Paul Sharek MD, MPH

All Publications

• Comparison of Collaborative Versus Single-Site Quality Improvement to Reduce NICU Length of Stay. Pediatrics Lee, H. C., Bennett, M. V., Crockett, M., Crowe, R., Gwiazdowski, S. G., Keller, H., Kurtin, P., Kuzniewicz, M., Mazzeo, A. M., Schulman, J., Nisbet, C. C., Sharek, P. J. 2018

  Abstract

  There is unexplained variation in length of stay (LOS) across NICUs, suggesting that there may be practices that can optimize LOS.Three groups of NICUs in the California Perinatal Quality Care Collaborative were followed: (1) collaborative centers participating in an 18-month collaborative quality improvement project to optimize LOS for preterm infants; (2) individual centers aiming to optimize LOS; and (3) nonparticipants. Our aim in the collaborative project was to decrease postmenstrual age (PMA) at discharge for infants born between 27 + 0 and <32 weeks' gestational age by 3 days. A secondary outcome was "early discharge," the proportion of infants discharged from the hospital before 36 + 5 weeks' PMA. The balancing measure of readmissions within 72 hours was tracked for the collaborative group.From 2013 to 2015, 8917 infants were cared for in 20 collaborative NICUs, 19 individual project NICUs, and 71 nonparticipants. In the collaborative group, the PMA at discharge decreased from 37.8 to 37.5 weeks (P = .02), and early discharge increased from 31.6% to 41.9% (P = .006). The individual project group had no significant change. Nonparticipants had a decrease in PMA from 37.5 to 37.3 weeks (P = .01) but no significant change in early discharge (39.8% to 43.6%; P = .24). There was no significant change in readmissions over time in the collaborative group.A structured collaborative project that was focused on optimizing LOS led to a 3-day decrease in LOS and was more effective than individualized quality improvement efforts.

  View details for DOI 10.1542/peds.2017-1395

  View details for PubMedID 29899043

• Children's Hospitals' Solutions for Patient Safety Collaborative Impact on Hospital-Acquired Harm PEDIATRICS Lyren, A., Brilli, R. J., Zieker, K., Marino, M., Muething, S., Sharek, P. J. 2017; 140 (3)

  View details for DOI 10.1542/peds.2016-3494

  View details for Web of Science ID 000408820300007

• Development of an Electronic Pediatric All-Cause Harm Measurement Tool Using a Modified Delphi Method JOURNAL OF PATIENT SAFETY Stockwell, D. C., Bisarya, H., Classen, D. C., Kirkendall, E. S., Lachman, P. I., Matlow, A. G., Tham, E., Hyman, D., Lehman, S. M., Searles, E., Muething, S. E., Sharek, P. J. 2016; 12 (4): 180-189

  Abstract

  To have impact on reducing harm in pediatric inpatients, an efficient and reliable process for harm detection is needed. This work describes the first step toward the development of a pediatric all-cause harm measurement tool by recognized experts in the field.An international group of leaders in pediatric patient safety and informatics were charged with developing a comprehensive pediatric inpatient all-cause harm measurement tool using a modified Delphi technique. The process was conducted in 5 distinct steps: (1) literature review of triggers (elements from a medical record that assist in identifying patient harm) for inclusion; (2) translation of triggers to likely associated harm, improving the ability for expert prioritization; (3) 2 applications of a modified Delphi selection approach with consensus criteria using severity and frequency of harm as well as detectability of the associated trigger as criteria to rate each trigger and associated harm; (4) developing specific trigger logic and relevant values when applicable; and (5) final vetting of the entire trigger list for pilot testing.Literature and expert panel review identified 108 triggers and associated harms suitable for consideration (steps 1 and 2). This list was pared to 64 triggers and their associated harms after the first of the 2 independent expert reviews. The second independent expert review led to further refinement of the trigger package, resulting in 46 items for inclusion (step 3). Adding in specific trigger logic expanded the list. Final review and voting resulted in a list of 51 triggers (steps 4 and 5).Application of a modified Delphi method on an expert-constructed list of 108 triggers, focusing on severity and frequency of harms as well as detectability of triggers in an electronic medical record, resulted in a final list of 51 pediatric triggers. Pilot testing this list of pediatric triggers to identify all-cause harm for pediatric inpatients is the next step to establish the appropriateness of each trigger for inclusion in a global pediatric safety measurement tool.

