Informed by a single institution pilot study (Starmer et al, JAMA 2013), the I-PASS Study was launched, an eleven-center handoff intervention study (Sectish et al, Pediatrics 2011). To develop the I-PASS Handoff Bundle for use in the multi-site study, we applied a rigorous approach to curriculum development (Starmer et al, Academic Medicine 2013). The I-PASS Handoff Bundle, includes a comprehensive suite of educational materials with six major complementary components. A cornerstone of the curriculum is I-PASS (Starmer et al, Pediatrics 2012), a mnemonic for the key elements of the handoff process: I: Illness severity; P: Patient summary; A: Action items; S: Situation awareness and contingency planning; S: Synthesis by receiver. The I-PASS mnemonic is integrated throughout each curricular module as a framework and way of standardizing the handoff process.
Across nine data collection sites, we conducted a prospective intervention study, the I-PASS Study, to assess the relationship of implementing the I-PASS Handoff Bundle to medical error rates (Starmer et al, NEJM 2014). Following implementation of the I-PASS Handoff Bundle across 10,740 patient admissions, we found that medical errors decreased by 23% (24.5 vs 18.8 per 100 admissions, p<0.001) and preventable adverse events—medical errors resulting in harm to patients— decreased by 30% (4.7 vs 3.3 per 100 admissions, p<0.001). As evidence of successful implementation, significant increases across all sites were observed in inclusion of key information in written handoff documents (improvements in 9 of 9 pre-specified key elements) and in verbal communications during handoffs (5 of 5 key elements) (p<0.001 for all 14 comparisons). There were no significant changes in the duration of oral handoff per patient (2.4 vs. 2.5 minutes, p=0.55) or resident workflow, including patient-family contact or computer time.
The I-PASS Study began in January 2010 and ended in May 2013 and was conducted in conjunction with the Pediatric Research in Inpatient Settings (PRIS) network and the Initiative for Innovation in Pediatric Education (IIPE), with funding from the Department of Health and Human Services. For additional questions about the I-PASS Study, please email firstname.lastname@example.org.
The I-PASS Study has paved the way for other related research endeavors, including I-PASS Mentored Implementation Program, Patient and Family Centered I-PASS Research Study.
For more information, please visit the I-PASS website.
Pediatric Respiratory Illness Inpatient Measurement System (PRIMES) is a previously developed quality measurement tool that is structured to generate quality scores using medical records data for four respiratory conditions: asthma (41 PRIMES quality indicators), bronchiolitis (21 PRIMES quality indicators), croup (17 quality indicators), and community acquired pneumonia (CAP) (18 PRIMES quality indicators).
Our major goal in the current study is to conduct an outcome validation analysis of PRIMES by assessing the relationship between level of adherence to the processes of care included in the tool, improved outcomes, and costs of care. Using PRIMES, we will conduct a detailed assessment of the hospital management of 2,457 patients admitted to one of 5 children's hospitals in the United States belonging to the PRIS Network. We will assess health related quality of lief (HRQOL) using a validated survey measure at three time points: the month prior to the index admission (baseline), the day of admission, and two-six weeks after admission. We will also assess costs of care for the index ED and/or hospital admission as well as length of stay (LOS), return ED visits, and re-admissions within 30 days of discharge.
PI: Chris Landrigan, MD, MPH
PI: Rita Mangione-Smith, MD, MPH
PI: Sunitha Kaiser, MD, MSc
Despite broad dissemination of evidence-based guidelines for asthma management, there are significant variations in care and risk-adjusted outcomes for children hospitalized with asthma, largely due to challenges integrating guidelines into care. Clinical pathways are structured, multidisciplinary, and detailed care plans for patients with a specific clinical problem; they link evidence to practice to optimize patient outcomes and delivery efficiency. In controlled trials, pathways reduce inappropriate variation in care and improve outcomes for children hospitalized with asthma; however, there is wide variability in performance and uptake of pediatric asthma pathways in real-world settings due to a dearth of evidence-based guidance on successful implementation methods.
