EMSC Opportunities for Enhancing Pediatric Emergency Care: Pediatric Readiness Data: An Opportunity to Improve Quality of Care in Your Emergency Department Moderator: Beth Edgerton, MD, MPH Presenters: Charles Macias, MD, MPH Katherine Remick, MD Evelyn Lyons, RN, MPH Date: Wednesday, December 17, 2014

HOUSEKEEPING RULES FOR THE WEB CONFERENCE Everyone will be muted upon entry. Please use the chat box (located on the bottom right corner) to ask any questions. DO NOT PLACE THE PHONE ON HOLD as this will disrupt the webinar.   If you have any technical difficulties, please contact Brandye Williams at BCWillia@childrensnational.org.

Distinguish quality assurance from quality improvement, As a result of having participated in this webinar, attendees will be able to: Define Quality Improvement and its scope and impact in pediatric emergency care, Distinguish quality assurance from quality improvement, List critical components of the quality improvement process, Illustrate via case presentation a pediatric emergency quality improvement opportunity, and Identify potential quality improvement initiatives via pediatric readiness data.  Quality improvement is important is pediatric emergency care. The National Pediatric Readiness Project--a multi-phase quality improvement initiative to ensure that all U.S. emergency departments (ED) have the essential guidelines and resources in place to provide effective emergency care to children assessed 4, 146 hospitals in a 2013 survey. The assessment found that the average readiness score was 69 out of 100 possible points (EMS for Children National Resource Center, 2014). The nearly 14 point (13.9 point) improvement from the 2003 assessment conducted by Marianne Gausche-Hill, MD and colleagues indicates both progress and opportunities for further improvement in the care of children.

This activity is designated 1.5 contact hours for nurses. ACCREDITATION This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the Indian Health Service (IHS) Clinical Support Center and the EMSC National Resource Center. The IHS Clinical Support Center is accredited by the ACCME to provide continuing medical education for physicians.   The IHS Clinical Support Center designates this live activity for a maximum of 1½ AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. The Indian Health Service Clinical Support Center is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. This activity is designated 1.5 contact hours for nurses. This course is accredited by the Indian Health Service for 1.5 nursing CE contact hours and 1.5 physician CMEs. Please remember to select the appropriate type of continuing education you are seeking on your evaluation.

DISCLAIMER Accreditation applies solely to this educational activity and does not imply approval or endorsement of any commercial product, services or processes by the CSC, IHS, the federal government, or the accrediting bodies.

FACULTY DISCLOSURE STATEMENT As a provider accredited by ACCME, ANCC, and ACPE, the IHS Clinical Support Center must ensure balance, independence, objectivity, and scientific rigor in its educational activities. Course directors/coordinators, planning committee members, faculty, reviewers and all others who are in a position to control the content of this educational activity are required to disclose all relevant financial relationships with any commercial interest related to the subject matter of the educational activity. Safeguards against commercial bias have been put in place. Faculty will also disclose any off-label and/or investigational use of pharmaceuticals or instruments discussed in their presentation. All those in a position to control the content of this educational activity have completed the disclosure process and have indicated that they do not have any significant financial relationships or affiliations with any manufacturers or commercial products to disclose.   There is no commercial interest support for this educational activity.

CE Evaluation and Certificate Continuing Education guidelines require that the attendance of all who participate be properly documented.   Those who participate and wish to receive continuing education need to attend the activity in its entirety and complete the online evaluation by December 24, 2014. The online evaluation link will be provided at end of the educational activity by the facilitators. The online link will be available for one week to complete your evaluation. If you need assistance accessing the online evaluation link, or have questions regarding this internet education event please contact Sametria McCammon at (smccammo@childrensnational.org). Continuing education certificates for doctors and nurses will be automatically generated and emailed to you upon completion of the online evaluation. The EMSC program recognizes that the content within this educational activity is significant to the program, its stakeholders and the national efforts to continuously improve the emergency care of children. As a result, the program has decided to convert this educational activity to an enduring product or continuing education activity with physician and nurse credits for 2 years. We will be sure to notify all participants of this webinar once this opportunity is realized.