  View details for DOI 10.1097/PTS.0000000000000139

  View details for Web of Science ID 000388948000002

  View details for PubMedID 25162206

• A Trigger Tool to Detect Harm in Pediatric Inpatient Settings PEDIATRICS Stockwell, D. C., Bisarya, H., Classen, D. C., Kirkendall, E. S., Landrigan, C. P., Lemon, V., Tham, E., Hyman, D., Lehman, S. M., Searles, E., Hall, M., Muething, S. E., Schuster, M. A., Sharek, P. J. 2015; 135 (6): 1036-1042

  Abstract

  An efficient and reliable process for measuring harm due to medical care is needed to advance pediatric patient safety. Several pediatric studies have assessed the use of trigger tools in varying inpatient environments. Using the Institute for Healthcare Improvement's adult-focused Global Trigger Tool as a model, we developed and pilot tested a trigger tool that would identify the most common causes of harm in pediatric inpatient environments.After formal training, 6 academic children's hospitals used this novel pediatric trigger tool to review 100 randomly selected inpatient records per site from patients discharged during the month of February 2012.From the 600 patient charts evaluated, 240 harmful events ("harms") were identified, resulting in a rate of 40 harms per 100 patients admitted and 54.9 harms per 1000 patient days across the 6 hospitals. At least 1 harm was identified in 146 patients (24.3% of patients). Of the 240 total events, 108 (45.0%) were assessed to have been potentially or definitely preventable. The most common patient harms were intravenous catheter infiltrations/burns, respiratory distress, constipation, pain, and surgical complications.Consistent with earlier rates of all-cause harm in adult hospitals, harm occurs at high rates in hospitalized children. Availability and use of an all-cause harm identification tool will establish the epidemiology of harm and will provide a consistent approach to assessing the effect of interventions on harms in hospitalized children.

  View details for DOI 10.1542/peds.2014-2152

  View details for Web of Science ID 000355557400041

  View details for PubMedID 25986015

• Decreasing Handoff-Related Care Failures in Children's Hospitals. Pediatrics Bigham, M. T., Logsdon, T. R., Manicone, P. E., Landrigan, C. P., Hayes, L. W., Randall, K. H., Grover, P., Collins, S. B., Ramirez, D. E., O'Guin, C. D., Williams, C. I., Warnick, R. J., Sharek, P. J. 2014; 134 (2): e572-9

  Abstract

  Patient handoffs in health care require transfer of information, responsibility, and authority between providers. Suboptimal patient handoffs pose a serious safety risk. Studies demonstrating the impact of improved patient handoffs on care failures are lacking. The primary objective of this study was to evaluate the effect of a multihospital collaborative designed to decrease handoff-related care failures.Twenty-three children's hospitals participated in a quality improvement collaborative aimed at reducing handoff-related care failures. The improvement was guided by evidence-based recommendations regarding handoff intent and content, standardized handoff tools/methods, and clear transition of responsibility. Hospitals tailored handoff elements to locally important handoff types. Handoff-related care failures were compared between baseline and 3 intervention periods. Secondary outcomes measured compliance to specific change package elements and balancing measure of staff satisfaction.Twenty-three children's hospitals evaluated 7864 handoffs over the 12-month study period. Handoff-related care failures decreased from baseline (25.8%) to the final intervention period (7.9%) (P < .05). Significant improvement was observed in every handoff type studied. Compliance to change package elements improved (achieving a common understanding about the patient from 86% to 96% [P < .05]; clear transition of responsibility from 92% to 96% [P < .05]; and minimized interruptions and distractions from 84% to 90% [P < .05]) as did overall satisfaction with the handoff (from 55% to 70% [P < .05]).Implementation of a standardized evidence-based handoff process across 23 children's hospitals resulted in a significant decrease in handoff-related care failures, observed over all handoff types. Compliance to critical components of the handoff process improved, as did provider satisfaction.

