Group-facilitated audit and feedback to improve bronchiolitis care in the emergency department

CJEM ◽  
2020 ◽  
Vol 22 (5) ◽  
pp. 678-686
Author(s):  
Shawn K. Dowling ◽  
Inelda Gjata ◽  
Nathan M. Solbak ◽  
Colin G.W. Weaver ◽  
Katharine Smart ◽  
...  
Keyword(s):  
Emergency Department ◽  
Control Charts ◽  
Patient Characteristics ◽  
Pediatric Emergency ◽  
Therapeutic Interventions ◽  
Audit And Feedback ◽  
Absolute Difference ◽  
Emergency Physicians ◽  
Feedback Session ◽  
Statistical Process

ABSTRACTObjectiveDespite strong evidence recommending supportive care as the mainstay of management for most infants with bronchiolitis, prior studies show that patients still receive low-value care (e.g., respiratory viral testing, salbutamol, chest radiography). Our objective was to decrease low-value care by delivering individual physician reports, in addition to group-facilitated feedback sessions to pediatric emergency physicians.MethodsOur cohort included 3,883 patients ≤ 12 months old who presented to pediatric emergency departments in Calgary, Alberta, with a diagnosis of bronchiolitis from April 1, 2013, to April 30, 2018. Using administrative data, we captured baseline characteristics and therapeutic interventions. Consenting pediatric emergency physicians received two audit and feedback reports, which included their individual data and peer comparators. A multidisciplinary group-facilitated feedback session presented data and identified barriers and enablers of reducing low-value care. The primary outcome was the proportion of patients who received any low-value intervention and was analysed using statistical process control charts.ResultsSeventy-eight percent of emergency physicians consented to receive their audit and feedback reports. Patient characteristics were similar in the baseline and intervention period. Following the baseline physician reports and the group feedback session, low-value care decreased from 42.6% to 27.1% (absolute difference: −15.5%; 95% CI: −19.8% to −11.2%) and 78.9% to 64.4% (absolute difference: −14.5%; 95% CI: −21.9% to −7.2%) in patients who were not admitted and admitted, respectively. Balancing measures, such as intensive care unit admission and emergency department revisit, were unchanged.ConclusionThe combination of audit and feedback and a group-facilitated feedback session reduced low-value care for patients with bronchiolitis.

scholarly journals MP32: Using physician practice reports and feedback sessions to reduce low value care in bronchiolitis

CJEM ◽  
2020 ◽  
Vol 22 (S1) ◽  
pp. S54-S54
Author(s):  
S. Dowling ◽  
I. Gjata ◽  
N. Solbak ◽  
C. Weaver ◽  
K. Smart ◽  
...  
Keyword(s):  
Control Charts ◽  
Pediatric Emergency ◽  
Audit And Feedback ◽  
Absolute Difference ◽  
Statistical Process ◽  
Process Measures ◽  
Respiratory Therapists ◽  
Process Control Charts ◽  
Statistical Process Control Charts ◽  
Baseline Characteristics

Background: Despite strong evidence recommending supportive care as the mainstay of management for most infants with bronchiolitis, prior studies suggest that many of these patients receive low-value interventions. Providing clinicians with their practice reports and peer comparator data or an achievable benchmark of care (audit and feedback) has been shown to be an effective strategy to improve adherence to guidelines. Aim Statement: To decrease low-value care (use of any or all of chest radiographs, viral testing and salbutamol) in infants with bronchiolitis by delivering individual physician reports in addition to Group Facilitated Feedback Sessions (GFFS) to pediatric emergency physicians (PEPs). Measures & Design: Our cohort included 3,883 patients ≤12 months old that presented to two emergency departments with a diagnosis of bronchiolitis from April 1, 2013 to April 30, 2018. Using administrative data we captured baseline characteristics and interventions. Consenting PEPs received two audit and feedback (A&F) reports which included their individual and peer comparator data. Two multi-disciplinary GFFS (including inpatient pediatricians, nurse, learners and respiratory therapists) presented data and identified barriers and enablers of reducing low-value care. The primary outcome was the proportion of patients who received any low-value intervention, and was analyzed using statistical process control charts. Process measures (consent to obtain report, attendance and evaluations from the feedback session) and balancing measures were also captured. Evaluation/Results: 78% of PEPs consented to receive their A&F reports. Patient baseline characteristics were similar in the baseline (n = 3109) and intervention period (n = 774). Following the baseline physician reports and the GFFS, low-value care decreased from 42.6% to 27.1% (absolute difference: -15.5%; 95% confidence interval (CI): -19.8% to -11.2%) and 78.9% to 64.4% (absolute difference: -14.5%; 95% CI: -21.9% to -7.2%) in patients who were not admitted and admitted, respectively. Balancing measures such as ICU admission (absolute difference: -0.6%; 95%CI: -5.7% to 4.4%) and ED revisit within 72 hours (absolute difference: -0.1%; 95% CI: -3.1% to 3.0% non-admitted patients, 1.0%; 95% CI: -1.2% to 3.2% admitted patients) were unchanged. Discussion/Impact: The combination of audit and feedback and a GFFS significantly reduced low-value care for pediatric patients with bronchiolitis by PEP's.