TODAY’S PRESENTERS Charles Macias, MD, MPH, Texas Children’s Hospital Katherine Remick, MD, Austin-Travis County EMS System and UT Southwestern Austin, Dell Children’s Medical Center Evelyn Lyons, RN, MPH, Illinois Emergency Medical Services for Children Program, Illinois Department of Public Health Dr. Macias is boarded in pediatrics and pediatric emergency medicine and completed a clinical research fellowship. He is a graduate of Stanford University, Southwestern Medical School and the UT School of Public Health. He is the chief clinical systems integration officer and the director of the Center for Clinical Effectiveness at Texas Children’s Hospital/Baylor College of Medicine. Dr. Remick completed her residency and chief residency in pediatrics at Washington University and fellowships in pediatric emergency medicine and emergency medical services at Harbor-UCLA Medical Center. She was co-primary investigator of the California Pediatric Readiness Project and one of the core investigators for the National Pediatric Readiness Project. Evelyn Lyons is the manager and co-principal investigator if the Illinois Emergency Medical Services for Children (EMSC) program at the Illinois Department of Public Health. She has coordinated the Illinois EMSC program since 1994.

Charles G Macias MD, MPH Chief Clinical Systems Integration Officer, Texas Children’s Director, Evidence Based Outcomes Center and Center for Clinical Effectiveness, Texas Children’/Baylor College of Medicine

Objectives 1.      Define Quality Improvement and its scope and impact in pediatric emergency care 2.      Distinguish quality assurance from quality improvement 3.      List critical components of the quality improvement process 4.      Illustrate via case presentation a pediatric emergency quality improvement opportunity 5.      Identify potential quality improvement initiatives via pediatric readiness data 6.      Summary and take home points

Pediatric Emergency Care in the United States Children account for 25 million visits to emergency departments every year (~25% of all visits) 80-90% are cared for in general EDs 50% of EDs see < 10 pediatric pts/day <5% require tertiary care Limited experience with critically ill children Children make 25M ED visits per year in the US which represents 25% of all ED visits. Approximately 80-90 percent of those visits occur in general emergency departments which on average see less than 10 pediatric patients per day and less than 5 percent of those require tertiary care. Thus most emergency department providers having limited ongoing experience with critically ill and injured children. This lack of experience is, in turn, easily exacerbated by the framework of a busy and overcrowded emergency department. If you add to that the deficiencies in pediatric readiness this becomes the perfect storm.

Quality Improvement and Pediatric Emergency Care Neither are Pediatric emergency care infrastructures. The Institute of Medicine findings from 19 meetings in 3 subcommittees involving evidence reviews and the input of hundreds of experts and stakeholders described gaps in the effective and safe delivery of care to children.

…As a system…it provides care of variable and often unknown quality… June 15, 2006 Emergency medical care in the United States is on the verge of collapse… …As a system…it provides care of variable and often unknown quality… The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge KN Lohr, N Engl J Med, 1990

Safe Equitable Patient-Centered Timely Efficient Effective Avoid injuries to patients from care intended to help them Equitable Provide care that does not vary in quality because of personal characteristics Patient-Centered Provide care that is respectful of and responsive to individual patient preferences, needs, values Timely Reduce waits and potentially harmful delays for both those who receive and those who give care Efficient Avoid waste of equipment, supplies, ideas, and energy Effective Services based on scientific knowledge to all who could benefit (avoid under-use and overuse, respectively) 14