  View details for DOI 10.1542/peds.2013-1844

  View details for PubMedID 25002665

• Performance Characteristics of a Methodology to Quantify Adverse Events over Time in Hospitalized Patients HEALTH SERVICES RESEARCH Sharek, P. J., Parry, G., Goldmann, D., Bones, K., Hackbarth, A., Resar, R., Griffin, F. A., Rhoda, D., Murphy, C., Landrigan, C. P. 2011; 46 (2): 654-678

  Abstract

  To assess the performance characteristics of the Institute for Healthcare Improvement Global Trigger Tool (GTT) to determine its reliability for tracking local and national adverse event rates.Primary data from 2008 chart reviews.A retrospective study in a stratified random sample of 10 North Carolina hospitals. Hospital-based (internal) and contract research organization-hired (external) reviewers used the GTT to identify adverse events in the same 10 randomly selected medical records per hospital in each quarter from January 2002 through December 2007.Interrater and intrarater reliability was assessed using κ statistics on 10 percent and 5 percent, respectively, of selected medical records. Additionally, experienced GTT users reviewed 10 percent of records to calculate internal and external teams' sensitivity and specificity.Eighty-eight to 98 percent of the targeted 2,400 medical records were reviewed. The reliability of the GTT to detect the presence, number, and severity of adverse events varied from κ=0.40 to 0.60. When compared with a team of experienced reviewers, the internal teams' sensitivity (49 percent) and specificity (94 percent) exceeded the external teams' (34 and 93 percent), as did their performance on all other metrics.The high specificity, moderate sensitivity, and favorable interrater and intrarater reliability of the GTT make it appropriate for tracking local and national adverse event rates. The strong performance of hospital-based reviewers supports their use in future studies.

  View details for DOI 10.1111/j.1475-6773.2010.01156.x

  View details for Web of Science ID 000287965600017

  View details for PubMedID 20722749

  View details for PubMedCentralID PMC3064924

• Temporal Trends in Rates of Patient Harm Resulting from Medical Care. NEW ENGLAND JOURNAL OF MEDICINE Landrigan, C. P., Parry, G. J., Bones, C. B., Hackbarth, A. D., Goldmann, D. A., Sharek, P. J. 2010; 363 (22): 2124-2134

  Abstract

  In the 10 years since publication of the Institute of Medicine's report To Err Is Human, extensive efforts have been undertaken to improve patient safety. The success of these efforts remains unclear.We conducted a retrospective study of a stratified random sample of 10 hospitals in North Carolina. A total of 100 admissions per quarter from January 2002 through December 2007 were reviewed in random order by teams of nurse reviewers both within the hospitals (internal reviewers) and outside the hospitals (external reviewers) with the use of the Institute for Healthcare Improvement's Global Trigger Tool for Measuring Adverse Events. Suspected harms that were identified on initial review were evaluated by two independent physician reviewers. We evaluated changes in the rates of harm, using a random-effects Poisson regression model with adjustment for hospital-level clustering, demographic characteristics of patients, hospital service, and high-risk conditions.Among 2341 admissions, internal reviewers identified 588 harms (25.1 harms per 100 admissions; 95% confidence interval [CI], 23.1 to 27.2) [corrected]. Multivariate analyses of harms identified by internal reviewers showed no significant changes in the overall rate of harms per 1000 patient-days (reduction factor, 0.99 per year; 95% CI, 0.94 to 1.04; P=0.61) or the rate of preventable harms. There was a reduction in preventable harms identified by external reviewers that did not reach statistical significance (reduction factor, 0.92; 95% CI, 0.85 to 1.00; P=0.06), with no significant change in the overall rate of harms (reduction factor, 0.98; 95% CI, 0.93 to 1.04; P=0.47).In a study of 10 North Carolina hospitals, we found that harms remain common, with little evidence of widespread improvement. Further efforts are needed to translate effective safety interventions into routine practice and to monitor health care safety over time. (Funded by the Rx Foundation.).

