Natalie Pageler, MD

Abstract

Implementing an electronic health record (EHR) is one of the most disruptive operational tasks a health system can undergo. Despite anecdotal reports of adverse events around the time of EHR implementations, there is limited corroborating research, particularly in pediatrics. We utilized data from Solutions for Patient Safety (SPS), a network of 145+ children's hospitals that share data and protocols to reduce harm in pediatric care delivery, to study the impact of EHR implementations on patient safety.Determine if there is an association between the time immediately surrounding an EHR implementation and hospital-acquired conditions (HAC) rates in pediatrics.A survey of IT leaders at pediatric institutions identified EHR implementations occurring between 2012 and 2022. This list was cross-referenced with the SPS database to create an anonymized dataset of 27 sites comprising monthly HAC and care bundle compliance rates in the 7 months preceding and succeeding the transition. Six HACs were analyzed: central-line associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), adverse drug events (ADE), surgical site infections (SSI), pressure injuries (PI), and falls, in addition to four associated care bundle compliance rates: CLABSI and CAUTI maintenance bundles, SSI bundle and PI bundle. To determine if there was a statistically significant association with EHR implementation, the observation period was divided into three eras: "before" (months -7 to -3), "during" (months -2 to +2), and "after" go-live (months +3 to +7). Average monthly HAC and bundle compliance rates were calculated across eras. Paired t-tests were performed to compare rates between the eras.No statistically significant increase in HAC rates or decrease in bundle compliance rates were observed across the EHR implementation eras.This multi-site study detected no significant increase in hospital-acquired conditions and no decrease in preventive care bundle compliance in the months surrounding an EHR implementation.

View details for DOI 10.1055/a-2077-4419

View details for PubMedID 37075806

Abstract

BACKGROUND: The 21st Century Cures Act mandates the immediate, electronic release of health information to patients. However, in the case of adolescents, special consideration is required to ensure that confidentiality is maintained. The detection of confidential content in clinical notes may support operational efforts to preserve adolescent confidentiality while implementing information sharing.OBJECTIVE: Determine if a natural language processing (NLP) algorithm can identify confidential content in adolescent clinical progress notes.METHODS: 1,200 outpatient adolescent progress notes written between 2016 and 2019 were manually annotated to identify confidential content. Labeled sentences from this corpus were featurized and used to train a two-part logistic regression model, which provides both sentence-level and note-level probability estimates that a given text contains confidential content. This model was prospectively validated on a set of 240 progress notes written in May 2022. It was subsequently deployed in a pilot intervention to augment an ongoing operational effort to identify confidential content in progress notes. Note-level probability estimates were used to triage notes for review and sentence-level probability estimates were used to highlight high-risk portions of those notes to aid the manual reviewer.RESULTS: The prevalence of notes containing confidential content was 21% (255/1200) and 22% (53/240) in the train/test and validation cohorts. The ensemble logistic regression model achieved an AUROC of 90% and 88% in the test and validation cohorts. Its use in a pilot intervention identified outlier documentation practices and demonstrated efficiency gains over completely manual note review.DISCUSSION: An NLP algorithm can identify confidential content in progress notes with high accuracy. Its human-in-the-loop deployment in clinical operations augmented an ongoing operational effort to identify confidential content in adolescent progress notes. These findings suggest NLP may be used to support efforts to preserve adolescent confidentiality in the wake of the information blocking mandate.

View details for DOI 10.1055/a-2051-9764

View details for PubMedID 36898410

Abstract

The 21st Century Cures Act information blocking final rule mandated the immediate and electronic release of health care data in 2020. There is anecdotal concern that a significant amount of information is documented in notes that would breach adolescent confidentiality if released electronically to a guardian.The purpose of this study was to quantify the prevalence of confidential information, based on California laws, within progress notes for adolescent patients that would be released electronically and assess differences in prevalence across patient demographics.This is a single-center retrospective chart review of outpatient progress notes written between January 1, 2016, and December 31, 2019, at a large suburban academic pediatric network. Notes were labeled into one of three confidential domains by five expert reviewers trained on a rubric defining confidential information for adolescents derived from California state law. Participants included a random sampling of eligible patients aged 12 to 17 years old at the time of note creation. Secondary analysis included prevalence of confidentiality across age, gender, language spoken, and patient race.Of 1,200 manually reviewed notes, 255 notes (21.3%) (95% confidence interval: 19-24%) contained confidential information. There was a similar distribution among gender and age and a majority of English speaking (83.9%) and white or Caucasian patients (41.2%) in the cohort. Confidential information was more likely to be found in notes for females (p<0.05) as well as for English-speaking patients (p<0.05). Older patients had a higher probability of notes containing confidential information (p<0.05).This study demonstrates that there is a significant risk to breach adolescent confidentiality if historical progress notes are released electronically to proxies without further review or redaction. With increased sharing of health care data, there is a need to protect the privacy of the adolescents and prevent potential breaches of confidentiality.