scholarly journals LO88: Bronchiolitis management in Calgary emergency departments

CJEM ◽  
2018 ◽  
Vol 20 (S1) ◽  
pp. S38-S38 ◽  
Author(s):  
S. K. Dowling ◽  
A. Stang ◽  
I. Gjata ◽  
S. Law ◽  
K. Burak ◽  
...  
Keyword(s):  
Care Pathway ◽  
Care Center ◽  
Significant Proportion ◽  
Vital Signs ◽  
Pediatric Emergency ◽  
Practice Variation ◽  
Therapeutic Interventions ◽  
Audit And Feedback ◽  
Urgent Care ◽  
Feedback Session

Introduction: Bronchiolitis is a viral respiratory infection and the most common reason for hospitalization of infants. Despite evidence that few interventions are beneficial in patients with bronchiolitis, other studies would have shown that a significant proportion of patients undergo various forms of low value care. This objective of this project was to 1. establish baseline management of bronchiolitis in the Calgary Zone, and 2. deliver audit and feedback (A&F) reports to pediatric emergency physicians (PEP) to identify opportunities and strategies for practice improvement. Methods: This retrospective cohort study included all patients 12 months old that presented to a Calgary emergency department or urgent care center with a diagnosis of bronchiolitis from April 1, 2013 to March 31, 2017. Using data from various electronic health data sources, we captured age, vital signs, CTAS, common therapeutic interventions (bronchodilators, steroids, antibiotics) and investigations (chest x-ray (CXR), viral studies, antibiotics). Results were stratified by site and by admission status. Descriptive statistics were used to report baseline characteristics and interventions. Interhospital ranges (IHR) were provided to compare different hospitals in the zone. For the A&F component of the project, consenting PEP received a report of both their individual and peer comparator data and an in-person multi-disciplinary facilitated feedback session. Results: We included 4023 patients from all 6 sites (range from 28 to 3316 patients). Admission rates were 21.7% (IHR 0-29%). Mean age was 5.4 months old. Bronchodilator use was 27.0% (IHR 21-41%). 22.0% of patients received a CXR (IHR 0-57%) and 30.3% had viral studies done (IHR range 0.8-33%). PEP had higher usage of viral studies (30% vs 5.7%), whereas non-PEP had higher CXR usage (46.2% vs 23.4%). 41 of 66 PEP consented to receive their individual A&F reports (62%). In the facilitated feedback session PEP 1. identified two areas (bronchodilators and viral studies) where improvements could be made and 2. discussed specific strategies to decrease practice variation and minimize low value care including development of a multi-disciplinary care pathway, alignment with in-patient management, education and repeated A&F reports. Conclusion: Significant variability exists in management of patients with bronchiolitis across different hospitals in our zone. A facilitated feedback session identified areas for improvement and multi-disciplinary strategies to reduced low value care for patients with bronchiolitis. Future phases of this project include repeated data in 6 months and implementation of a provincial care pathway for the management of bronchiolitis.