  View details for Web of Science ID 000284587800007

  View details for PubMedID 21105794

• Prevalence of adverse events in pediatric intensive care units in the United States PEDIATRIC CRITICAL CARE MEDICINE Agarwal, S., Classen, D., Larsen, G., Tofil, N. M., Hayes, L. W., Sullivan, J. E., Storgion, S. A., Coopes, B. J., Craig, V., Jaderlund, C., Bisarya, H., Parast, L., Sharek, P. 2010; 11 (5): 568-578

  Abstract

  Selection of relevant patient safety interventions for the pediatric intensive care (PICU) requires identification of the types and severity of adverse events (AEs) and adverse drug events (ADEs) that occur in this setting. The study's objectives were to: 1) determine the rates of AEs/ADEs, including types, severity, and preventability, in PICU patients; 2) identify population characteristics associated with increased risk of AEs/ADEs; 3) develop and test a PICU specific trigger tool to facilitate identification of AEs/ADEs.Retrospective, cross-sectional, randomized review of 734 patient records who were discharged from 15 U.S. PICUs between September and December 2005.A novel PICU-focused trigger tool for AE/ADE detection.Sixty-two percent of PICU patients had at least one AE. A total of 1488 AEs, including 256 ADEs, were identified. This translates to a rate of 28.6 AEs and 4.9 ADEs per 100 patient-days. The most common types of AEs were catheter complications, uncontrolled pain, and endotracheal tube malposition. Ten percent of AEs were classified as life-threatening or permanent; 45% were deemed preventable. Higher adjusted rates of AEs were found in surgical patients (p = .02), patients intubated at some point during their PICU stay (p = .002), and patients who died (p < .001). Surgical patients had higher preventable adjusted AE (p = .01) and ADE rates (p = .02). The adjusted cumulative risk of an AE per PICU day was 5.3% and 1.6% for an ADE alone. There was a 4% increase in adjusted ADEs rates for every year increase in age.AEs and ADEs occur frequently in the PICU setting. These data provide areas of focus for evidence-based prevention strategies to decrease the substantial risk to this vulnerable pediatric population.

  View details for DOI 10.1097/PCC.0b013e3181d8e405

  View details for Web of Science ID 000281629300004

  View details for PubMedID 20308932

• Decrease in Hospital-wide Mortality Rate After Implementation of a Commercially Sold Computerized Physician Order Entry System PEDIATRICS Longhurst, C. A., Parast, L., Sandborg, C. I., Widen, E., Sullivan, J., Hahn, J. S., Dawes, C. G., Sharek, P. J. 2010; 126 (1): 14-21