44,000-98,000 deaths annually in the US due to preventable error HealthGrades 2007-2009 46% lower risk of a safety incident at a top hospital 7.3 billion in excess costs “…Now comes a study in the current issue of the Journal of Patient Safety that says the numbers may be much higher — between 210,000 and 440,000 patients each year who go to the hospital for care suffer some type of preventable harm that contributes to their death, the study says. That would make medical errors the third-leading cause of death in America, behind heart disease, which is the first, and cancer, which is second. “ www.propublica.org, accessed 11/26/2014 The Institute of Medicine (IOM) report on building a safer health system (1) created an intense public response by stating that the number of deaths due to preventable error in the United States is between 44,000 and 98,000 per year. The report cited two studies, one based on hospital discharges in New York in 1984 (2) and the other based on discharges in Colorado and Utah in 1992. (3) The federal government and professional organizations responded to the public outcry by pledging to reduce the number of errors in health care. The HealthGrades study also found that: Four patient safety indicators (death among surgical inpatients with serious treatable complications, pressure ulcer, post-operative respiratory failure, and post-operative sepsis) accounted for 68.51% of all patient safety events during the three years analyzed. The 13 patient safety events studied were associated with $7.3 billion of excess cost, which equates to an additional $181.17 per Medicare patient hospitalization. Preventable medical errors are so pervasive and costly that the federal government has proposed linking incentive-based hospital compensation to four of the AHRQ Patient Safety Indicators, starting in 2014. In addition, the Centers for Medicare and Medicaid Services are currently developing a 10-year, $70 billion plan aimed at reducing hospital-acquired infections. 1 death every 378 admissions Recommended care received about 55% of the time (2003 NEJM) xxx00.#####.ppt 4/20/2017

Is this pertinent to PEM? Medical error risk in EM settings Chaotic environments that create latent environments of risk No prior relationship with families High acuity settings/resuscitations Shift work/handoffs Pediatrics Weight-based medication/treatments Varied developmental state Need for Pediatric QI in health care infrastructures Chaotic environments that create latent environments of risk: overcrowding and understaffing

What do we hope to achieve? Quality Cost There is a limited ability to cut costs in our current paradigm for delivering care. In an environment where cost, at best, is marginally increasing, healthcare must markedly improve quality. Value = Payor, consumer/patient, legislator/advocate, provider/health care worker Make the distinction, although some bit of it is importantly describing return on investment, that we're really focused on the value piece. That if we imagine a Porter equation, in which he's described value is equal to quality over cost, that some relatively fixed amount of dollars are spent on creating, implementing and maintaining at the EMR and that what an enterprise data warehouse gives us the capability to do, what our clinical systems model gives us the capability to do, is to take that investment and understand how we improve the value of it. Minimal, I think, is the cost of the EDW in respect to the entire investment in the EMR, and the proof of that, I think, is somewhat mathematical, that Put Quality over cost

Why does it matter? A parallel example RCT of treatment of hypertension on the jobsite (a steel mill) versus referral to the PCP No difference in compliance between the groups Exploration of factors relating to therapy revealed specific determinants of the clinical decision to treat some, but not other, hypertensive patients: The level of diastolic blood pressure. The patient’s age. ???? The amount of target-organ damage.

A parallel example RCT of treatment of hypertension on the jobsite (a steel mill) versus referral to the PCP No difference in compliance between the groups Exploration of factors relating to therapy revealed specific determinants of the clinical decision to treat some, but not other, hypertensive patients: The level of diastolic blood pressure. The patient’s age. The year the physician graduated from medical school The amount of target-organ damage.

Minimizing variation Wide variations in practice are often not related to differences among patients Minimizing variations in practice can improve quality of health care delivery Variation in clinical practice Variation in beliefs Variation in interpretation of evidence Variation in response when evidence is lacking

Variation in pediatric care models

Solutions? traditional approach to quality assurance # of Cases Mean Excellent Outcomes Poor Outcomes 1 box = 100 cases in a year 1.96 std # of Cases Excellent Outcomes Poor Outcomes Option 1: Focus on Outliers – the prescriptive approach Strategy eliminate the unfavorable tail of the curve (“quality assurance”) Result The impact is minimal in improving care and the impact on culture from a prescriptive approach has its own untoward outcomes f the outlier trim point is set at 1.96 standard deviations, only 2.5% of cases fall under the adverse outcome tail, so 22 22

