Comparative effectiveness of Direct Admission and Admissions through Emergency Departments for Children

PI: Dr. JoAnna K Leyenaar , MD, PhD, MPH

Motivation and Aims:

Approximately 2 million children are hospitalized each year in the United States, with more than three-quarters of non-elective hospitalizations admitted through emergency departments (EDs). Direct admission, defined as admission to hospital without first receiving care in the hospital’s ED, may offer benefits for patients and healthcare systems in quality, timeliness, and experience of care. While ED utilization patterns are well studied, there is a paucity of research comparing the effectiveness of direct and ED admissions. The overall aim of this project is to compare the effectiveness of a standardized direct admission approach to admission beginning in the ED for hospitalized children.

Novel Approach:

· First randomized controlled trial to compare the effectiveness of direct admission to admission through the ED for pediatric patients.

· Pairing a stepped wedge design with a multi-level assessment of barriers to and facilitators of implementation, will generate valuable data about how positive findings can be reproduced across other healthcare systems.

A Multicenter Randomized Controlled Trial of a Patient Safety Reporting Intervention for
Families to Improve Medical Error Detection

PI: Alisa Khan, MD

I-SHARE (Patients and Families Improving Safety in Hospitals by Actively Reporting Experiences) is a $2 million 5-year AHRQ-funded R01 of a 4-center randomized controlled trial to develop and investigate a family safety reporting intervention known as the I-SHARE Comment Card. The specific aims are to: (1) evaluate the effectiveness of the I-SHARE reporting tool in improving error detection and other safety outcomes (comparing the I-SHARE reporting tool to hospital incident reporting), (2) assess the impact of the I-SHARE reporting tool on disparities in reporting, and (3) understand contextual factors contributing to successful implementation of the I-SHARE reporting tool. Data collection for this 4-center randomized controlled trial will start in January 2023 at 4 hospitals across the US and study materials will be translated into Arabic, Armenian, Chinese, Haitian Creole, Hmong, Korean, Spanish, and Portuguese.

Comparing Three Approaches to Communication with Hospitalized Children and Families with Limited English Proficiency.

PI: Alisa Khan, MD

Patient and Family Centered (PFC) I-PASS LISTEN (Language, Inclusion, Safety, and Teamwork for Equity Now) is a $7-million PCORI-funded 8-center cluster randomized controlled trial. The goal of this study is to compare the effectiveness of PFC I-PASS+, PFC I-PASS, and usual care in hospitalized children and families who prefer languages other than English. PFC I-PASS is multifaceted structured communication intervention, and PFC I-PASS+ is bolstered with additional elements (cultural humility training, interpreter use standardization, and provider communication training) to tailor the intervention to be particularly effective in this population. We will compare safety, experience, discrimination, and communication outcomes and disparities amongst patients and families who have preferred languages other than English and those whose have English as their preferred language.

Eliminating Monitor Overuse (EMO) Hybrid Effectiveness-Deimplementation Trial

PI: Chris Bonafide, MD, MSCE

Deimplementing overused health interventions is an essential step in maximizing quality and minimizing waste in the United States health care system. Acute bronchiolitis is a common lung disease of young children caused by respiratory viral infection. Continuous pulse oximetry monitoring in hospitalized infants with bronchiolitis who are not receiving supplemental oxygen is an overused intervention that has persisted despite evidence that it is ineffective in this population and may cause harm. Three national guidelines now discourage continuous pulse oximetry monitoring in hospitalized infants with bronchiolitis who are not receiving supplemental oxygen. In preliminary studies, the investigators showed that continuous pulse oximetry overuse occurs in nearly half of all hospitalized infants with bronchiolitis for whom there is no monitoring indication, and there is high between-hospital variability in overuse. The overarching goal of the applicants is to determine which strategies are most effective for deimplementing overused health interventions that have the potential to harm children. The overall objective of this application is to conduct the Eliminating Monitor Overuse (EMO) SpO2 trial, a hybrid type III effectiveness-deimplementation trial with a longitudinal cluster-randomized design in 32 Pediatric Research in Inpatient Settings Network hospitals. The trial will test an unlearning deimplementation strategy (educational outreach with audit & feedback) vs. a combined unlearning + substitution deimplementation strategy (adding an electronic health record-integrated clinical pathway) on sustainability of continuous pulse oximetry monitoring deimplementation in children with bronchiolitis who are not receiving supplemental oxygen. This proposal includes three Specific Aims: (1) Compare the effects of the unlearning only strategy versus the unlearning + substitution strategy on deimplementation outcomes, (2) Identify deimplementation strategy mechanisms linked to penetration and sustainability using mixed methods, and (3) Examine the effects of deimplementation on clinical outcomes and unintended consequences. This approach is innovative because it focuses on the under-researched area of pediatric deimplementation, the experimental design reflects state-of-the-art theoretical framing of deimplementation interventions, and the primary outcome focuses on long-term sustainability of deimplementation, which is highly relevant to the public. The proposed research is significant because it will advance the science of health care delivery for a high incidence pediatric lung disease that hospitalizes 100,000 children annually, acute viral bronchiolitis. The trial will also provide new insights into the processes, mechanisms, costs, and outcomes of large, rigorously-designed deimplementation efforts.

