Many children who are admitted to pediatric hospitals with new, acute neurological conditions do not receive adequate support to help them reintegrate into school. Lack of communication between the hospital team and school may lead to safety problems, delayed return to school, academic challenges, increased mental health concerns, and/or delayed assessment for special education services. Our team used Quality Improvement (QI) methodology to establish an inpatient consult workflow by including neuropsychological consultation and school reintegration recommendations for inpatients with new (or unaddressed) cognitive and functional needs. Education was provided by the neuropsychology team to medical providers and therapy teams about the school reintegration process and workflow. Additional processes were put into place to ensure that consults were received and completed within an appropriate timeframe. In the first 12 months of implementation, our team successfully completed 36 consults. The percentage of completed consults that included school reintegration recommendations increased from 0% to 100% over the 12-month period. The diagnostic populations included stroke (33%), neuroimmune diagnoses (19%), cardiac arrest (11%), traumatic brain injury (11%), encephalitis (6%), and brain tumor/oncology patients (6%). Our team successfully implemented a consultant workflow aimed at providing school reintegration support. The implementation of a school-reintegration neuropsychology service was feasible and practical. Additional work is needed to demonstrate patient outcomes, improve individualized approaches to service provision, and analyze long-term sustainability across large service lines.

OBJECTIVES:Pediatric hospitalists have increasingly been relied on to care for hospitalized patients. While hospitalist care models have shown many benefits, studies examining the transition from subspecialist to hospitalist-led teams are lacking. This study aimed to monitor the impact of transitioning an inpatient pediatric neurology service to a hospitalist model on several key outcome measures, with the hypothesis that these measures would be unaffected by the transition. METHODS:In July 2019, the neurology service at a freestanding pediatric academic center transitioned a hospitalist model. Statistical process control charts tracked patient-level outcomes related to quality, safety, and patient/caregiver experience. A medical education-focused survey was distributed to residents before and after service transition with survey responses analyzed using descriptive statistics. RESULTS:During the 42-month posttransition period, seizure length of stay (LOS) improved from 2.42 to 1.96 days, while headache LOS remained unchanged at 1.44 days. The days between both reported safety events reaching a patient and clinical deterioration events remained stable, although 5 clinical deterioration events were observed in the first 12 months after the transition. Top-box response percentage for posthospitalization survey questions about physicians improved from 70% to 81%. Survey-based medical education evaluations showed no significant changes in resident confidence or neurology knowledge around neurological issues. CONCLUSIONS:Our institution successfully transitioned a pediatric neurology subspecialty inpatient service to a hospitalist-led model while monitoring the effect on quality, safety, patient/caregiver experience, and medical education outcome measures. Studying transitions in care models is necessary to understand their impact and value for pediatric patients.

Purpose To examine the implementation and effectiveness of a contraception care intervention for adolescents hospitalized with psychiatric disorders. Methods This prospective, observational, hybrid type 2 effectiveness-implementation study examined the effectiveness of the Contraception Care at the Behavioral Health Pavilion (CC@BHP) intervention in 4 inpatient psychiatric units at a quaternary children's hospital. A multifaceted implementation blueprint guided implementation. CC@BHP is a clinical pathway intervention designed to increase access to contraceptive counseling and initiation during hospitalization. Eligible patients were assigned female at birth, at least 14 years old, and admitted to one of four units between December 2021 and February 2023. Implementation outcomes were provider adoption (documentation of assessing interest in contraception care) and intervention reach (order placed for contraception consultation). Intervention effectiveness outcomes assessed downstream health service access, including patient receipt of contraception consultation and contraceptive prescription/initiation. Results Across 1,461 visits, the mean patient age was 15.9 years and 63.4% were White. Forty percent (n = 586) of visits included at least one intervention component. Overall, healthcare providers adopted CC@BHP in 29.0% (n = 424) of visits and ordered contraception consultations in 19.1% (n = 279) of visits (reach). Adolescents received contraception consultations in 16.7% (n = 244) of visits and 116 patients (7.9%) initiated a contraceptive (effectiveness). Later study waves demonstrated greater adoption and reach. Discussion Implementation improved over time and CC@BHP delivered contraceptive counseling and initiation, including implants and intrauterine devices, in a large quaternary hospital to interested adolescents. Inpatient psychiatry admissions offer a timely opportunity to address reproductive health needs of adolescents.