Changing outcomes through QI: changing infrastructures Excellent Outcomes # of Cases Poor Outcomes Excellent Outcomes Poor Outcomes # of Cases Mean 1 box = 100 cases in a year Option 2: Focus On Inliers – improving quality outcomes across the majority Strategy Evidence and QI methods applied through EBP clinical standards targets inlier variation and other strategies to improve the routine processes Result Shifting more cases towards excellent outcomes has much more significant impact. Now your hospital is impacting the majority of the target population 23 23

One definition of quality The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge The New England Journal authors define quality as … These definitions are broad – but the institute of medicine report has helped us to operationalize our definition of quality. K Lohr, N Engl J Med, 1990

Outcomes Quality MEASUREMENT First arrow defines Second arrow measures Clinical outcomes measure the end result of the health care we provide to our patients. Today, we will discuss developing valid and relevant outcomes for PEM. One of the most important reasons for measuring outcomes is to assess the quality of the care we give. If we are able to agree on important outcome measures in our field, it will facilitate our ability to compare quality of pediatric emergency care, including differences in quality of care between settings, practitioners and patient populations. Although there was a New England Journal article this week that found that increased adherence to process measures for cardiovascular disease resulted in decreased mortality, our session today will focus on patient outcomes and not structure or process measures.

One definition of quality The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge The New England Journal authors define quality as … These definitions are broad – but the institute of medicine report has helped us to operationalize our definition of quality. K Lohr, N Engl J Med, 1990

Evidence to expertise Patient values and preferences Evidence Clinical Decisions •Although often misperceived as the reflex application of data from randomized controlled trials into cost-effective medical practice, evidence-based decision making is much more complex. This graphic modeled after work by Dr. Brian Haynes of McMaster University tries to highlight that complexity. •Of course, research evidence does and should play an important role in guiding decisions. However, there are clearly many more important factors at work that can sharply affect the way in which that research evidence is applied in each patient encounter. •This leads us to the second fundamental principle of EBEM (after the hierarchy of evidence) and that is that research evidence alone can never tell you what to do as a clinician. Every decision we take can and should integrate, if relevant, factors related to patient circumstances and preferences, our comfort level and competence in delivering a specific intervention to a patient and an appreciation of resource availability and a global appreciation of cost-effectiveness. •The ability to weigh the evidence (either directly or with the help of a pre-appraised resource or synopsis) and assess and incorporate all of the other factors that pertain to decision-making illustrates the evidence-based perspective of what constitutes clinical expertise. Physician preferences Resource issues SAEM. Evidence Based Medicine Online Course 2005

Tenets of Quality Improvement Evidence-based approaches Proactive rather than reactive approach to errors and inefficiencies Safety is a priority Errors should be made transparent Needs are anticipated- building a high reliability organization Focus improvements within the boundaries of the infrastructure Minimization of wide variations Change should be centered around the needs of patients

SMART Aim Specific Single focus directed at that which you are trying to accomplish Measurable Must have a quantifiable metric Actionable The end point needs to be defined and within the team’s control Relevant/Realistic Is your aim important to your patients, the providers, and the overall goals of the department/hospital Time bound Decide on a time period during which this aim can be accomplished

Quality Improvement Process Aim: Decide what you are trying to accomplish Measures: Determine how to assess whether change would be an improvement Ideas: Determine what changes should be made that will result in an improvement Plan-Do-Study-Act (PDSA) cycle Plan Do Study Act Langley GJ, Nolan KM, Nolan TW, Normal CL, Provost LP. The Improvement Guide. A Practical Approach to Enhancing Organizational Performance. San Francisco, CA: Jossey-Bass Publishers; 1996.

Various Approaches to Determining Which Changes Will Result in Improvement Brainstorming Process mapping Identify key drivers Fishbone Diagrams (Cause and effect diagrams) Evidence-based medicine (review of the literature) Best practices (successful efforts in other units or institutions)

Decide Which Change(s) to Implement Choose ideas for change based on approach used to identify elements most likely to effect outcome Identify leverage points Strategies should be meaningful Change should be important improvement Measurement should be feasible

Quality Improvement Process Aim: Decide what you are trying to accomplish Measures: Determine how to assess whether changes would be an improvement Ideas: Determine what changes should be made that will result in an improvement Plan-Do-Study-Act Plan Do Study Act Langley GJ, Nolan KM, Nolan TW, Normal CL, Provost LP. The Improvement Guide. A Practical Approach to Enhancing Organizational Performance. San Francisco, CA: Jossey-Bass Publishers; 1996.