  Abstract

  Implementations of computerized physician order entry (CPOE) systems have previously been associated with either an increase or no change in hospital-wide mortality rates of inpatients. Despite widespread enthusiasm for CPOE as a tool to help transform quality and patient safety, no published studies to date have associated CPOE implementation with significant reductions in hospital-wide mortality rates.The objective of this study was to determine the effect on the hospital-wide mortality rate after implementation of CPOE at an academic children's hospital.We performed a cohort study with historical controls at a 303-bed, freestanding, quaternary care academic children's hospital. All nonobstetric inpatients admitted between January 1, 2001, and April 30, 2009, were included. A total of 80,063 patient discharges were evaluated before the intervention (before November 1, 2007), and 17,432 patient discharges were evaluated after the intervention (on or after November 1, 2007). On November 4, 2007, the hospital implemented locally modified functionality within a commercially sold electronic medical record to support CPOE and electronic nursing documentation.After CPOE implementation, the mean monthly adjusted mortality rate decreased by 20% (1.008-0.716 deaths per 100 discharges per month unadjusted [95% confidence interval: 0.8%-40%]; P = .03). With observed versus expected mortality-rate estimates, these data suggest that our CPOE implementation could have resulted in 36 fewer deaths over the 18-month postimplementation time frame.Implementation of a locally modified, commercially sold CPOE system was associated with a statistically significant reduction in the hospital-wide mortality rate at a quaternary care academic children's hospital.

  View details for DOI 10.1542/peds.2009-3271

  View details for Web of Science ID 000279431000003

  View details for PubMedID 20439590

• Development, testing, and findings of a pediatric-focused trigger tool to identify medication-related harm in US children's hospitals PEDIATRICS Takata, G. S., Mason, W., Taketomo, C., Logsdon, T., Sharek, P. J. 2008; 121 (4): E927-E935

  Abstract

  The purposes of this study were to develop a pediatric-focused tool for adverse drug event detection and describe the incidence and characteristics of adverse drug events in children's hospitals identified by this tool.A pediatric-specific trigger tool for adverse drug event detection was developed and tested. Eighty patients from each site were randomly selected for retrospective chart review. All adverse drug events identified using the trigger tool were evaluated for severity, preventability, ability to mitigate, ability to identify the event earlier, and presence of associated occurrence report. Each trigger and the entire tool were evaluated for positive predictive value.Review of 960 randomly selected charts from 12 children's hospitals revealed 2388 triggers (2.49 per patient) and 107 unique adverse drug events. Mean adverse drug event rates were 11.1 per 100 patients, 15.7 per 1000 patient-days, and 1.23 per 1000 medication doses. The positive predictive value of the trigger tool was 3.7%. Twenty-two percent of all adverse drug events were deemed preventable, 17.8% could have been identified earlier, and 16.8% could have been mitigated more effectively. Ninety-seven percent of the identified adverse drug events resulted in mild, temporary harm. Only 3.7% of adverse drug events were identified in existing hospital-based occurrence reports. The most common adverse drug events identified were pruritus and nausea, the most common medication classes causing adverse drug events were opioid analgesics and antibiotics, and the most common stages of the medication management process associated with preventable adverse drug events were monitoring and prescribing/ordering.Adverse drug event rates in hospitalized children are substantially higher than previously described. Most adverse drug events resulted in temporary harm, and 22% were classified as preventable. Only 3.7% were identified by using traditional voluntary reporting methods. Our pediatric-focused trigger tool is effective at identifying adverse drug events in inpatient pediatric populations.

  View details for DOI 10.1542/peds.2007-1779

  View details for Web of Science ID 000254576800073

  View details for PubMedID 18381521

• Effect of a rapid response team on hospital-wide mortality and code rates outside the ICU in a children's hospital JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Sharek, P. J., Parast, L. M., Leong, K., Coombs, J., Earnest, K., Sullivan, J., Frankel, L. R., Roth, S. J. 2007; 298 (19): 2267-2274