OBJECTIVES:Direct admission (DA) to the hospital has the potential to improve family satisfaction and timeliness of care by bypassing the emergency department. Using the RE-AIM implementation framework, we sought to characterize variation across health systems in the reach, effectiveness, adoption, and implementation of a DA program from the perspectives of parents and multidisciplinary clinicians.METHODS:As part of a stepped-wedge cluster randomized trial to compare the effectiveness of DA to admission through the emergency department, we evaluated DA rates across 69 clinics and 3 health systems and conducted semi-structured interviews with parents and clinicians. We used thematic analysis to identify themes related to the reach, effectiveness, adoption, and implementation of the DA program and applied axial coding to characterize thematic differences across sites.RESULTS:Of 2599 hospitalizations, 171 (6.6%) occurred via DA, with DA rates varying 10-fold across health systems from 0.9% to 9.3%. Through the analysis of 137 interviews, including 84 with clinicians and 53 with parents, we identified similarities across health systems in themes related to perceived program effectiveness and patient and family engagement. Thematic differences across sites in the domains of program implementation and clinician adoption included variation in transfer center efficiency, trust between referring and accepting clinicians, and the culture of change within the health system.CONCLUSIONS:The DA program was adopted variably, highlighting unique challenges and opportunities for implementation in different hospital systems. These findings can inform future quality improvement efforts to improve transitions to the hospital.

OBJECTIVE:Direct admission (DA) to hospital can reduce emergency department (ED) utilization by bypassing the ED during the admission process. We implemented a DA program across 3 health systems and compared timeliness of care, family experience of care, and post-admission clinical deterioration among children admitted via DA versus the ED after their clinic was randomized to begin the DA program. METHODS:Using a stepped-wedge design, 69 primary and urgent care clinics were randomized to 1 of 4 time points to begin a voluntary DA program, February 1, 2020 to April 30, 2023. Outcomes in children <18 years admitted with 7 common medical diagnoses were compared using adjusted logistic or linear regression. RESULTS:A total of 2599 children were admitted with eligible diagnoses during the study period , including 145 children admitted directly and 1852 admitted through EDs after program implementation at their clinic. Median age was 2.8 (interquartile range: 1.1-6.8) years, 994 (49.8%) were female, and 1324 (66.3%) were Medicaid-insured. Adjusted regression analyses showed that if each child was admitted via DA versus the ED, average time to initial clinical assessment was 3.1 minute (95% confidence interval: 1.7-4.5) slower, whereas time to initial therapeutic management was 49.6 minutes faster on average (95% confidence interval: 30.3.2-68.9). There were no significant differences in time to initial diagnostic testing or rates of post-admission clinical deterioration. CONCLUSIONS:Compared with ED admission, DA appears equally safe and acceptable to families, and may be associated with a significantly shorter time to initial therapeutic management with modestly longer time to initial clinical assessment.

OBJECTIVES Pediatric direct admissions (DA) have multiple benefits including reduced emergency department (ED) volumes, greater patient and provider satisfaction, and decreased costs without compromising patient safety. We sought to compare resource utilization and outcomes between patients with a primary diagnosis of neonatal hyperbilirubinemia directly admitted with those admitted from the ED. METHODS Single-center, retrospective study at a large, academic, free-standing children’s hospital (2017–2021). Patients were between 24 hours and 14 days old with a gestational age of ≥35 weeks, admitted with a primary diagnosis of neonatal hyperbilirubinemia. Outcomes included length of stay (LOS), time to clinical care, resource utilization, NICU transfer, and 7-day readmission for phototherapy. RESULTS A total of 1098 patients were included, with 276 (25.1%) ED admissions and 822 (74.9%) DAs. DAs experienced a shorter median time to bilirubin level collection (1.9 vs 2.1 hours, P = .003), received less intravenous fluids (8.9% vs 51.4%, P < .001), had less bilirubin levels collected (median of 3.0 vs 4.0, P < .001), received phototherapy sooner (median of 0.8 vs 4.2 hours, P < .001), and had a shorter LOS (median of 21 vs 23 hours, P = .002). One patient who was directly admitted required transfer to the NICU. No differences were observed in the 7-day readmission rates for phototherapy. CONCLUSIONS Directly admitting patients for the management of neonatal hyperbilirubinemia is a preferred alternative to ED admission as our study demonstrated that DAs had a shorter time to clinical care, shorter LOS, and less unnecessary resource utilization with no difference in 7-day readmissions for phototherapy.