PDSA Cycle Plan Determine your aim and how you will measure it Decide which change to make and create a plan for implementation (test period) Develop a data collection plan Do Gather data Record observations including unexpected consequences Study Compare results to previous performance Act: Adopt, Adapt, or Abandon Consider need for continued testing Develop a plan for sustainability Plan Do Study Act

Changes that Result in Process Improvement Act Plan Study Do Multiple PDSA cycles can take ideas to improvement Act Plan Study Do Act Plan Study Do Improvement Ideas

Roadmap for Quality Improvement Develop a SMART Aim Identify Key Drivers Observe process Quantify inefficiencies Choose interventions Design a PDSA cycle Implement changes Develop a sustainable plan

Improved Population Health The science Using and innovating best practices QI education and culture change Assuring an excellent patient experience Improved Population Health Evidence Integrated practice via guidelines, order sets and measures The implementation Deployment strategy—Care Process Teams Data/predictive analytics: measuring through meaningful metrics Measurement and analytics

Pediatric Readiness Data and QI Initiatives Katherine Remick, MD Associate Medical Director, Austin-Travis County EMS System Pediatric Emergency Medicine, Dell Children’s Medical Center Faculty, UTSW-Austin, Pediatric Emergency Medicine Fellowship

Disclosure My spouse is a salaried, Manager of Core Labs for transcatheter heart valves at Edwards Lifesciences

Guidelines for Care of Children in the ED Gausche-Hill M, Krug S, and the American Academy of Pediatrics, American College of Emergency Physicians, Emergency Nurses Association Pediatrics 2009; 124(4):1233-43 Recommendations regarding personnel, training, equipment, supplies, medications, support services, quality and process improvement, policies, protocols, and other resources necessary for optimal pediatric care Updated version of 2001 AAP/ACEP joint policy statement Recommendations for patient safety & disaster readiness added Applicable standard for all EDs with 24/7 physician staffing Endorsed by 22 organizations, notable additions: ENA, AAFP, TJC 40

2009 Guidelines for Care of Children in the Emergency Department Administration and Coordination Physicians, Nurses, and Other Healthcare Providers Quality Improvement Patient Safety Policies, Procedures, and Protocols Support Services Equipment, Supplies, and Medications

National Pediatric Readiness Project xxx00.#####.ppt 4/20/2017 8:15:01 PM National Pediatric Readiness Project Based on 2009 Guidelines for Care of Children in the Emergency Department Establish a baseline of the nation’s capacity to provide pediatric emergency care in every 24/7 ED Voluntary, confidential, and web-based National assessment Over 4100 EDs (82.7% response)

National Pediatric Readiness Project xxx00.#####.ppt 4/20/2017 8:15:01 PM National Pediatric Readiness Project Collaborative QI effort for pediatric care in EDs Create a foundation for a QI process based on the 2009 Guidelines Benchmarking to measure improvement over time Immediate feedback Readiness score (compared to similar hospitals) Gap analysis (of strengths and weaknesses)

Assessment Tool 6 Major Sections* 189 Items on the assessment Coordination (19 pts) Staffing (10 pts) QI/PI (7 pts) Safety (14 pts) Policies (17 pts) Equipment (33 points) 189 Items on the assessment 82 Items Scored for “Pediatric Readiness” Perfect Score = 100 *Modified Delphi Process Used

Benchmarking

National Pediatric Readiness Project: Overall Results Key Guidelines Recommendations All EDs   Pediatric QI Process 1867 (45.1%)   Pediatric Disaster Plan 1938 (46.8%)   Interfacility Transfer Guidelines 1952 (50.0%)   Interfacility Transfer Agreements 2595 (66.5%)   Weigh only in Kg 2802 (67.7%) Physician PECC 1966 (47.5%) Nurse PECC 2455 (59.3%)