  Abstract

  Introduction of a rapid response team (RRT) has been shown to decrease mortality and cardiopulmonary arrests outside of the intensive care unit (ICU) in adult inpatients. No published studies to date show significant reductions in mortality or cardiopulmonary arrests in pediatric inpatients.To determine the effect on hospital-wide mortality rates and code rates outside of the ICU setting after RRT implementation at an academic children's hospital.A cohort study design with historical controls at a 264-bed, free-standing, quaternary care academic children's hospital. Pediatric inpatients who spent at least 1 day on a medical or surgical ward between January 1, 2001, and March 31, 2007, were included. A total of 22,037 patient admissions and 102,537 patient-days were evaluated preintervention (before September 1, 2005), and 7257 patient admissions and 34,420 patient-days were evaluated postintervention (on or after September 1, 2005).The RRT included a pediatric ICU-trained fellow or attending physician, ICU nurse, ICU respiratory therapist, and nursing supervisor. This team was activated using standard criteria and was available at all times to assess, treat, and triage decompensating pediatric inpatients.Hospital-wide mortality rates and code (respiratory and cardiopulmonary arrests) rates outside of the ICU setting. All outcomes were adjusted for case mix index values.After RRT implementation, the mean monthly mortality rate decreased by 18% (1.01 to 0.83 deaths per 100 discharges; 95% confidence interval [CI], 5%-30%; P = .007), the mean monthly code rate per 1000 admissions decreased by 71.7% (2.45 to 0.69 codes per 1000 admissions), and the mean monthly code rate per 1000 patient-days decreased by 71.2% (0.52 to 0.15 codes per 1000 patient-days). The estimated code rate per 1000 admissions for the postintervention group was 0.29 times that for the preintervention group (95% likelihood ratio CI, 0.10-0.65; P = .008), and the estimated code rate per 1000 patient-days for the postintervention group was 0.28 times that for the preintervention group (95% likelihood ratio CI, 0.10-0.64; P = .007).Implementation of an RRT was associated with a statistically significant reduction in hospital-wide mortality rate and code rate outside of the pediatric ICU setting.

  View details for Web of Science ID 000251055900026

  View details for PubMedID 18029830

• Adverse events in the neonatal intensive care unit: Development, testing, and findings of an NICU-focused trigger tool to identify harm in North American NICUs PEDIATRICS Sharek, P. J., Horbar, J. D., Mason, W., Bisarya, H., Thurm, C. W., Suresh, G., Gray, J. E., Edwards, W. H., Goldmann, D., Classen, D. 2006; 118 (4): 1332-1340

  Abstract

  Currently there are few practical methods to identify and measure harm to hospitalized children. Patients in NICUs are at high risk and warrant a detailed assessment of harm to guide patient safety efforts. The purpose of this work was to develop a NICU-focused tool for adverse event detection and to describe the incidence of adverse events in NICUs identified by this tool.A NICU-focused trigger tool for adverse event detection was developed and tested. Fifty patients from each site with a minimum 2-day NICU stay were randomly selected. All adverse events identified using the trigger tool were evaluated for severity, preventability, ability to mitigate, ability to identify the event earlier, and presence of associated occurrence report. Each trigger, and the entire tool, was evaluated for positive predictive value. Study chart reviewers, in aggregate, identified 88.0% of all potential triggers and 92.4% of all potential adverse events.Review of 749 randomly selected charts from 15 NICUs revealed 2218 triggers or 2.96 per patient, and 554 unique adverse events or 0.74 per patient. The positive predictive value of the trigger tool was 0.38. Adverse event rates were higher for patients <28 weeks' gestation and <1500 g birth weight. Fifty-six percent of all adverse events were deemed preventable; 16% could have been identified earlier, and 6% could have been mitigated more effectively. Only 8% of adverse events were identified in existing hospital-based occurrence reports. The most common adverse events identified were nosocomial infections, catheter infiltrates, and abnormal cranial imaging.Adverse event rates in the NICU setting are substantially higher than previously described. Many adverse events resulted in permanent harm and the majority were classified as preventable. Only 8% were identified using traditional voluntary reporting methods. Our NICU-focused trigger tool appears efficient and effective at identifying adverse events.