Background Acute care hospitals increasingly provide care for youth experiencing mental health crises while they await transfer for psychiatric hospitalization. To inform quality improvement efforts, we aimed to characterize hospitalists’ perceptions of health care quality during pediatric mental health boarding and their experiences of moral distress in caring for this population. Methods In March 2021, we conducted a web-based survey of hospitalists who participate in the Pediatric Research in Inpatient Settings (PRIS) network. Closed- and open-ended questions queried the quality of care provided to youth during boarding and clinician experience of moral distress in caring for these youth. We iteratively coded qualitative data for emergent themes. Moral distress was measured using 11 items from the Measure of Moral Distress for Health Care Professionals (MMD-HP), which categorizes sources of moral distress into system-, team-, and patient-level factors. Results Eighty-eight of 111 PRIS site leaders (79%) and 76 of 383 other PRIS members (20%) responded, representing 12 community hospitals, 38 freestanding children’s hospitals, and 35 children’s hospitals in adult centers. Emergent themes related to health care quality included the following: access to psychiatric services; safety; standardized workflows; clinician training; compassion/patient engagement; and collaboration and disposition planning. Hospitals often lacked desired resources, resulting in poor perceived therapeutic value of care, limited patient engagement, and provider moral distress. Four of the 5 highest MMD-HP item scores were related to system-level factors. Conclusion Hospitalists identified several foci for quality improvement and described significant moral distress in caring for youth experiencing boarding, particularly related to health system factors.

Introduction: Failure to recognize and mitigate critical patient deterioration remains a source of serious preventable harm to hospitalized pediatric cardiac patients. Emergency transfers (ETs) occur 10–20 times more often than code events outside the intensive care unit (ICU) and are associated with morbidity and mortality. This quality improvement project aimed to increase days between ETs and code events on an acute care cardiology unit (ACCU) from a baseline median of 17 and 32 days to ≥70 and 90 days within 12 months. Methods: Institutional leaders, cardiology-trained physicians and nurses, and trainees convened, utilizing the Institution for Healthcare Improvement model to achieve the project aims. Interventions implemented focused on improving situational awareness (SA), including a “Must Call List,” evening rounds, a visual management board, and daily huddles. Outcome measures included calendar days between ETs and code events in the ACCU. Process measures tracked the utilization of interventions, and cardiac ICU length of stay was a balancing measure. Statistical process control chart methodology was utilized to analyze the impact of interventions. Results: Within the study period, we observed a centerline shift in primary outcome measures with an increase from 17 to 56 days between ETs and 32 to 62 days between code events in the ACCU, with sustained improvement. Intervention utilization ranged from 87% to 100%, and there was no observed special cause variation in our balancing measure. Conclusions: Interventions focused on improving SA in a particularly vulnerable patient population led to sustained improvement with reduced ETs and code events outside the ICU.

Objective To compare hospital costs and resource utilization for pediatric asthma admissions based on the hospitals' availability of continuous albuterol aerosolization administration (CAA) in non-intensive care unit (ICU) settings. Methods We conducted a retrospective cohort study of children ages 2-17 years admitted in 2019 with a principal diagnosis of asthma using the Pediatric Health Information System. Hospitals and hospitalizations were categorized based on location of CAA administration, ICU-only versus general inpatient floors. Hospitals preforming CAA in an intermediate care unit were excluded. We calculated total cost, standardized unit costs and rates of interventions. Groups were compared using Chi-Square, t-test and Wilcoxon rank-sum test as indicated. A log linear mixed model was created to evaluate potential confounders. Results Twenty-one hospitals (7084 hospitalizations) allowed CAA on the floor. Twenty-four hospitals (6100 hospitalizations) allowed CAA in the ICU-only. Median total cost was $4639 (Interquartile Range (IQR) $3060-$7512) for the floor group and $5478 (IQR $3444-$8539) for the ICU-only group (p < 0.001) (mean cost difference of $775 per patient). Hospitalization costs were $4,726,829 (95% CI $3,459,920-$5,993,860) greater for the children treated at hospitals restricting CAA to the ICU. We observed higher standardized laboratory, imaging, clinical and other unit costs, along with higher use of interventions in the ICU-only group. After adjustment, we found that ICU stay and hospital LOS were the main drivers of cost difference between the groups. Conclusions There was cost savings and decreased resource utilization for hospitals that performed CAA on the floor. Further studies exploring variations in asthma management are warranted.