View details for DOI 10.1055/s-0043-1767682

View details for PubMedID 37137339

View details for PubMedCentralID PMC10156443

Abstract

CASE PRESENTATION: The parent of an adolescent patient noticed an upcoming appointment in the patient's portal account that should have remained confidential to the parent. As it turned out, this parent was directly accessing their child's adolescent patient portal account instead of using a proxy account. After investigation of this case, it was found that the adolescent account had been activated with the parent's demographic information. This case illustrates the challenges of using adult-centric electronic health record (EHR) systems and how our institution addressed the problem of incorrect portal account activations.BACKGROUND: Confidentiality is fundamental to providing healthcare to adolescents. To comply with the 21st Century Cures Act's information blocking rules, confidential information must be released to adolescent patients when appropriate while also remaining confidential from their guardians. While complying with this national standard, systems of care must also account for interstate variability in which services allow for confidential adolescent consent. Unfortunately, there are high rates of guardian access to adolescent portal accounts. Therefore, measures must be taken to minimize the risk of inadvertent confidentiality breaches via adolescent patient portals. Solutions and Lessons Learned: Our institution implemented a guardrail system that checks the adolescent patient's contact information against the contact information of their parent/guardian/guarantor. This guardrail reduced the rate of account activation errors after implementation. However, the guardrail can be bypassed when demographic fields are missing. Thus, ongoing efforts to create pediatric-appropriate demographic fields in the EHR and workflows for registration of proxy accounts in the patient portal are needed.

View details for DOI 10.1055/a-2015-0964

View details for PubMedID 36652961

Abstract

For caregivers of adolescents and young adults with severe cognitive deficits, or "diminished capacity," access to the medical record can be critical. However, this can be a challenge when utilizing the electronic health record (EHR) as information is often restricted in order to protect adolescent confidentiality. Having enhanced access for these proxies would be expected to improve engagement with the health system for the families of these medically complex adolescents and young adults.To describe a process for granting full EHR access to proxies of adolescents with diminished capacity and young adults who are legally conserved while respecting regulations supporting adolescent confidentiality.The first step in this initiative was to define the "diminished capacity" access class for both adolescents and young adults. Once defined, workflows utilizing best practice alerts were developed to support clinicians in providing the appropriate documentation. In addition, processes were developed to minimize the possibility of erroneously activating the diminished capacity access class for any given patient. To enhance activation, a support tool was developed to identify patients who might meet the criteria for diminished capacity proxy access. Finally, outreach and educations were developed for providers and clinics to make them aware of this initiative.Since activating this workflow, proxies of 138 adolescents and young adults have been granted the diminished capacity proxy access class. Approximately 54% are between 12 and 17 years with 46% 18 years and older. Proxies for both age groups have engaged with portal functionality at higher rates when compared to institutional rates of use by proxies of the general pediatric population.With this quality improvement initiative, we were able to enhance EHR access and engagement of families of some of the most complex adolescent and young adult patients without inadvertently compromising adolescent confidentiality.

View details for DOI 10.1055/s-0043-1760847

View details for PubMedID 36792056

View details for Web of Science ID 000921450900081

View details for DOI 10.1016/j.chest.2022.08.2208

View details for PubMedID 36494125

Abstract

OBJECTIVE: The purpose of this study is to evaluate the ability of three metrics to monitor for a reduction in performance of a chronic kidney disease (CKD) model deployed at a pediatric hospital.METHODS: The CKD risk model estimates a patient's risk of developing CKD 3 to 12 months following an inpatient admission. The model was developed on a retrospective dataset of 4,879 admissions from 2014 to 2018, then run silently on 1,270 admissions from April to October, 2019. Three metrics were used to monitor its performance during the silent phase: (1) standardized mean differences (SMDs); (2) performance of a "membership model"; and (3) response distribution analysis. Observed patient outcomes for the 1,270 admissions were used to calculate prospective model performance and the ability of the three metrics to detect performance changes.RESULTS: The deployed model had an area under the receiver-operator curve (AUROC) of 0.63 in the prospective evaluation, which was a significant decrease from an AUROC of 0.76 on retrospective data (p=0.033). Among the three metrics, SMDs were significantly different for 66/75 (88%) of the model's input variables (p <0.05) between retrospective and deployment data. The membership model was able to discriminate between the two settings (AUROC=0.71, p <0.0001) and the response distributions were significantly different (p <0.0001) for the two settings.CONCLUSION: This study suggests that the three metrics examined could provide early indication of performance deterioration in deployed models' performance.