Using Your Gap Analysis to Identify Opportunities for Improvement Specific deficiencies based on 6 major sections of the 2009 Guidelines Top 3-4 measures most likely to result in enhanced pediatric readiness

Pediatric Readiness Toolkit xxx00.#####.ppt 4/20/2017 Pediatric Readiness Toolkit www.pediatricreadiness.org

Pediatric Quality Improvement in Illinois Evelyn Lyons, RN, MPH EMSC Manager Illinois Department of Public Health

Illinois Demographics Population: 12.9 million 5th most populous state Over 2.7 million <15 y/o 637,000 age <3 y/o 11 EMS Regions Provide infrastructure/oversight for EMS EMSC Trauma Hospital Resources 185 hospitals with Emergency Department’s 110 hospitals (60%) participate in Pediatric Facility Recognition program

Pediatric Facility Recognition Implemented in Illinois in 1998 by the Illinois Department of Public Health (IDPH) Initially voluntary process In 2005, mandatory for EMS System Hospitals Tiered recognition - 110 recognized hospitals (60%) PCCC (Pediatric Critical Care Center) – 10 EDAP (Emergency Department Approved for Pediatrics) – 87 SEDP (Standby Emergency Department Approved for Pediatrics) – 13 Hospital utilization In 2013, ~ 1 million ED visits 0-15 y/o 78% of visits to a designated PCCC, EDAP, SEDP 30,000 visits required inpatient admission 94% admitted to PCCC, EDAP or SEDP

PCCC, EDAP and SEDP Requirements Requirements are outlined in State regulations Facility criteria Physician, Nursing and Mid-Level Practitioner Qualifications Continuing education Coverage, On-call specialists, response times Pediatric policies/procedures and treatment guidelines Interfacility Transfer/Transport Equipment/supplies/medications Pediatric disaster preparedness Pediatric quality improvement

Quality Improvement Requirements Pediatric quality improvement requirements Multidisciplinary Emergency Department QI Committee/process Documented pediatric monitors must minimally address Pediatric ED deaths Pediatric interfacility transfers Child abuse and neglect cases Critically ill/injured children in need of stabilization Pediatric strategic priorities of the institution Pediatric Physician Champion Appointed by ED Medical Director Responsible for oversight, support, review of pediatric quality activities Pediatric Quality Coordinator Job description includes appropriate allocation of time and resources Works with Pediatric Physician Champion Coordinates data collection/review of indicators/monitors Participates in regional pediatric QI meetings and QI activities

Regional Pediatric Quality Improvement Examples of Regional Projects Child Abuse/Neglect Febrile Neonate/Infant Interfacility Transfers Injury Prevention/Safety Equipment Use in the Trauma Patient Pain Management Pediatric Mental Health Pediatric Mild Traumatic Head Injury Pediatric Sepsis Prehospital Seizure Care

Ongoing Oversight Hospital site visits by Illinois Department of Public Health Conducted every 3-4 years Assists in assessing compliance with Facility Recognition requirements Pediatric Physician Champion and Pediatric Quality Coordinator review: Quality organizational structure and reporting mechanisms Integration of pediatrics into quality improvement processes Medical record review of required monitors: Pediatric ED deaths, Interfacility transfers, Child abuse and neglect, Critically ill/injured children Quality improvement documentation undergoes review Monitor tools QI findings/benchmark/trending documentation Loop closure process Multidisciplinary quality meeting minutes Staff meeting minutes

EMSC Facility Recognition Committee Resources State Committee structure EMSC Advisory Board Meets quarterly Provides guidance/oversight Illinois Facility Recognition Committee and Illinois QI Subcommittee Meet every other month Provide oversight to Facility Recognition program Recommend changes to Facility Recognition regulations Responsible for developing quality improvement and educational resources Reports by each of the eleven Regional Chairs on their regional QI activities Can access guidance and direction EMSC Advisory Board EMSC Facility Recognition Committee EMSC QI Subcommittee