  View details for DOI 10.1542/peds.2006-0565

  View details for Web of Science ID 000240959300002

  View details for PubMedID 17015521

• Adverse Events in Hospitalized Pediatric Patients PEDIATRICS Stockwell, D. C., Landrigan, C. P., Toomey, S. L., Loren, S. S., Jang, J., Quinn, J. A., Ashrafzadeh, S., Wang, M. J., Wu, M., Sharek, P. J., Classen, D. C., Srivastava, R., Parry, G., Schuster, M. A., GAPPS Study Grp 2018; 142 (2)

  Abstract

  : media-1vid110.1542/5789657761001PEDS-VA_2017-3360Video Abstract BACKGROUND: Patient safety concerns over the past 2 decades have prompted widespread efforts to reduce adverse events (AEs). It is unclear whether these efforts have resulted in reductions in hospital-wide AE rates. We used a validated safety surveillance tool, the Global Assessment of Pediatric Patient Safety, to measure temporal trends (2007-2012) in AE rates among hospitalized children.We conducted a retrospective surveillance study of randomly selected pediatric inpatient records from 16 teaching and nonteaching hospitals. We constructed Poisson regression models with hospital random intercepts, controlling for patient age, sex, insurance, and chronic conditions, to estimate changes in AE rates over time.Examining 3790 records, reviewers identified 414 AEs (19.1 AEs per 1000 patient days; 95% confidence interval [CI] 17.2-20.9) and 210 preventable AEs (9.5 AEs per 1000 patient days; 95% CI 8.2-10.8). On average, teaching hospitals had higher AE rates than nonteaching hospitals (26.2 [95% CI 23.7-29.0] vs 5.1 [95% CI 3.7-7.1] AEs per 1000 patient days, P < .001). Chronically ill children had higher AE rates than patients without chronic conditions (33.9 [95% CI 24.5-47.0] vs 14.0 [95% CI 11.8-16.5] AEs per 1000 patient days, P < .001). Multivariate analyses revealed no significant changes in AE rates over time. When stratified by hospital type, neither teaching nor nonteaching hospitals experienced significant temporal AE rate variations.AE rates in pediatric inpatients are high and did not improve from 2007 to 2012. Pediatric AE rates were substantially higher in teaching hospitals as well as in patients with more chronic conditions.

  View details for DOI 10.1542/peds.2017-3360

  View details for Web of Science ID 000440459900012

  View details for PubMedID 30006445

• Diagnostic errors in paediatric cardiac intensive care CARDIOLOGY IN THE YOUNG Bhat, P. N., Costello, J. M., Aiyagari, R., Sharek, P. J., Algaze, C. A., Mazwi, M. L., Roth, S. J., Shin, A. Y. 2018; 28 (5): 675–82

  Abstract

  IntroductionDiagnostic errors cause significant patient harm and increase costs. Data characterising such errors in the paediatric cardiac intensive care population are limited. We sought to understand the perceived frequency and types of diagnostic errors in the paediatric cardiac ICU.Paediatric cardiac ICU practitioners including attending and trainee physicians, nurse practitioners, physician assistants, and registered nurses at three North American tertiary cardiac centres were surveyed between October 2014 and January 2015.The response rate was 46% (N=200). Most respondents (81%) perceived that diagnostic errors harm patients more than five times per year. More than half (65%) reported that errors permanently harm patients, and up to 18% perceived that diagnostic errors contributed to death or severe permanent harm more than five times per year. Medication side effects and psychiatric conditions were thought to be most commonly misdiagnosed. Physician groups also ranked pulmonary overcirculation and viral illness to be commonly misdiagnosed as bacterial illness. Inadequate care coordination, data assessment, and high clinician workload were cited as contributory factors. Delayed diagnostic studies and interventions related to the severity of the patient's condition were thought to be the most commonly reported process breakdowns. All surveyed groups ranked improving teamwork and feedback pathways as strategies to explore for preventing future diagnostic errors.Paediatric cardiac intensive care practitioners perceive that diagnostic errors causing permanent harm are common and associated more with systematic and process breakdowns than with cognitive limitations.