View details for DOI 10.1055/s-0042-1746168

View details for PubMedID 35508197

View details for DOI 10.1055/s-0042-1744386

View details for PubMedID 35219280

Abstract

The coronavirus disease 2019 (COVID-19) pandemic necessitated using telehealth to bridge the clinical gap, but could increase health disparities. This article reports on a chart review of diabetes telehealth visits occurring before COVID-19, during shelter-in-place orders, and during the reopening period. Visits for children with public insurance and for those who were non-English speaking were identified. Telehealth visits for children with public insurance increased from 26.2% before COVID-19 to 37.3% during shelter-in-place orders and 34.3% during reopening. Telehealth visits for children who were non-English speaking increased from 3.5% before COVID-19 to 17.5% during shelter-in-place orders and remained at 15.0% during reopening. Pandemic-related telehealth expansion included optimization of workflows to include patients with public insurance and those who did not speak English. Increased participation by those groups persisted during the reopening phase, indicating that prioritizing inclusive telehealth workflows can reduce disparities in access to care.

View details for DOI 10.2337/cd20-0123

View details for PubMedID 35669301

Abstract

PURPOSE: Managing confidential adolescent health information in patient portals presents unique challenges. Adolescent patients and guardians electronically access medical records and communicate with providers via portals. In confidential matters like sexual health, ensuring confidentiality is crucial. A key aspect of confidential portals is ensuring that the account is registered to and utilized by the intended user. Inappropriately registered or guardian-accessed adolescent portal accounts may lead to confidentiality breaches.METHODS: We used a quality improvement framework to develop screening methodologies to flag guardian-accessible accounts. Accounts of patients aged 12-17 were flagged via manual review of account emails and natural language processing of portal messages. We implemented a reconciliation program to correct affected accounts' registered email. Clinics were notified about sign-up errors and educated on sign-up workflow. An electronic alert was created to check the adolescent's email prior to account activation.RESULTS: After initial screening, 2,307 of 3,701 (62%) adolescent accounts were flagged as registered with a guardian's email. Those accounts were notified to resolve their logins. After five notifications over 8 weeks, 266 of 2,307 accounts (12%) were corrected; the remaining 2,041 (88%) were deactivated.CONCLUSIONS: The finding that 62% of adolescent portal accounts were used/accessed by guardians has significant confidentiality implications. In the context of the Cures Act Final Rule and increased information sharing, our institution's experience with ensuring appropriate access to adolescent portal accounts is necessary, timely, and relevant. This study highlights ways to improve patient portal confidentiality and prompts institutions caring for adolescents to review their systems and processes.

View details for DOI 10.1016/j.jadohealth.2021.09.009

View details for PubMedID 34666956

Abstract

Introduction: Medication reconciliation errors (MREs) are common and can lead to significant patient harm. Quality improvement efforts to identify and reduce these errors typically rely on resource-intensive chart reviews or adverse event reporting. Quantifying these errors hospital-wide is complicated and rarely done. The purpose of this study is to define a set of 6 MREs that can be easily identified across an entire healthcare organization and report their prevalence at 2 pediatric hospitals.Methods: An algorithmic analysis of discharge medication lists and confirmation by clinician reviewers was used to find the prevalence of the 6 discharge MREs at 2 pediatric hospitals. These errors represent deviations from the standards for medication instruction completeness, clarity, and safety. The 6 error types are Duplication, Missing Route, Missing Dose, Missing Frequency, Unlisted Medication, and See Instructions errors.Results: This study analyzed 67,339 discharge medications and detected MREs commonly at both hospitals. For Institution A, a total of 4,234 errors were identified, with 29.9% of discharges containing at least one error and an average of 0.7 errors per discharge. For Institution B, a total of 5,942 errors were identified, with 42.2% of discharges containing at least 1 error and an average of 1.6 errors per discharge. The most common error types were Duplication and See Instructions errors.Conclusion: The presented method shows these MREs to be a common finding in pediatric care. This work offers a tool to strengthen hospital-wide quality improvement efforts to reduce pediatric medication errors.