Example - Statewide Quality Improvement Project Pediatric Mild Traumatic Head Injury in the Emergency Department Mild head trauma is common CT use increasing with associated risk of radiation induced malignancy State Facility Recognition Committee and QI Committee Multidisciplinary process Literature search Aim Statement IRB approval Plan/Do/Study/Act process Developed/piloted Survey Monitor tool Developed Educational module Educational resources

Statewide Quality Improvement Project Conducted in 2008 and 2009 AIM Statement To provide safe and effective care for pediatric patients (<15 years) presenting to the Emergency Department with mild traumatic head injury (GCS > 14) as evidenced by: Appropriate Assessment Appropriate Management Appropriate Disposition and Discharge Instructions Each year, participating hospitals Completed a survey Conducted 20 medical record reviews of head injured children 10 records of patients who received a CT scan 10 additional records regardless of diagnostic testing

Project Survey Elements Policy/guideline/clinical pathway for traumatic head injury Specifically addresses pediatric patient Includes screening for child maltreatment/neglect Identifies specific criteria to determine need for CT CT scanning practices Presence of in-house CT scanner Typical person responsible for reading CTs (in-house radiology, consultant services, ED physicians) Administrative processes Process in place to address/resolve discrepancies between preliminary and final CT scan findings Availability of neurological services

Project Survey Components (cont’d) Discharge planning Pediatric specific head injury education Process ensuring patient/caregiver understands discharge instructions Quality Improvement Medical record review process in place Severe or moderate head injuries (e.g. GCS <13) Mild head injuries (e.g. GCS 14 or 15) Components assessed in medical review

Project Medical Record Monitor Tool Assessment Vital signs Presence of Scalp abnormality (prior to CT scan) Emesis within last 24 hours Loss of consciousness Other body systems involved Focal neurologic findings/deficits Others Child abuse screening Neurosurgical consultation Reassessment and Discharge Neurological reassessment Disposition Discharge instructions Patient history Age Mode of arrival Time of injury Mechanism of injury Use of safety equipment (as applicable)

PECARN Publication Kuppermann N, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet 2009; 374: 1160-1170. 25 participating EDs Prospective cohort study Analyzed 42,412 children (age 0-17 y/o) presenting to ED within 24 hours of head trauma with GCS scores of 14-15 Aim - identify children at very low risk of clinically-important traumatic brain injuries for whom CT might be unnecessary Provides data to guide clinical decision making for children presenting with head injury. Suggested algorithm for children <2 years and those age 2 and older with GCS score of 14-15.

IL EMSC Educational Module (excerpt) Pediatric Mild Traumatic Head Injury

Patient /Parent Education

Highlights: Survey Response Highlighted findings include: 112 hospitals responded in 2008 99 hospitals responded in 2009 Highlighted findings include: 57% respondents reported taking action (i.e. providing education or revising documentation) as a result of participation in the statewide QI monitor. Over half of hospitals (52%) reported taking action related to their CT scanning practices based on participation in this project. Slight increase in percentage of facilities with a policy, guideline or clinical pathway for traumatic head injury (increase from 28% in 2008 to 31% in 2009) Policies that specifically addressed pediatrics increased from 42% in 2008 to 59% in 2009 Policies that include a process for screening for signs of child maltreatment/neglect increased from 58% in 2008 to 62% in 2009

Medical Record Review Process During a two-year timeframe (2008-2009), over 6800 medical records were reviewed by participating hospitals. 113 participating hospitals in 2008 114 participating hospitals in 2009 Record review focused on infants age 0–23 months and children age 2–15 y/o. Roll-out of the educational module and guidance from PECARN researcher occurred between the 2008 and 2009 data collection cycles.