Introduction: Emergency transfers are associated with increased inpatient pediatric mortality. Therefore, interventions to improve system-level situational awareness were utilized to decrease a subset of emergency transfers that occurred within four hours of admission to an inpatient medical-surgical unit called very rapid emergency transfers (VRET). Specifically, we aimed to increase the days between VRET from non-ICU inpatient units from every 10 days to every 25 days over 1 year. Methods: Using the Model for Improvement, we developed an interdisciplinary team to reduce VRET. The key drivers targeted were the admission process from the emergency department and ambulatory clinics, sepsis recognition and communication, and expansion of our situational awareness framework. Days between VRET defined the primary outcome metric for this improvement project. Results: After six months of interventions, our baseline improved from a VRET every 10 days to every 79 days, followed by another shift to 177 days, which we sustained for 3 years peaking at 468 days between events. Conclusion: Interventions targeting multiple admission sources to improve early recognition and communication of potential clinical deterioration effectively reduced and nearly eliminated VRET at our organization.

The goal of quality improvement (QI) in healthcare is to improve patient outcomes. An easily supported, simple, and desirable objective. Fortunately, over the past 20 years, healthcare has “embraced” quality improvement, but that journey is remarkably incomplete. QI has infiltrated mainstream thinking for many clinicians and healthcare administrators; however, using the words and speaking the QI language does not always translate to the effective execution of improvement processes that lead to better outcomes.

OBJECTIVES:Develop and deploy a disease cohort-based machine learning algorithm for timely identification of hospitalized pediatric patients at risk for clinical deterioration that outperforms our existing situational awareness program. DESIGN:Retrospective cohort study. SETTING:Nationwide Children's Hospital, a freestanding, quaternary-care, academic children's hospital in Columbus, OH. PATIENTS:All patients admitted to inpatient units participating in the preexisting situational awareness program from October 20, 2015, to December 31, 2019, excluding patients over 18 years old at admission and those with a neonatal ICU stay during their hospitalization. INTERVENTIONS:We developed separate algorithms for cardiac, malignancy, and general cohorts via lasso-regularized logistic regression. Candidate model predictors included vital signs, supplemental oxygen, nursing assessments, early warning scores, diagnoses, lab results, and situational awareness criteria. Model performance was characterized in clinical terms and compared with our previous situational awareness program based on a novel retrospective validation approach. Simulations with frontline staff, prior to clinical implementation, informed user experience and refined interdisciplinary workflows. Model implementation was piloted on cardiology and hospital medicine units in early 2021. MEASUREMENTS AND MAIN RESULTS:The Deterioration Risk Index (DRI) was 2.4 times as sensitive as our existing situational awareness program (sensitivities of 53% and 22%, respectively; p < 0.001) and required 2.3 times fewer alarms per detected event (121 DRI alarms per detected event vs 276 for existing program). Notable improvements were a four-fold sensitivity gain for the cardiac diagnostic cohort (73% vs 18%; p < 0.001) and a three-fold gain (81% vs 27%; p < 0.001) for the malignancy diagnostic cohort. Postimplementation pilot results over 18 months revealed a 77% reduction in deterioration events (three events observed vs 13.1 expected, p = 0.001). CONCLUSIONS:The etiology of pediatric inpatient deterioration requires acknowledgement of the unique pathophysiology among cardiology and oncology patients. Selection and weighting of diverse candidate risk factors via machine learning can produce a more sensitive early warning system for clinical deterioration. Leveraging preexisting situational awareness platforms and accounting for operational impacts of model implementation are key aspects to successful bedside translation.