View details for DOI 10.1097/pq9.0000000000000436

View details for PubMedID 34345749

Abstract

BACKGROUND: To characterize telemedicine use among pediatric subspecialties with respect to clinical uses of telemedicine, provider experience, and patient perceptions during the COVID-19 pandemic.METHODS: We performed a mixed-methods study of telemedicine visits across pediatric endocrinology, nephrology, orthopedic surgery, and rheumatology at a large children's hospital. We used deductive analysis to review observational data from 40 video visits. Providers and patients/caregivers were surveyed around areas of satisfaction and communication.RESULTS: We found adaptations of telemedicine including shared-screen use and provider-guided parent procedures among others. All providers felt that it was safest for their patients to conduct visits by video, and 72.7% reported completing some component of a clinical exam. Patients rated the areas of being respected by the clinical staff/provider and showing care and concern highly, and the mean overall satisfaction was 86.719.3%.CONCLUSIONS: Telemedicine has been used to deliver care to pediatric patients during the pandemic, and we found that patients were satisfied with the telemedicine visits during this stressful time and that providers were able to innovate during visits. Telemedicine is a tool that can be successfully adapted to patient and provider needs, but further studies are needed to fully explore its integration in pediatric subspecialty care.IMPACT: This study describes telemedicine use at the height of the COVID-19 pandemic from both a provider and patient perspective, in four different pediatric subspecialties. Prior to COVID-19, pediatric telehealth landscape analysis suggested that many pediatric specialty practices had pilot telehealth programs, but there are few published studies evaluating telemedicine performance through the simultaneous patient and provider experience as part of standard care. We describe novel uses and adaptations of telemedicine during a time of rapid deployment in pediatric specialty care.

View details for DOI 10.1038/s41390-021-01443-4

View details for PubMedID 33753896

Abstract

BACKGROUND: OpenNotes, the sharing of medical notes via a patient portal, has been extensively studied in adults but not in pediatric populations. This has been a contributing factor in the slower adoption of OpenNotes by children's hospitals. The 21st Century Cures Act Final Rule has mandated the sharing of clinical notes electronically to all patients and as health systems prepare to comply, some concerns remain particularly with OpenNotes for pediatric populations.OBJECTIVES: After a gradual implementation of OpenNotes at an academic pediatric center, we sought to better understand how pediatric patients and families perceived OpenNotes. This article presents the detailed steps of this informatics-led rollout and patient survey results with a focus on pediatric-specific concerns.METHODS: We adapted a previous OpenNotes survey used for adult populations to a pediatric outpatient setting (with parents of children <12 years old). The survey was sent to patients and families via a notification email sent as a standard practice after a clinic visit, in English or Spanish.RESULTS: Approximately 7% of patients/families with access to OpenNotes read the note during the study period, and 159 (20%) of those patients responded to the survey. Of the survey respondents, 141 (89%) of patients and families understood their notes; 126 (80%) found the notes always or usually accurate; 24 (15%) contacted their clinicians after reading a note; and 153 (97%) patients/families felt the same or better about their doctor after reading the note.CONCLUSION: Although limited by relatively low survey response rate, OpenNotes was well-received by parents of pediatric patients without untoward consequences. The main concerns pediatricians raise about OpenNotes proved to not be issues in the pediatric population. Our results demonstrate clear benefits to adoption of OpenNotes. This provides reassurance that the transition to sharing notes with pediatric patients can be successful and value additive.

View details for DOI 10.1055/s-0040-1721781

View details for PubMedID 33567464

Abstract

Time spent in the electronic health record (EHR) has been identified as an important unit of measure for health care provider clinical activity. The lack of validation of audit-log based inpatient EHR time may have resulted in underuse of this data in studies focusing on inpatient patient outcomes, provider efficiency, provider satisfaction, etc. This has also led to a dearth of clinically relevant EHR usage metrics consistent with inpatient provider clinical activity.The aim of our study was to validate audit-log based EHR times using observed EHR-times extracted from screen recordings of EHR usage in the inpatient setting.This study was conducted in a 36-bed pediatric intensive care unit (PICU) at Lucile Packard Children's Hospital Stanford between June 11 and July 14, 2020. Attending physicians, fellow physicians, hospitalists, and advanced practice providers with 0.5 full-time equivalent (FTE) for the prior four consecutive weeks and at least one EHR session recording were included in the study. Citrix session recording player was used to retrospectively review EHR session recordings that were captured as the provider interacted with the EHR.EHR use patterns varied by provider type. Audit-log based total EHR time correlated strongly with both observed total EHR time (r=0.98, p<0.001) and observed active EHR time (r=0.95, p<0.001). Each minute of audit-log based total EHR time corresponded to 0.95 (0.87-1.02) minutes of observed total EHR time and 0.75 (0.67-0.83) minutes of observed active EHR time. Results were similar when stratified by provider role.Our study found inpatient audit-log based EHR time to correlate strongly with observed EHR time among pediatric critical care providers. These findings support the use of audit-log based EHR-time as a surrogate measure for inpatient provider EHR use, providing an opportunity for researchers and other stakeholders to leverage EHR audit-log data in measuring clinical activity and tracking outcomes of workflow improvement efforts longitudinally and across provider groups.