Reducing Unnecessary Respiratory Viral Testing to Promote High-Value Care

PEDIATRICS ◽  
2022 ◽  
Author(s):  
Olivia Ostrow ◽  
Deena Savlov ◽  
Susan E. Richardson ◽  
Jeremy N. Friedman
Keyword(s):  
Control Charts ◽  
Respiratory Infections ◽  
Audit And Feedback ◽  
Improvement Strategy ◽  
Statistical Process ◽  
Process Control Charts ◽  
Statistical Process Control Charts ◽  
Viral Testing ◽  
Return Visits ◽  
Viral Respiratory Infections

BACKGROUND AND OBJECTIVES: Viral respiratory infections are common in children, and practice guidelines do not recommend routine testing for typical viral illnesses. Despite results often not impacting care, nasopharyngeal swabs for viral testing are frequently performed and are an uncomfortable procedure. The aim of this initiative was to decrease unnecessary respiratory viral testing (RVT) in the emergency department (ED) and the pediatric medicine wards (PMWs) by 50% and 25%, respectively, over 36 months. METHODS: An expert panel reviewed published guidelines and appropriate evidence to formulate an RVT pathway using plan-do-study-act cycles. A multifaceted improvement strategy was developed that included implementing 2 newer, more effective tests when testing was deemed necessary; electronic order modifications with force functions; audit and feedback; and education. By using statistical process control charts, the outcomes analyzed were the percentage of RVT ordered in the ED and the rate of RVT ordered on the PMWs. Balancing measures included return visits leading to admission and inpatient viral nosocomial outbreaks. RESULTS: The RVT rate decreased from a mean of 3.0% to 0.5% of ED visits and from 44.3 to 30.1 per 1000 patient days on the PMWs and was sustained throughout the study. Even when accounting for the new rapid influenza test available in the ED, a 50% decrease in overall ED RVT was still achieved without any significant impact on return visits leading to admission or inpatient nosocomial infections. CONCLUSIONS: Through implementation of a standardized, electronically integrated RVT pathway, a decrease in unnecessary RVT was successfully achieved. Audit and feedback, reminders, and biannual education all supported long-term sustainability of this initiative.

scholarly journals Adjacent Primary Care May Reduce Less Urgent Pediatric Emergency Department Visits

2020 ◽  
Vol 11 ◽  
pp. 215013272092627
Author(s):  
Julia Ellbrant ◽  
Jonas Åkeson ◽  
Helena Sletten ◽  
Jenny Eckner ◽  
Pia Karlsland Åkeson
Keyword(s):  
Primary Care ◽  
Emergency Department ◽  
Patient Characteristics ◽  
Pediatric Emergency ◽  
Emergency Department Visits ◽  
University Hospital ◽  
Pediatric Emergency Department ◽  
Hospital Data ◽  
Cross Sectional ◽  
Ed Visits

Aims: Pediatric emergency department (ED) overcrowding is a challenge. This study was designed to evaluate if a hospital-integrated primary care unit (HPCU) reduces less urgent visits at a pediatric ED. Methods: This retrospective cross-sectional study was carried out at a university hospital in Sweden, where the HPCU, open outside office hours, had been integrated next to the ED. Children seeking ED care during 4-week high- and low-load study periods before (2012) and after (2015) implementation of the HPCU were included. Information on patient characteristics, ED management, and length of ED stay was obtained from hospital data registers. Results: In total, 3216 and 3074 ED patient visits were recorded in 2012 and 2015, respectively. During opening hours of the HPCU, the proportions of pediatric ED visits (28% lower; P < .001), visits in the lowest triage group (36% lower; P < .001), patients presenting with fever ( P = .001) or ear pain ( P < .001), and nonadmitted ED patients ( P = .033), were significantly lower in 2015 than in 2012, whereas the proportion of infants ≤3 months was higher in 2015 ( P < .001). Conclusions: By enabling adjacent management of less urgent pediatric patients at adequate lower levels of medical care, implementation of a HPCU outside office hours may contribute to fewer and more appropriate pediatric ED visits.

scholarly journals Bedside emergency department ultrasonography availability and use for blunt abdominal trauma in Canadian pediatric centres