OBJECTIVE:To describe changes in neonatal use of acute care services during the coronavirus disease 2019 (COVID-19) pandemic. We hypothesized neonatal visits would decrease and the degree of decline would vary by condition.METHODS:We conducted a retrospective cohort study of neonatal visits to the urgent cares, emergency departments, inpatient units, and intensive care units at a free-standing pediatric healthcare system during the COVID-19 pandemic and a comparator period. We included visits of infants presenting for acute care within the first 30 days of life. Transfers from a referring nursery, inpatient unit, or ICU were excluded. Data collected included demographics, patient characteristics, and visit characteristics. Descriptive statistics and χ2 tests were used for analyses and to determine statistically significant differences.RESULTS:We identified 4439 neonatal acute care visits, of which 2677 occurred in the prepandemic period and 1762 in the COVID-19 pandemic period, representing a 34.2% decline. Urgent cares and emergency departments experienced the greatest decline in visits for infectious conditions (49%) and the proportion of these visits also significantly decreased. Similarly, the largest clinically significant declines in hospitalizations were for infectious and respiratory diagnoses (48% and 52%, respectively) and the proportions of these hospitalizations also significantly decreased. Despite a small decline in hospitalizations for jaundice, the proportion of jaundice hospitalizations significantly increased by 5.7% (P = .02).CONCLUSIONS:The COVID-19 pandemic was associated with a significant reduction in neonatal visits across a spectrum of acute care settings. The impact on use varied by diagnosis with the most notable decline in visits for infectious conditions.