View details for DOI 10.1055/s-0041-1733851

View details for PubMedID 34380167

View details for Web of Science ID 000672597100301

Abstract

Medical student note writing is an important part of the training process but has suffered in the electronic health record (EHR) era as a result of student notes being excluded from the billable encounter. The 2018 CMS billing changes allow for medical student notes to be used for billable services provided that physical presence requirements are met, and attending physicians satisfy performance requirements and verify documentation. This has the potential to improve medical student engagement and decrease physician documentation burden.Our institution implemented medical student notes as part of the billable encounter in August 2018 with support of our compliance department. Note characteristics including number, type, length, and time in note were analyzed before and after implementation. Rotating medical students were surveyed regarding their experience following implementation.There was a statistically significant increase in the number of student-authored notes following implementation. Attending physicians' interactions with student notes greatly increased following the change (4% of student notes reviewed vs. 84% of student notes). Surveyed students reported that having their notes as part of the billable record made their notes more meaningful and enhanced their learning. The majority of surveyed students also agreed that they received more feedback following the change.Medical students are interested in writing notes for education and feedback. Inclusion of their notes as part of the billable record can facilitate their learning and increase their participation in the note writing process.

View details for DOI 10.1055/s-0041-1731342

View details for PubMedID 34233368

Abstract

In 2013, the American Board of Preventive Medicine (ABPM) and the American Board of Pathology (ABPath) offered the first board certification examination in Clinical Informatics to eligible physicians in the United States. In 2022, the Practice Pathway will expire and in 2023 only candidates eligible through the Fellowship Pathway will be eligible for the board certification. To date, Clinical Informatics as a specialty has not had a regular match process and used a controlled offer-acceptance process that does not meet candidates' or programs' needs. Fellows may not be offered a position with their top choice program initially, and they may accept offers from other programs to avoid risk by ensuring that they have a fellowship position. Programs have to consider losing an applicant in the first round in the ranking of applicants. The process is open to manipulation including early agreements between program directors and candidates. In this open letter to the ABPM, program directors make the case for a third-party match and are calling on the ABPM to leverage its status as the Clinical Informatics certifying body and its existing infrastructure to implement a Clinical Informatics match.

View details for DOI 10.1055/s-0040-1714348

View details for PubMedID 32668481

Abstract

To reduce pathogen exposure, conserve personal protective equipment, and facilitate health care personnel work participation in the setting of the COVID-19 pandemic, three affiliated institutions rapidly and independently deployed inpatient telemedicine programs during March 2020. We describe key features and early learnings of these programs in the hospital setting.Relevant clinical and operational leadership from an academic medical center, pediatric teaching hospital, and safety net county health system met to share learnings shortly after deploying inpatient telemedicine. A summative analysis of their learnings was re-circulated for approval.All three institutions faced pressure to urgently standup new telemedicine systems while still maintaining secure information exchange. Differences across patient demographics and technological capabilities led to variation in solution design, though key technical considerations were similar. Rapid deployment in each system relied on readily available consumer-grade technology, given the existing familiarity to patients and clinicians and minimal infrastructure investment. Preliminary data from the academic medical center over one month suggested positive adoption with 631 inpatient video calls lasting an average (standard deviation) of 16.5 minutes (19.6) based on inclusion criteria.The threat of an imminent surge of COVID-19 patients drove three institutions to rapidly develop inpatient telemedicine solutions. Concurrently, federal and state regulators temporarily relaxed restrictions that would have previously limited these efforts. Strategic direction from executive leadership, leveraging off-the-shelf hardware, vendor engagement, and clinical workflow integration facilitated rapid deployment.The rapid deployment of inpatient telemedicine is feasible across diverse settings as a response to the COVID-19 pandemic.

View details for DOI 10.1093/jamia/ocaa077

View details for PubMedID 32495830

Abstract

Recent regulatory and technological advances have enabled a new era of health apps that are controlled by patients and contain valuable health information. These health apps will be numerous and use novel interfaces that appeal to patients but will likely be unfamiliar to practitioners. We posit that understanding the origin of the health data is the most meaningful and versatile way for physicians to understand and effectively use these apps in patient care. This will allow providers to better support patients and encourage patient engagement in their own care.