Highlights: Medical Record Review By the end of the project, notable findings include: Increased awareness of history taking that included documenting: Similar recurrent head injury Scalp abnormality present (prior to CT imaging) Safety equipment usage Neurological reassessment improved Child abuse screening improved significantly between 2008 and 2009 (p<0.0001). Of particular note were increases reported in specific regions (significant improvements p<0.05): Region 1 (36% to 57%) Region 4 (49% to 71%) Region 5 (63% to 73%) Region 8 (52% to 70%) Subsequent analysis of Statewide Emergency Department data Suggests hospital participation in facility recognition was associated with lower head CT usage in the ED

Next Steps Katherine Remick, MD Associate Medical Director, Austin-Travis County EMS System Pediatric Emergency Medicine, Dell Children’s Medical Center Faculty, UTSW-Austin, Pediatric Emergency Medicine Fellowship

Summary: QI lessons learned Components that can benefit from QI efforts Local infrastructure Variation in care Multidisciplinary team approach Pediatric Quality Coordinator Pediatric Physician Champion Combine performance feedback with clinical practice guidelines/education Collaborative and multi-center initiatives Support benchmarking Engage community hospitals Create a larger system of care

Areas of Focus for Quality Improvement in Your ED Family-centered/patient-centered care Cost Patient safety Best practices Efficiency

Top 15 Performance Measures in Pediatric Emergency Care*   System-Based Measures Patient Triage Measurement of weight in kilograms for patients under 18 years of age Method to identify age-based abnormal pediatric vital signs Infrastructure and Personnel Presence of all recommended pediatric equipment in the emergency department Presence of physician and nurse coordinators for pediatric emergency care Patient-Centered Care Patient and/or caregiver understanding of discharge instructions Emergency Department Flow Door-to-Provider time Total length of stay Pain Management Pain assessment and reassessment for children with acute fractures Quality and Safety Number of return visits within 48 hours resulting in hospitalization Medication error rates Disease Specific Measures Trauma Use of head CT in children with minor head trauma Protocol for suspected child maltreatment Respiratory Diseases Administration of systemic steroids for pediatric asthma exacerbations Use of an evidence-based guideline to manage bronchiolitis Infectious Diseases Use of antibiotics in children with suspected viral illness *Based on the work of Alessandrini et al, 2011

The Business of QI: How to be an Effective Liaison Identify a team Hospital/Administrative leadership Technical expertise Day-to-day clinical leadership Regular meetings and updates

Data Extraction Identify a performance measure Data collection planning: Specific data points Sources of information Timeline Standardize the process Decide frequency of data measurement Depends on area of focus

Data Analysis Give validity to the data extraction process Standardized Thorough Sufficient Quantify the impact of your QI efforts Demonstrate improved performance Compare results to initial goals

Performance Management Establish standards within your institution Define specific measures Infrastructure Services Outcomes Measure and report on progress Ongoing QI program

Developing a Message for Leadership Demonstrate the value of the QI process Financial incentives Quality of care Minimize variation Improve overall efficiency and safety Utilize best practices Patient-centered Accreditation Recognition as a regional expert and/or Patient-Centered Medical Home

Improved Population Health The science Using and innovating best practices QI education and culture change Assuring an excellent patient experience Improved Population Health Evidence Integrated practice via guidelines, order sets and measures The implementation Deployment strategy—Care Process Teams Data/predictive analytics: measuring through meaningful metrics Measurement and analytics

Pediatric Readiness Toolkit xxx00.#####.ppt 4/20/2017 Pediatric Readiness Toolkit www.pediatricreadiness.org

Questions and Discussion Time for questions and discussion

CE Evaluation and Certificate Continuing Education guidelines require that the attendance of all who participate be properly documented.  Those who participate and wish to receive continuing education need to attend the activity in its entirety and complete the online evaluation by December 24, 2014. The online link will be available for one week to complete your evaluation. The link to complete your online evaluation is: http://emscnrc.org/Events/Webinar_Evaluation.aspx (Note that you can only gain access to the page by copying and pasting the URL into your browser. ) If you need assistance accessing the online evaluation link, please contact Sametria McCammon (smccammo@childrensnational.org). Your Continuing Education certificate will be automatically generated and emailed to you upon completion of the online evaluation. Again, thank you for participating! Please complete the evaluation using the link above.

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