Our objective is to identify, test, and disseminate best practices for pathway implementation to improve quality of care for children hospitalized with asthma. The central hypothesis, derived from the “positive deviance” approach, is that identification and examination of hospitals that demonstrate exceptional performance with pathway implementation can facilitate the discovery and wide dissemination of strategies to improve care. This hypothesis will be tested by pursuing three specific aims:
Identify hospitals where implementation of inpatient pediatric asthma pathways has led to the largest improvements in quality of care. Key personnel from children’s hospitals that contribute to the PHIS database will be surveyed to determine if and when asthma pathways were implemented, then the database will be used to identify which hospitals had the greatest gains in quality of care with pathway implementation.
Determine best practices for implementation of inpatient pediatric asthma pathways through in-depth qualitative analysis of key personnel from the high-performing hospitals identified in Aim 1.
Conduct a pilot trial to determine the feasibility of implementing inpatient pediatric asthma pathways utilizing best practices in both tertiary and community hospital settings.
This research will advance and expand knowledge on best practices for pathway implementation, which will enable increased uptake and successful implementation of clinical pathways and improve evidence-based practices and quality of care for children with asthma. Ultimately, this new knowledge could support pathway implementation across a range of pediatric illnesses to improve quality of care and decrease unnecessary costs.
This research is supported by a grant from the Agency for Healthcare Research and Quality.
PI: Rita Mangione-Smith, MD, MPH
The Pediatric Hospital Care Improvement Project (P‐ HIP) is a comprehensive field test of two new quality measure sets: The Transitions of Care Measure Set, and The Mental Healthcare in Hospital Settings Measure Set. We will accomplish this by bringing together a multidisciplinary, multi-stakeholder team of experts representing state Medicaid agencies from thress states, and External Quality Review Organization (ERO), eight PRIS network hospitals (Seattle Children's Hospital, UCSF Benioff Children's Hospital, Children's Hospital and Research Center Oakland, The Children's Hospital Colorado, University of Iowa Children's Hospital, Monroe Carell Jr. Children's Hospital at Vanderbilt, Cincinnati Children's Hospital, Medical University of South Carolina Children's Hospital, Mt. Sinai Children's Hospital) serving children insured by Medicaid or the Child Health Insurance Program (CHIP), experts in quality measurement, dissemination and implementation science, conducting hospital-based QI collaboratives, and academic researchers.
The major aims for the P-HIP study are as follows:
1. To disseminate and implement the Pediatric Quality Measures Program (PQMP) Center of Excellence on Quality of Care Measures for Children with Complex Needs (COE4CCN) Transitions of Care and Mental Healthcare in Hospital settings quality measure sets by deploying the previously developed electronic medical record (MR) abstraction tool in an eight hospital collaborative to examine a) feasibility of tool implementation, b) quality measure validity, and c) quality measure reliability in a variety of healthcare settings.
2. To identify one quality measure from each COE4CCN measure set as a target for QI collaborative intervention by evaluating variation in baseline performance on individual measures within each set across the eight hospitals.
3. To improve overall performance by 50% among the hospitals participating in the QI collaborative, on the two targeted COE4CCN measures by the end of the collaborative and to assess whether performance is associated with utilization and costs.
4. To asses the responsiveness of both a) the measures targeted for QI intervention and b) the full measure sets to the QI collaborative interventions.
This study is part of a career development award supported by AHRQ with the ultimate goal to improve pediatric patient safety by leveraging the expertise and experience of both clinicians and families of children with neurologic impairment. The goal of the recently completed first stage was to develop a comprehensive understanding of how families identify and discuss their child’s evolving illness with the inpatient healthcare team. The team recruited a targeted sample of family members who were legal guardians of hospitalized children with neurologic impairment. Interviews, conducted in the hospital, were audio‐recorded, de‐ identified, and transcribed verbatim. Using inductive thematic analysis, each transcript was independently coded by three‐four members of our study team. Members met regularly to develop and refine a codebook and reach consensus on coding decisions. Patterns observed in the coded data were organized into themes and subthemes, and representative quotes were extracted. The research team recruited family members of 26 hospitalized children 9 months to 17 years of age. Their children had a mean of 9 prior hospitalizations and an average of 80 days in the hospital in the previous three years. Analysis resulted in six themes listed below:
Theme 1: "He Writes His Own Book," textbooks of little help
Theme 2: Informal, learned pathways to native complex and confusing systems
Theme 3: Importance of advocacy and persistence
Theme 4: "We're not your typical parents," parents learn roles as part of hospital care teams
Theme 5: Medical culture and practice do not support partnership