View details for DOI 10.2196/14288

View details for PubMedID 33055064

View details for PubMedCentralID PMC7434101

Abstract

To understand if providers who had additional electronic health record (EHR) training improved their satisfaction, decreased personal EHR-use time, and decreased turnaround time on tasks.This pre-post study with no controls evaluated the impact of a supplemental EHR training program on a group of academic and community practice clinicians that previously had go-live group EHR training and 20 months experience using this EHR on self-reported data, calculated EHR time, and vendor-reported metrics.Providers self-reported significant improvements in their knowledge of efficiency tools in the EHR after training and doubled (significant) their preference list entries (mean pre = 38.1 [65.88], post = 63.5 [90.47], P<.01). Of the 7 EHR satisfaction variables, only 1 self-reported variable significantly improved after training: Control over my workload in the EHR (mean pre = 2.7 [0.96], post = 3.0 [1.04], P<.01). There was no significant decrease in their calculated EHR usage outside of clinic (mean pre = 0.39 [0.77] to post = 0.37 [0.48], P=.73). No significant difference was seen in turnaround time for patient calls (mean pre=2.3 [2.06] days, post=1.9 [1.76] days, P=.08) and results (mean before = 4.0 [2.79] days, after = 3.2 [2.33] days, P=.03).Multiple sources of data provide a holistic view of the provider experience in the EHR. This study suggests that individualized EHR training can improve the knowledge of EHR tools and satisfaction with their perceived control of EHR workload, however this did not translate into less Clinician Logged-In Outside Clinic (CLOC) time, a calculated metric, nor quicker turnaround on in box tasks. CLOC time emerged as a potential less-costly surrogate metric for provider satisfaction in EHR work than surveying clinicians. Further study is required to understand the cost-benefit of various interventions to decrease CLOC time.This supplemental EHR training session, 20 months post go-live, where most participants elected to receive 2 or fewer sessions did significantly improve provider satisfaction with perceived control over their workload in the EHR, but it was not effective in decreasing EHR-use time outside of clinic. CLOC time, a calculated metric, could be a practical trackable surrogate for provider satisfaction (inverse correlation) with after-hours time spent in the EHR. Further study into interventions that decrease CLOC time and improve turnaround time to respond to inbox tasks are suggested next steps.

View details for DOI 10.1093/jamiaopen/ooz003

View details for PubMedID 31984357

View details for PubMedCentralID PMC6952029

View details for PubMedID 30228169

View details for DOI 10.1542/peds.2018-0601

View details for Web of Science ID 000449034300021

Abstract

Difficult intubations are not uncommon in tertiary care children's hospitals, and effective documentation of the difficult airway is a fundamental element of safe airway management. The primary goal of our quality improvement initiative was to improve access to airway information via an alert and documentation system within the electronic medical record (EMR).We created a difficult airway alert within the EMR, linking common airway evaluation templates used by specialists involved in airway management. We assessed the time required for different specialists to answer an airway information questionnaire using the electronic charts of patients before and after the EMR modification. Satisfaction with the EMR modification was also surveyed.Questionnaires were administered to 12 participants before the Epic (Epic Systems Corp., Verona, WI) changes were implemented and to 19 participants after they were implemented. Each participant was asked to answer the airway data questionnaire for two patients, for a total of 24 questionnaires before the EMR changes and 38 questionnaires after the changes. Respondents averaged 7.24 minutes to complete the entire airway data questionnaire before the EMR changes and 3.16 minutes following modification (P<0.0001). Correct airway information was more consistently collected with the modified EMR (98.6% vs 51.4%, P<0.00001). Satisfaction surveys revealed that participants found the accessibility of airway data to be significantly improved following the EMR changes.An EMR airway alert that provides rapid access to relevant airway information critical tool during urgent and emergent events. Based on our preliminary data, further use of this instrument is expected to continue to improve patient safety and practitioner satisfaction.4. Laryngoscope, 2018.