CJEM ◽  
2012 ◽  
Vol 14 (01) ◽  
pp. 14-19 ◽  
Author(s):  
Robin Cardamore ◽  
Joe Nemeth ◽  
Christine Meyers
Keyword(s):  
Emergency Department ◽  
Abdominal Trauma ◽  
Blunt Abdominal Trauma ◽  
Positive Impact ◽  
Pediatric Trauma ◽  
Great Majority ◽  
Pediatric Emergency ◽  
Perceived Barriers ◽  
Emergency Physicians ◽  
The Future

ABSTRACT Objectives: To quantify the current availability and use of bedside emergency department ultrasonography (EDUS) for blunt trauma at Canadian pediatric centres and to identify any perceived barriers to the use of bedside EDUS in such centres. Methods: An electronic survey was sent to 162 pediatric emergency physicians and 12 site directors from the 12 pediatric emergency departments across Canada. Results: Ninety-two percent (11 of 12) of centres completed the survey. The individual physician response rate was 65% (106 of 162), with 100% of site directors responding. Ultrasound machines were available in 45% (5 of 11) of centres. Forty-two percent (32 of 77) of emergency physicians working in equipped pediatric centres used bedside EDUS to evaluate blunt abdominal trauma (BAT). In the subgroup of staff who also worked at adults sites, the frequency of ultrasonography use for the evaluation of pediatric BAT was 75%. In the 55% (6 of 11) of centres without ultrasonography, 88% of staff intend to incorporate its use in the future and 81% indicated that they believed the incorporation of ultrasonography would have a positive impact on patient care. The main perceived barriers to the use of ultrasonography in the evaluation of BAT were a lack of training (41%) and a lack of equipment (26%). Conclusion: Bedside EDUS is currently used in almost half of pediatric trauma centres, a frequency that is significantly lower than adult centres. Physicians in pediatric centres who use ultrasonography report that it has a high utility, and a great majority of physicians at pediatric centres without EDUS plan to incorporate it in the future. The main reported barriers to its use are a lack of training and a lack of equipment availability.

scholarly journals The removal of coins from the upper esophageal tract of children by emergency physicians: a pilot study

CJEM ◽  
2004 ◽  
Vol 6 (06) ◽  
pp. 434-440 ◽  
Author(s):  
Edward J. Vargas ◽  
Ameer P. Mody ◽  
Tommy Y. Kim ◽  
T. Kent Denmark ◽  
James A. Moynihan ◽  
...  
Keyword(s):  
Emergency Department ◽  
Pilot Study ◽  
Emergency Physician ◽  
Foley Catheter ◽  
Tertiary Care ◽  
Pediatric Emergency ◽  
Rapid Sequence Intubation ◽  
Emergency Physicians ◽  
Common Procedure ◽  
Data Set

ABSTRACT:Objective:There are few reports in the medical literature describing removal of a coin from the upper esophageal tract of a child by an emergency physician. However, given the nature of their training and practice, emergency physicians are well suited to perform this common procedure. We describe our experience with this procedure.Methods:This was a retrospective review of a continuous quality improvement data set from a university-based tertiary care pediatric emergency department between Nov. 1, 2003, and Mar. 31, 2004.Results:Thirteen children, with a median age of 20 months, underwent rapid sequence intubation and had coins successfully removed from their upper esophageal tract by emergency physicians. In 10 cases, the coin was visible at laryngoscopy and removed with Magill forceps. In 3 cases this approach failed and a Foley catheter was used to remove the coin. One child suffered a tonsillar abrasion and two sustained minor lip trauma, but all were extubated and discharged home from the emergency department with no significant complications. Eleven of the 13 patients were successfully followed up, and the parents reported no problems.Conclusions:This pilot study suggests that the removal of a coin from the upper esophageal tract by an emergency physician can be both safe and effective. A larger study is needed before this procedure can be generally recommended.