The SHAKE Study: Sustaining High-quality Asthma care for Kids Everywhere

PI: Suni Kaiser, MD

Healthcare providers’ face many challenges adhering to evidence-based guidelines, and this contributes to poor health outcomes for the >100,000 children hospitalized with asthma annually in the United States. Successful methods to promote providers’ initial adoption of guidelines have been developed, but to date, little research has focused on methods to robustly sustain guideline adherence. Adherence commonly deteriorates after initial implementation resources are removed. This adversely impacts children with asthma, as >70% are cared for in general hospitals, where resources tend to be preferentially allocated to adult care. Pathways (succinct versions of guidelines that provide visual, step-by-step guidance for healthcare providers) improve quality of care for children hospitalized with asthma. Pathway implementation strategies (methods for promoting pathway implementation) have achieved short-term improvements in care of children in general hospitals. However, to reap maximum value from limited implementation resources, we must identify asthma pathway implementation strategies that promote sustained delivery of high-quality care for children in general hospitals. To achieve that objective, this proposal harnesses the ?positive deviance? approach, which asserts that identification and examination of higher- and lower-performing hospitals can facilitate the discovery and wide dissemination of strategies to improve care.

Specific aim 1 will involve a secondary quantitative analysis of existing data. Multi- level regression models with an interrupted-time series approach will be used to identify hospital-level factors associated with sustainability and hospitals with higher and lower sustainability performance. Sustainability will be defined as maintenance of higher guideline adherence and higher quality of care at 2 years after pathway implementation (long-term benefit) without declines after implementation resources are removed. Outcomes will include length of stay (clinical outcome that reflects time to recovery) and use of metered-dose inhalers (guideline adherence).

Specific aim 2 will study the higher- and lower-performing general hospitals identified in Aim 1 using qualitative, constant comparative methods. The ERIC Framework of implementation strategies will be used to develop a semi-structured interview guide for key personnel involved in pathway implementation. This analysis will identify pathway implementation strategies that promote sustainability and important contextual factors that influence their success. This mixed-methods approach will produce a multi-dimensional, comprehensive understanding of how general hospitals can promote sustained delivery of high-quality care for children with asthma. These findings will fill crucial gaps in our understanding of sustainability, enable general hospitals to more effectively target limited resources, and enable us to develop a comparative-effectiveness trial of sustainability interventions. Thus, these findings will have important positive impacts– they will advance the science of clinical practice improvement, facilitate sustained use of evidence-based guidelines, and improve health care quality for children, an AHRQ priority population.

Public Health Relevance
The aims of the proposed research are to identify hospital-level factors and pathway implementation strategies that promote sustained delivery of high-quality care for children with asthma in general hospitals. The proposed research is relevant to public health because will fill crucial gaps in our understanding of sustaining guideline adherence and enable general hospitals to more effectively target limited resources for achieving sustained delivery of high-quality care to children. Thus, the proposed research is relevant to the AHRQ’s goals of advancing the science of clinical practice improvement, overcoming barriers to sustaining use of evidence- based guidelines, and improving health care quality for children, an AHRQ priority population.

Optimizing Care for Hospitalized Children during and after the COVID-19 Pandemic

PI: Suni Kaiser, MD

Background: The COVID-19 pandemic has necessitated rapid changes in healthcare delivery in the United States, including changes in the care of hospitalized children. The objectives of this study were to identify major changes in healthcare delivery for hospitalized children during the COVID-19 pandemic, identify lessons learned from these changes, and compare and contrast the experiences of children’s and community hospitals.

Methods: We purposefully sampled participants from both community and children’s hospitals serving pediatric patients in the six U.S. states with the highest COVID-19 hospitalization rates at the onset of the pandemic. We recruited 2-3 participants from each hospital (mix of administrators, front-line physicians, nurses, and parents/caregivers) for semi-structured interviews. We analyzed interview data using constant comparative methods to identify major themes.

Results: We interviewed 30 participants from 12 hospitals. Participants described how leaders rapidly developed new hospital policies (e.g., directing use of personal protective equipment) and how this was facilitated by reviewing internal and external data frequently and engaging all relevant stakeholders. Hospital leaders optimized communication through regular, transparent, multi-modal, and bi-directional communication. Clinicians increased use of videoconference and telehealth to facilitate physical distancing, but these technologies may have disadvantaged non-English speakers. Due to declining volumes of hospitalized children and surges of adult patients, clinicians newly provided care for hospitalized adults. This was facilitated by developing care teams supported by adult hospitalists, multidisciplinary support via videoconference, and educational resources. Participants described how the pandemic negatively impacted clinicians’ mental health, and they stressed the importance of mental health resources and wellness activities/spaces.

Conclusions: We identified several major changes in inpatient pediatric care delivery during the COVID-19 pandemic, including the adoption of new hospital policies, video communication, staffing models, education strategies, and staff mental health supports. We outline important lessons learned, including strategies for successfully developing new policies, effectively communicating with staff, and supporting clinicians’ expanding scope of practice. Potentially important focus areas in pandemic recovery include assessing and supporting clinicians’ mental health and well-being, re-evaluating trainees’ skills/competencies, and adapting educational strategies as needed. These findings can help guide hospital leaders in supporting pandemic recovery and addressing future crises.