View details for PubMedID 30195274

Abstract

Pediatric early warning systems using expert-derived vital sign parameters demonstrate limited sensitivity and specificity in identifying deterioration. We hypothesized that modified tools using data-driven vital sign parameters would improve the performance of a validated tool.Retrospective case control.Quaternary-care children's hospital.Hospitalized, noncritically ill patients less than 18 years old. Cases were defined as patients who experienced an emergent transfer to an ICU or out-of-ICU cardiac arrest. Controls were patients who never required intensive care. Cases and controls were split into training and testing groups.The Bedside Pediatric Early Warning System was modified by integrating data-driven heart rate and respiratory rate parameters (modified Bedside Pediatric Early Warning System 1 and 2). Modified Bedside Pediatric Early Warning System 1 used the 10th and 90th percentiles as normal parameters, whereas modified Bedside Pediatric Early Warning System 2 used fifth and 95th percentiles.The training set consisted of 358 case events and 1,830 controls; the testing set had 331 case events and 1,215 controls. In the sensitivity analysis, 207 of the 331 testing set cases (62.5%) were predicted by the original tool versus 206 (62.2%; p = 0.54) with modified Bedside Pediatric Early Warning System 1 and 191 (57.7%; p < 0.001) with modified Bedside Pediatric Early Warning System 2. For specificity, 1,005 of the 1,215 testing set control patients (82.7%) were identified by original Bedside Pediatric Early Warning System versus 1,013 (83.1%; p = 0.54) with modified Bedside Pediatric Early Warning System 1 and 1,055 (86.8%; p < 0.001) with modified Bedside Pediatric Early Warning System 2. There was no net gain in sensitivity and specificity using either of the modified Bedside Pediatric Early Warning System tools.Integration of data-driven vital sign parameters into a validated pediatric early warning system did not significantly impact sensitivity or specificity, and all the tools showed lower than desired sensitivity and specificity at a single cutoff point. Future work is needed to develop an objective tool that can more accurately predict pediatric decompensation.

View details for DOI 10.1097/PCC.0000000000001150

View details for PubMedID 28338520

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

View details for DOI 10.4338/040054

View details for Web of Science ID 000413010400013

Abstract

Modification of alarm limits is one approach to mitigating alarm fatigue. We aimed to create and validate heart rate (HR) and respiratory rate (RR) percentiles for hospitalized children, and analyze the safety of replacing current vital sign reference ranges with proposed data-driven, age-stratified 5th and 95th percentile values.In this retrospective cross-sectional study, nurse-charted HR and RR data from a training set of 7202 hospitalized children were used to develop percentile tables. We compared 5th and 95th percentile values with currently accepted reference ranges in a validation set of 2287 patients. We analyzed 148 rapid response team (RRT) and cardiorespiratory arrest (CRA) events over a 12-month period, using HR and RR values in the 12 hours prior to the event, to determine the proportion of patients with out-of-range vitals based upon reference versus data-driven limits.There were 24,045 (55.6%) fewer out-of-range measurements using data-driven vital sign limits. Overall, 144/148 RRT and CRA patients had out-of-range HR or RR values preceding the event using current limits, and 138/148 were abnormal using data-driven limits. Chart review of RRT and CRA patients with abnormal HR and RR per current limits considered normal by data-driven limits revealed that clinical status change was identified by other vital sign abnormalities or clinical context.A large proportion of vital signs in hospitalized children are outside presently used norms. Safety evaluation of data-driven limits suggests they are as safe as those currently used. Implementation of these parameters in physiologic monitors may mitigate alarm fatigue. Journal of Hospital Medicine 2015;11:817-823. 2015 Society of Hospital Medicine.

View details for DOI 10.1002/jhm.2635

View details for Web of Science ID 000389420100001

View details for PubMedID 27411896

Abstract

The objective of this project was to use statistical techniques to determine the completeness and accuracy of data migrated during electronic health record conversion.Data validation during migration consists of mapped record testing and validation of a sample of the data for completeness and accuracy. We statistically determined a randomized sample size for each data type based on the desired confidence level and error limits.The only error identified in the post go-live period was a failure to migrate some clinical notes, which was unrelated to the validation process. No errors in the migrated data were found during the 12- month post-implementation period.Compared to the typical industry approach, we have demonstrated that a statistical approach to sampling size for data validation can ensure consistent confidence levels while maximizing efficiency of the validation process during a major electronic health record conversion.

View details for DOI 10.1093/jamia/ocv173

View details for PubMedID 26977100

Abstract

The majority of hospital physiologic monitor alarms are not clinically actionable and contribute to alarm fatigue. In 2014, The Joint Commission declared alarm safety as a National Patient Safety Goal and urged prompt action by hospitals to mitigate the issue [1]. It has been demonstrated that vital signs in hospitalized children are quite different from currently accepted reference ranges [2]. Implementation of data-driven, age stratified vital sign parameters (Table 1) for alarms in this patient population could reduce alarm frequency.