Experiences of Pediatric Emergency Physicians in Providing Alcohol-Related Care to Adolescents in the Emergency Department

2013 ◽  
Vol 29 (12) ◽  
pp. 1260-1265 ◽  
Author(s):  
Neelam Mabood ◽  
Samina Ali ◽  
Kathryn A. Dong ◽  
T. Cameron Wild ◽  
Amanda S. Newton
Keyword(s):  
Emergency Department ◽  
Pediatric Emergency ◽  
Emergency Physicians

scholarly journals Comparisons between Full-time and Part-time Pediatric Emergency Physicians in Pediatric Emergency Department

2016 ◽  
Vol 57 (5) ◽  
pp. 371-377 ◽  
Author(s):  
I-Anne Huang ◽  
Pao-Lan Tuan ◽  
Tang-Her Jaing ◽  
Chang-Teng Wu ◽  
Minston Chao ◽  
...  
Keyword(s):  
Emergency Department ◽  
Pediatric Emergency ◽  
Pediatric Emergency Department ◽  
Full Time ◽  
Emergency Physicians ◽  
Part Time

scholarly journals Effect of a Resident Physician Educational Program on Pediatric Emergency Department Pharmacy Interventions and Medication Errors

2013 ◽  
Vol 18 (1) ◽  
pp. 53-62
Author(s):  
Megan E. Foster ◽  
Donald E. Lighter ◽  
Ashok V. Godambe ◽  
Brandon Edgerson ◽  
Randy Bradley ◽  
...  
Keyword(s):  
Emergency Department ◽  
Medication Errors ◽  
Educational Program ◽  
Adverse Drug Events ◽  
Pediatric Emergency ◽  
Resident Physician ◽  
Pediatric Emergency Department ◽  
Chi Square ◽  
Statistical Process ◽  
Pharmacy Interventions

PURPOSE To determine the effects of a resident physician educational program in a pediatric emergency department (ED) on pharmacy interventions and medication errors, particularly dose adjustments, order clarifications, and adverse drug events (ADE). METHODS The ED pharmacist recorded all interventions and medication errors on weekdays from 3 to 11 pm during a 9-month period, consisting of a preobservational (Quarter 1), observational (Quarter 2), and interventional (Quarter 3) phases. Program implementation occurred in Quarter 3, with an initial 3-hour lecture during the ED orientation, followed by daily patient case discussions. Weekly interventions and errors were analyzed using statistical process control u-chart analyses. Chi-square analyses of independence were also performed. Resident and ED staff feedback on the program was obtained through anonymous internet-based surveys. RESULTS A total of 3507 interventions were recorded during the 9-month period. Chi-square approximation and interval estimation of odds ratio showed a statistically significant decrease between Quarters 1 and 3 in the number of dose adjustments (95% confidence interval [CI], 0.324–0.689) and order clarifications (95% CI, 0.137 to 0.382) after initiation of the program. The decline in ADE, while not as substantial (95% CI, 0.003 to 1.078), still achieved a level of significance (90% CI, 0.006 to 0.674). Survey results were positive toward the program. CONCLUSIONS The implementation of a resident physician educational program in our pediatric ED significantly decreased the number of medication errors, increased resident physician awareness of the potential for errors, and increased ED pharmacist utilization.

Fractures in the Pediatric Emergency Department: Are We Considering Abuse?

2018 ◽  
Vol 57 (10) ◽  
pp. 1161-1167 ◽  
Author(s):  
Lindsay R. Lavin ◽  
Cody H. Penrod ◽  
Cristina M. Estrada ◽  
Donald H. Arnold ◽  
Benjamin R. Saville ◽  
...  
Keyword(s):  
Emergency Department ◽  
Primary Outcome ◽  
Pediatric Emergency ◽  
Primary Objective ◽  
Predictor Variables ◽  
Secondary Outcome ◽  
Outcome Variable ◽  
Pediatric Emergency Department ◽  
Emergency Physicians ◽  
Primary Outcome Variable

Approximately one fourths of infant fractures are due to abuse. Recognition of abuse is important to avoid further morbidity/mortality. There is limited knowledge regarding how frequently pediatric emergency department clinicians consider abuse in infants with fractures. Our primary objective was to estimate the percentage of infants with fractures for whom abuse was considered, and to examine characteristics associated with abuse consideration. We performed a retrospective review of infants <1 year of age presenting to a pediatric emergency department. Our primary outcome variable was consideration of abuse. Our secondary outcome measures were identification of predictor variables associated with consideration of abuse. We identified 509 infants meeting study criteria. Pediatric emergency physicians considered abuse in approximately two thirds of infants with fractures. Consideration was more likely to occur in younger infants, in the presence of no history or unwitnessed injury mechanism, when evaluated by male physicians, and emergency department encounters from 12 am to 6 am.

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