There is a clearly established and alarming increase in the prevalence of mental health disorders impacting our children and adolescents with a corresponding increase in the number of youth presenting with mental health crises to emergency departments (EDs) in need of hospitalization.1–4 Coupled with a lack of pediatric and adolescent inpatient psychiatry beds and providers, these trends have resulted in an increase in boarding in EDs and inpatient medical or surgical units.5–7 The coronavirus disease 2019 (COVID-19) pandemic has exacerbated and potentiated these concerns, leading to a joint statement by the American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatry, and Children's Hospital Association declaring a national emergency in child and adolescent mental health in October 2021.8–10 Shortly after this declaration, in December of 2021, the US Surgeon General issued an advisory entitled "Protecting Youth Mental Health" further defining and outlining this crisis.11In this issue of Hospital Pediatrics, Ibeziako et al12 describe a single center retrospective study of pediatric mental health–related ED and inpatient admissions, comparing 12 months before and after the COVID-19 pandemic. They reported statistically significant increases in postpandemic proportions of presentations for suicidal ideation and attempts, depression, anxiety, eating disorders, substance use, and obsessive-compulsive– related disorders. Although these proportions changed, the overall volume of mental health–related visits actually decreased slightly in the postpandemic period. This is probably not surprising given pandemic-related mitigation efforts and decreased health care utilization observed in the first year of the COVID-19 pandemic. Yet, despite decreased volumes, this hospital's average length of boarding, defined as medically-cleared patients awaiting definitive inpatient psychiatry placement, more than doubled postpandemic with 50% of patients boarding for ≥2 days compared to 30% before the pandemic. Concluding that patient volumes were not the primary driver of length of boarding stays, the authors proposed multifactorial etiologies including more severe and acute presentations (reflected in the changing proportions of different mental health diagnoses), challenges related to availability and/or coordination of outpatient behavioral health services, and a lack of inpatient psychiatry beds and/or staffing. However, the actual reasons for the longer mean boarding stay observed in their study is not clear and could reflect longer lengths of stay for most patients or disproportionate lengths of stay for a subset of patients, such as those with concurrent COVID-19 infection or those with comorbid medical conditions or in need of residential or foster care. The authors also analyzed pre- and postpandemic mental health visits with interrupted time series analyses. Again, as reflected in other recent studies, in the year before COVID, there was a positive linear slope of ED mental health visits, most striking among youth with suicidality and length of boarding. Postpandemic, these slopes showed a further sharp increase with the biggest sloped changes observed for anxiety, eating disorders, and boarding length.The primary limitation of this study is the context of a single institution, large, urban, free-standing children's hospital. The authors report that their hospital's resources included 24/7 ED-based psychiatry availability, an inpatient psychiatric consult team, dedicated psychology, social work and nurse practitioner services, and resource specialists helping to coordinate disposition, placement, and referrals. This study's findings may not be generalizable to general hospitals, in which most children with mental health conditions present for care, and likely underrepresents rural-residing children who have higher suicide rates and reduced access to mental health care.Limitations aside, this study supports a growing concern by highlighting a significant trend of increasing mental health ED visits and inpatient boarding with inadequate inpatient psychiatry bed availability, further exacerbated and accelerated by the pandemic. With the cascading impacts of the pandemic on mental health, we speculate the findings may be even more alarming now. Child and adolescent acute mental health presentations continue to rise. At present, prevention and early detection and treatment are clearly not optimized and, in many underresourced areas, not possible. Severity of acute presentations and associated comorbid medical complexity is daunting. Lack of available mental health professionals and clinician moral distress and burnout are significant challenges now and moving forward. ED and inpatient boarding are an unfortunate current reality that clearly does not represent the right care at the right time in the right location.As illustrated by the interrupted time series analyses presented by Ibeziako et al,12 this crisis was already well underway when the pandemic began. Parents and children across the country faced lengthy wait lists to see mental health professionals if they could find a psychiatrist or therapist at all. Correspondingly, increases in services across the continuum of care are necessary to solve this current crisis and to prevent the next one. In addition to health policy changes and child mental health payment reform, addressing this crisis requires engagement and commitment from hospital and health system leadership. Most areas of the country are in need of more inpatient psychiatric beds, and hospital systems need to increase these resources to meet this need. Advocacy regarding inpatient behavioral health availability needs to capitalize on what we have learned from the pandemic with telemedicine and virtual consultation and care.13 Another potential solution is greater availability of intensive outpatient programs, which are composed of many of the elements of inpatient psychiatry but are tailored to the needs of patients who do not require around the clock supervision. These allow for a transition to home while still treating serious conditions and can be integrated into existing inpatient and outpatient programs. Similarly, hospital systems can partner with specific outpatient providers or clinics to more effectively facilitate timely safe discharge planning. Because the wait list to see a new provider is quite long in most areas of the country, it is helpful to partner with a psychiatrist who can "bridge," ie, follow the patients after the hospitalization until they can be seen by their new long-term provider. These and other community-based resources must be a part of the solution.As for pediatric hospitalists, what is within our sphere of influence to improve the care of this vulnerable population? Although most pediatric hospitalists may not have training or expertise in behavioral health, we are part of the solution in optimizing the care, quality, and outcomes for our boarded patients. We are experts in patient safety, quality improvement (QI), and high-value care. A recent survey on boarding answered by pediatric hospitalists in 88 different US hospitals showed that only 24% and 10% of hospitals used electronic order sets or had clinical pathways, respectively, for this patient population.14 We can promote quality and decrease costs by standardizing care in the form of evidence based clinical pathways and order sets decreasing unnecessary variation and testing, for example with suicide risk assessment, medical clearance evaluations, and approach to delirium.15–17 We can help to ensure patient and staff safety by seeking out and establishing best practices in patient agitation management, physical and chemical restraints, unit design, and provider deescalation training. We can define and track metrics relative to boarding care; a study by Bardach et al18 proposed a set of 8 measures for patients presenting with suicidality, psychosis, or substance use. As the adage goes, "what is not measured can't be improved": the number of youth experiencing boarding and length of stay are a great place to start, but we must go beyond these to truly improve care of this population. Where there are gaps in the available literature, we can help to create evidence and generalizable knowledge starting with local QI efforts.We are also leaders and stewards of medical education, specifically training and mentoring the next generation of pediatric hospitalists. Multiple recent studies have demonstrated the gap in pediatric resident education, experience, and competency in behavioral health.19,20 Behavioral health education will be more meaningful if it is championed by practicing pediatric hospitalists who learners see as experts on inpatient health care. As pediatric hospitalists, we can enhance our own education and competence like we have with so many other conditions that have developed or increased in prevalence since our medical training. We can demonstrate and model our expertise in operational efficiency, transitions of care, and patient or family-centered care and rounds. We must serve as educators and mentors to our inpatient student and residents so as to not perpetuate the lack of training and competence in the next generation of pediatric hospitalists.Solutions to the youth mental health crisis are complicated and challenging. Inpatient psychiatric resources are clearly a bottleneck leading to ED and inpatient boarding. More proximal interventions and programs are necessary to help decrease the need for these beds. There are no easy or encompassing solutions. We will need to come together as leaders from behavioral health, ED, hospital medicine, hospitals and health systems, and community partners with ideas and innovation. Where can we start? By building on our expertise in QI and medical education, pediatric hospitalists can play key roles in improving the care of boarded patients. We are part of the solution.

