. R., Rothschild, J. M., Wien, M. F., Yoon, C. S., Zigmont, K. R., Wilson, K. M., O'Toole, J. K., Solan, L. G., Aylor, M., Bismilla, Z., Coffey, M., Mahant, S., Blankenburg, R. L., Destino, L. A., EVERHART, J. L., Patel, S. J., Bale, J. F., Spackman, J. B., Stevenson, A. T., Calaman, S., Cole, F. S., Balmer, D. F., Hepps, J. H., Lopreiato, J. O., Yu, C. E., Sectish, T. C., Landrigan, C. P. 2014; 371 (19): 1803-1812
Development, Implementation, and Dissemination of the I-PASS Handoff Curriculum: A Multisite Educational Intervention to Improve Patient Handoffs ACADEMIC MEDICINE Starmer, A. J., O'Toole, J. K., Rosenbluth, G., Calaman, S., Balmer, D., West, D. C., Bale, J. F., Yu, C. E., Noble, E. L., Tse, L. L., Srivastava, R., Landrigan, C. P., Sectish, T. C., Spector, N. D. 2014; 89 (6): 876-884

Abstract

Patient handoffs are a key source of communication failures and adverse events in hospitals. Despite Accreditation Council for Graduate Medical Education requirements for residency training programs to provide formal handoff skills training and to monitor handoffs, well-established curricula and validated skills assessment tools are lacking. Developing a handoff curriculum is challenging because of the need for standardized processes and faculty development, cultural resistance to change, and diverse institution- and unit-level factors. In this article, the authors apply a logic model to describe the process they used from June 2010 to February 2014 to develop, implement, and disseminate an innovative, comprehensive handoff curriculum in pediatric residency training programs as a fundamental component of the multicenter Initiative for Innovation in Pediatric Education-Pediatric Research in Inpatient Settings Accelerating Safe Sign-outs (I-PASS) Study. They describe resources, activities, and outputs, and report preliminary learner outcomes using data from resident and faculty evaluations of the I-PASS Handoff Curriculum: 96% of residents and 97% of faculty agreed or strongly agreed that the curriculum promoted acquisition of relevant skills for patient care activities. They also share lessons learned that could be of value to others seeking to adopt a structured handoff curriculum or to develop large-scale curricular innovations that involve redesigning firmly established processes. These lessons include the importance of approaching curricular implementation as a transformational change effort, assembling a diverse team of junior and senior faculty to provide opportunities for mentoring and professional development, and linking the educational intervention with the direct measurement of patient outcomes.

View details for DOI 10.1097/ACM.0000000000000264

View details for Web of Science ID 000337176300018

View details for PubMedID 24871238

Placing Faculty Development Front and Center in a Multisite Educational Initiative: Lessons From the I-PASS Handoff Study ACADEMIC PEDIATRICS O'Toole, J. K., West, D. C., Starmer, A. J., Yu, C. E., Calaman, S., Rosenbluth, G., Hepps, J. H., Lopreiato, J. O., Landrigan, C. P., Sectish, T. C., Spector, N. D. 2014; 14 (3): 221-224

View details for Web of Science ID 000335368000002

View details for PubMedID 24767774

Validity of respiratory scores in bronchiolitis. Hospital pediatrics Destino, L., Weisgerber, M. C., Soung, P., Bakalarski, D., Yan, K., Rehborg, R., Wagner, D. R., Gorelick, M. H., Simpson, P. 2012; 2 (4): 202-209

Abstract

The primary objective of this study was to establish the validity and reliability of 2 respiratory scores, the Respiratory Distress Assessment Instrument (RDAI) and the Children's Hospital of Wisconsin Respiratory Score (CHWRS), in bronchiolitis. A secondary objective was to identify the respiratory score components that most determine overall respiratory status.This was a prospective cohort study in infants aged < 1 year seen at Children's Hospital of Wisconsin for bronchiolitis. We evaluated: (1) discriminative validity (the score's ability to discriminate between 2 different outcomes) of the respiratory scores to identify emergency department (ED) disposition by using receiver operating characteristic curves; and (2) construct validity (the score's ability to measure what it is thought to measure, overall respiratory status) by using length of stay (LOS) as a proxy for disease severity and comparing correlations between changes in respiratory scores and LOS. Interrater reliability was established by using intraclass correlation. The contribution of individual respiratory score components to determine ED disposition was studied by using multivariate logistic regression.A total of 195 infants were included. The area under the receiver operating characteristic curve was 0.68 for CHWRS versus 0.51 for RDAI in predicting disposition. There was no correlation between initial respiratory scores or change in respiratory scores over the first 24 hours and LOS. Item analysis revealed that oxygen delivery, subcostal retractions, and respiratory rate were independently correlated with ED disposition. The CHWRS was more reliable than the RDAI.The CHWRS had modest discriminative validity in predicting ED disposition. Neither the CHWRS nor the RDAI had good construct validity. Respiratory rate, oxygen need, and presence of retractions were most useful in predicting ED disposition.

View details for PubMedID 24313026

I-PASS, a Mnemonic to Standardize Verbal Handoffs PEDIATRICS Starmer, A. J., Spector, N. D., Srivastava, R., Allen, A. D., Landrigan, C. P., Sectish, T. C. 2012; 129 (2): 201-204

View details for DOI 10.1542/peds.2011-2966

View details for Web of Science ID 000300395100040

View details for PubMedID 22232313

Establishing a Multisite Education and Research Project Requires Leadership, Expertise, Collaboration, and an Important Aim PEDIATRICS Sectish, T. C., Starmer, A. J., Landrigan, C. P., Spector, N. D. 2010; 126 (4): 619-622

View details for DOI 10.1542/peds.2010-1793

View details for Web of Science ID 000282526100030

View details for PubMedID 20876168

Severe osteomyelitis caused by Myceliophthora thermophila after a pitchfork injury. Annals of clinical microbiology and antimicrobials Destino, L., Sutton, D. A., Helon, A. L., Havens, P. L., Thometz, J. G., Willoughby, R. E., Chusid, M. J. 2006; 5: 21-?

Abstract

Traumatic injuries occurring in agricultural settings are often associated with infections caused by unusual organisms. Such agents may be difficult to isolate, identify, and treat effectively.A 4-year-old boy developed an extensive infection of his knee and distal femur following a barnyard pitchfork injury. Ultimately the primary infecting agent was determined to be Myceliophthora thermophila, a thermophilic melanized hyphomycete, rarely associated with human infection, found in animal excreta. Because of resistance to standard antifungal agents including amphotericin B and caspofungin, therapy was instituted with a prolonged course of terbinafine and voriconazole. Voriconazole blood levels demonstrated that the patient required a drug dosage (13.4 mg/kg) several fold greater than that recommended for adults in order to attain therapeutic blood levels.Unusual pathogens should be sought following traumatic farm injuries. Pharmacokinetic studies may be of critical importance when utilizing antifungal therapy with agents for which little information exists regarding drug metabolism in children.

View details for PubMedID 16961922