View details for PubMedID 26262220

View details for DOI 10.3233/978-1-61499-564-7-918

View details for Web of Science ID 000455836700222

Abstract

Propylene glycol (PG) is a commonly used solvent for oral, intravenous, and topical pharmaceutical agents. Although PG is generally considered safe, when used in high doses or for prolonged periods, PG toxicity can occur. Reported adverse effects from PG include central nervous system (CNS) toxicity, hyperosmolarity, hemolysis, cardiac arrhythmia, seizures, agitation, and lactic acidosis. Patients at risk for toxicity include infants, those with renal or hepatic insuficiency, epilepsy, and burn patients receiving extensive dermal applications of PG containing products. Laboratory monitoring of PG levels, osmolarity, lactate, pyruvate, bicarbonate, creatinine, and anion gap can assist practitioners in making the diagnosis of PG toxicity. Numerous studies and case reports have been published on PG toxicity in adults. However, very few have been reported in pediatric patient populations. A review of the literature is presented.

View details for DOI 10.5863/1551-6776-19.4.277

View details for PubMedID 25762872

View details for PubMedCentralID PMC4341412

Abstract

A 16-year-old perioperative paediatric patient presented with refractory lactic acidosis and multiorgan failure due to thiamine-deficient total parenteral nutrition during a recent national multivitamin shortage. Urgent empiric administration of intravenous thiamine resulted in prompt recovery from this life-threatening condition. Despite readily available treatment, a high index of suspicion is required to prevent cardiovascular collapse and mortality.

View details for DOI 10.1136/bcr-2014-205264

View details for PubMedID 24895398

View details for DOI 10.1097/ACM.0000000000000034

View details for PubMedID 24280794

Abstract

Tricyclic antidepressant (TCA) ingestions are a relatively common pediatric ingestion, with significant potential for both cardiac and neurological toxicity. Previous studies on pediatric TCA ingestions have found the threshold of toxicity to be 5 mg/kg.We report a case of an 8-year-old girl who presented to the emergency department with depressed mental status and seizure-like movements. An extensive workup was pursued to evaluate the cause of her mental status, which only revealed a positive urine toxicology screen for TCA. Quantified serum levels of amitriptyline were 121 ng/mL (therapeutic range, 50-300 ng/mL) and nortriptyline were 79 ng/mL (therapeutic range 70-170 ng/mL), 18 hours after onset of symptoms. Subsequent history obtained after her mental status returned to normal revealed that she had ingested amitriptyline at a dose of 0.8 mg/kg.Tricyclic antidepressant ingestion has a high potential for toxicity in pediatric patients. This case suggests, contrary to previous literature, that toxicity may occur even with small doses.

View details for DOI 10.1097/PEC.0b013e31826cebfb

View details for Web of Science ID 000309656900025

View details for PubMedID 23034495

View details for DOI 10.1016/j.jpeds.2006.06.006

View details for Web of Science ID 000239352000001

View details for PubMedID 16860111

Abstract

To explore heart rate (HR) correlates of attachment behavior in young mothers and their infants to generate specific hypotheses and to provide pilot data on which studies to test those hypotheses might be based.Using the strange situation procedure, patterns of attachment were assessed in 41 low-income adolescent mothers and their infants. During the procedure, the HRs of the infants and mothers were recorded. The HR changes were analyzed and infant attachment group differences were examined.Infants in all attachment groups demonstrated a similar HR response. There were, however, notably different behavioral reactions in the insecure groups: relatively increased behavioral distress in the insecure/resistant infants and relatively decreased behavioral distress in insecure-avoidant infants. Mothers of insecure-resistant infants demonstrated elevated HRs during reunions and the insecure/resistant dyads demonstrated lower consistency between HR changes in infant and mother than the secure dyads.The results suggest the discrepancy between attachment-related behavioral reactions and HR response in insecurely attached infants. Maternal and dyadic HR changes vary between the attachment groups.

View details for DOI 10.1097/01.chi.0000157325.10232.b1

View details for PubMedID 15843769

Abstract

We used functional MRI with an event-related design to dissociate the brain activation in the fusiform gyrus (FG) and posterior superior temporal sulcus (STS) for multiple face and gaze orientations. The event-related design allowed for concurrent behavioral analysis, which revealed a significant effect of both head and gaze orientation on the speed of gaze processing, with the face and gaze forward condition showing the fastest reaction times. In conjunction with this behavioral finding, the FG responded with the greatest activation to face and gaze forward, perhaps reflecting the unambiguous social salience of congruent face and gaze directed toward the viewer. Random effects analysis showed greater activation in both the FG and posterior STS when the subjects viewed a direct face compared to an angled face, regardless of gaze direction. Additionally, the FG showed greater activation for forward gaze compared to angled gaze, but only when the face was forward. Together, these findings suggest that head orientation has a significant effect on gaze processing and these effects are manifest not only in the STS, but also the FG.

View details for DOI 10.1016/S1053-8119(03)00229-5

View details for Web of Science ID 000185746400028

View details for PubMedID 14527592