Providing Safer, Higher Quality Pediatric Care

A grantee team focuses on how to do a better job of caring for children

    • March 6, 2013

Protecting infants from life-threatening infections; ensuring that every child gets the preventive care they need; helping medical practitioners avoid medication and treatment errors—these are just three of the critical issues tackled in the March 1 issue of the journal Pediatrics. The special issue features 11 studies conducted by Robert Wood Johnson Foundation (RWJF) Clinical Scholars.

“It’s not that we are in the midst of a crisis. It is that we know that there are many things that we can do better to improve the quality and safety of pediatric care,” explained neonatologist and 2010-2012 RWJF Clinical Scholar Stephen Patrick, MD, MPH, author of two of the studies. To that end, Patrick and his fellow Clinical Scholars assessed a broad range of pediatric care procedures. Findings from five, key studies from the group are explored here.

Eliminating Central Line Infections

Each year, central lines (IVs inserted into a central vein) are used in the treatment of approximately 100,000 infants. “It’s a common method for administering antibiotics or IV nutrition,” Patrick said. “But central-line associated bloodstream infections [CLABSIs] in newborns can result in neurologic injury and even death.”

Preventing CLABSIs requires careful monitoring. To achieve that goal, Medicaid (the payer for roughly 45% of births) began imposing financial penalties on hospitals when infections like CLABSIs occur. “Assessing the quality of the data reported to Medicaid will help them do a better job of accurately implementing this policy,” Patrick said. “For our research, we looked at the two most common sources of reporting for hospitals—billing records and infection control reports based upon criteria from the Centers for Disease Control and Prevention.”

The study “Accuracy of Hospital Administrative Data in Reporting Central-Line Associated Bloodstream Infections in Newborns” revealed that the quality of CLABSIs reporting based on billing data was very poor. In fact, billing records often underreported the number of infections.

Patrick and his team found that infection control-based reports were far more accurate in assessing the number of CLABSIs. “We hope our results will benefit patients, providers and payers in their efforts to provide safer care for newborns.”

Giving Every Child A Chance

The preventive care received by toddlers may affect their health for the rest of their lives. “Well-child care visits conducted in the first three years of life are an important part of pediatric care,” said Tumaini Coker, MD, MBA, a 2004-2006 RWJF Clinical Scholar and pediatrician at UCLA Medical Center.

Physician infant and toddler office visits offer critical opportunities to identify potential developmental, health, psychological or social problems early enough in a child’s life to genuinely make a difference. “In families with few financial resources, children might not see any other professional besides the pediatrician before age 4. By that time, we may have already missed a chance to intervene and achieve optimal outcomes for that child,” Coker said.

The American Academy of Pediatrics recommends more than ten visits in the first three years of life, a target often missed by busy parents. And, Coker added, “even when families do make all of the visits, many will not have their needs met in the brief 10- to 15-minute sessions.”

For their study “Well-Care Practice Redesign for Young Children: A Systematic Review of Strategies and Tools,” Coker and her co-researchers looked at evidence-based strategies to help providers improve the way well-child care is delivered to families. They recommended that providers consider:

  • Group visits to allow parents to have more time with the provider to discuss development and behavior.
  • Greater utilization of the Internet and non-face-to-face communication to share guidance and educational information with parents.
  • Enlisting non-physician providers, such as pediatric nurse practitioners, to provide developmental and clinical evaluations.

Better Guidance for Physicians & Nurses

Computerized physician order entry (CPOE) is meant “to reduce errors, in part, by reducing the cognitive load on health care providers when they are making decisions–making it easier for them to do the right thing,” said Michael Leu, MD, a pediatrician at Seattle Children’s Hospital and a 2005-2007 RWJF Clinical Scholar. His research evaluated the CPOEs at his institution.

“I wanted to see how we were doing, several years after a pilot study of our CPOE system,” Leu said. His team’s study “Systematic Update of Computerized Physician Order Entry (CPOE) Order Sets to Improve Quality of Care: A Case Study” uncovered issues in the Seattle Children’s CPOE system that may serve to instruct other pediatric departments in how to reduce errors.

His team reviewed 235 order sets. Of these, 37 percent had medication issues, including inaccurate instructions for administering epinephrine, incorrect antibiotic dosages, and dosing inconsistent with the hospital’s formulary. Treatment instruction, nursing and laboratory order errors were also found.

“We concluded, among other things, that we had to establish medical and technological standards, including content standards, before asking analysts to build order sets,” Leu said. “It is also critical for every order set to have an owner responsible for its clinical intent. Each order set must be maintained periodically through careful multidisciplinary review, and updated to conform to the latest evidence and care standards.”

Contributing to Quality & Value

In addition to the topics explored by Patrick, Leu, and Coker, other studies in the group assessed surgical outcomes and provider/patient communication.

  • In the article “Variation in Surgical Outcomes for Adolescents and Young Adults with Inflammatory Bowel Disease,” lead author Sophia Jan, MD, a 2009-2011 RWJF Clinical Scholar, and her team documented higher complication rates among young people receiving bowel surgery at children’s hospitals, as opposed to general hospitals. Conversely, complications were lower when the procedures were performed by pediatric rather than colorectal surgeons. The researchers recommended more research on the differences in the two care settings.
  • The study “The Factors Associated with High Quality Communication for Critically-Ill Children” was the first to document conversations about prognosis or care goals for patients admitted to the pediatric intensive care unit (PICU), regardless of clinical outcomes. Jennifer K. Walter, MD, PhD, a 2010-2012 RWJF Clinical Scholar, and her co-authors, found that increased high-quality communication between providers and families would improve family-centered care in the PICU. Their survey of 645 patients found that only one third of the sickest patients had conversations documented. 

Patrick notes that the research group’s global focus on measuring the use and effectiveness of quality measures in the studies in the Pediatrics issue was “intended to help us assess broad variations in the quality of treatment for children and identify areas that need improvement in order to provide better care.”

Read abstracts of all the articles in the special issue of Pediatrics.
Learn more about the RWJF Clinical Scholars program.
For an overview of RWJF scholar and fellow opportunities, visit www.RWJFLeaders.org.

Leading the Way to Safer Pediatric Care

Eleven new studies from the RWJF Clinical Scholars were published in Pediatrics on March 1. The work explores new ways to improve safety and quality in pediatric care. Read the stories, blog posts, and research.

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