This study estimates the frequency and duration of boarding for pediatric mental health conditions at US acute care hospitals and describes hospital resources available to support youths during boarding.

Introduction: Pediatric in-hospital cardiac arrests and emergent transfers to the pediatric intensive care unit (ICU) represent a serious patient safety concern with associated increased morbidity and mortality. Some institutions have turned to the electronic health record and predictive analytics in search of earlier and more accurate detection of patients at risk for decompensation. Methods: Objective electronic health record data from 2011 to 2017 was utilized to develop an automated early warning system score aimed at identifying hospitalized children at risk of clinical deterioration. Five vital sign measurements and supplemental oxygen requirement data were used to build the Vitals Risk Index (VRI) model, using multivariate logistic regression. We compared the VRI to the hospital’s existing early warning system, an adaptation of Monaghan’s Pediatric Early Warning Score system (PEWS). The patient population included hospitalized children 18 years of age and younger while being cared for outside of the ICU. This dataset included 158 case hospitalizations (102 emergent transfers to the ICU and 56 “code blue” events) and 135,597 control hospitalizations. Results: When identifying deteriorating patients 2 hours before an event, there was no significant difference between Pediatric Early Warning Score and VRI’s areas under the receiver operating characteristic curve at false-positive rates ≤ 10% (pAUC10 of 0.065 and 0.064, respectively; P = 0.74), a threshold chosen to compare the 2 approaches under clinically tolerable false-positive rates. Conclusions: The VRI represents an objective, simple, and automated predictive analytics tool for identifying hospitalized pediatric patients at risk of deteriorating outside of the ICU setting.

BACKGROUND AND OBJECTIVES:The problem list (PL) is a meaningful use-incentivized criterion for electronic health record documentation. Inconsistent use or inaccuracy of the PL can create communication gaps among providers, potentially leading to diagnostic delays and serious safety events. The objective of the study was to increase the rate of PL review by attending physicians for inpatients discharged from hospital pediatrics and infectious disease services from a baseline of 70% to 80% by June 2018 and to sustain the rate for 6 months. The secondary aim was to improve PL accuracy by decreasing the rate of duplicate codes and red code diagnoses that should resolve before discharge from a baseline of 12% and 11%, respectively, to 5% and sustaining the rate for 6 months.METHODS:A quality improvement team used the Institute for Healthcare Improvement Model for Improvement. We tracked duplicate codes and red codes as surrogate markers of PL quality. Rates of PL review and PL quality were analyzed monthly via statistical process control charts (p-charts) with 3-σ control limits to identify special cause variation.RESULTS:PL review improved from a baseline of 70% to 90%, and the change was sustained for 1 year. PL quality improved as duplicate codes at the time of discharge decreased from 12% to 6% and as red codes decreased from a baseline of 11% to 6%.CONCLUSIONS:The PL is an important communication tool that is underused. By engaging and educating stakeholders, incentivizing compliance, standardizing PL management, leveraging electronic health record enhancements, and providing physician feedback, we improved PL meaningful use and quality.

OBJECTIVE:To develop a diagnostic error index (DEI) aimed at providing a practical method to identify and measure serious diagnostic errors. STUDY DESIGN:A quality improvement (QI) study at a quaternary pediatric medical center. Five well-defined domains identified cases of potential diagnostic errors. Identified cases underwent an adjudication process by a multidisciplinary QI team to determine if a diagnostic error occurred. Confirmed diagnostic errors were then aggregated on the DEI. The primary outcome measure was the number of monthly diagnostic errors. RESULTS:From January 2017 through June 2019, 105 cases of diagnostic error were identified. Morbidity and mortality conferences, institutional root cause analyses, and an abdominal pain trigger tool were the most frequent domains for detecting diagnostic errors. Appendicitis, fractures, and nonaccidental trauma were the 3 most common diagnoses that were missed or had delayed identification. CONCLUSIONS:A QI initiative successfully created a pragmatic approach to identify and measure diagnostic errors by utilizing a DEI. The DEI established a framework to help guide future initiatives to reduce diagnostic errors.