  View details for DOI 10.1017/S1047951117002906

  View details for Web of Science ID 000433542200008

  View details for PubMedID 29409553

• Changing the game for hand hygiene conversations Hospital Pediatrics Schwartz, R., Sharek, P. J. 2018; 8 (3): 168-169

  View details for DOI 10.1542/hpeds.2017-0205

• Improving Satisfaction with Pediatric Pain Management by Inviting the Conversation. Joint Commission journal on quality and patient safety Caruso, T. J., Kung, T. H., Good, J., Taylor, K., Ashland, M., Cunningham, C., Gonzalez, E., Wood, M., Sharek, P. 2018; 44 (4): 227–32

  Abstract

  Patient satisfaction with pain management is associated with improved patient adherence to medical management and efficient service utilization. Pediatric pain control is challenging, given the inability to elicit reliable histories, particularly in younger patients. Several studies have suggested that communication surrounding pain management can improve satisfaction, although there are limited data describing structured interventions with measurable outcomes. A quality improvement project was conducted to determine if reliably asking families about pain management was associated with improved patient satisfaction with pain management.In an academic pediatric hospital, nurse manager rounds were used to invite a conversation about pain management. The question, "Pain management is very important to us. Has your child's pain been well controlled?" was added to the established standard questions asked during nurse manager rounds. Effectiveness was measured using the preexisting Press Ganey survey question, "How well was your child's pain controlled?" Responses were compared between those patients who were and were not exposed to the rounding question.Data for 1,032 patients were used to establish baseline satisfaction with pain management scores. In the intervention period, 328 patients received nurse manager rounds and 121 did not. The median of the weighted mean patient survey satisfaction scores were baseline, 91.5%; receiving intervention, 94.2%; and not receiving intervention, 90.0%. Patients who received the intervention reported higher satisfaction with pain management than those who did not (p <0.0001).Hospitals seeking to improve satisfaction with pain management should encourage health care providers to reliably discuss pain control with pediatric patients.

  View details for DOI 10.1016/j.jcjq.2017.10.003

  View details for PubMedID 29579448

• Inpatient-Derived Vital Sign Parameters Implementation: An Initiative to Decrease Alarm Burden. Pediatrics Kipps, A. K., Poole, S. F., Slaney, C., Feehan, S., Longhurst, C. A., Sharek, P. J., Goel, V. V. 2017; 140 (2)

  Abstract

  OBJECTIVES: To implement data-driven vital sign parameters to reduce bedside monitor alarm burden.METHODS: Single-center, quality-improvement initiative with historical controls assessing the impact of age-based, inpatient-derived heart rate (HR) and respiratory rate (RR) parameters on a 20-bed acute care ward that serves primarily pediatric cardiology patients. The primary outcome was the number of alarms per monitored bed day (MBD) with the aim to decrease the alarms per MBD. Balancing measures included the frequency of missed rapid response team activations, acute respiratory code events, and cardiorespiratory arrest events in the unit with the new vital sign parameters.RESULTS: The median number of all cardiorespiratory monitor alarms per MBD decreased by 21% from 52 (baseline period) to 41 (postintervention period) (P < .001). This included a 17% decrease in the median HR alarms (9-7.5 per MBD) and a 53% drop in RR alarms (16.8-8.0 per MBD). There were 57 rapid response team activations, 8 acute respiratory code events, and no cardiorespiratory arrest events after the implementation of the new parameters. An evaluation of HRs and RRs recorded at the time of the event revealed that all patients with HRs and/or RRs out of range per former default parameters would also be out of range with the new parameters.CONCLUSIONS: Implementation of data-driven HR and iteratively derived RR parameters safely decreased the total alarm frequency by 21% in a pediatric acute care unit.

  View details for DOI 10.1542/peds.2016-2458

  View details for PubMedID 28687637

• A quality improvement initiative to optimize dosing of surgical antimicrobial prophylaxis. Paediatric anaesthesia Caruso, T. J., Wang, E., Schwenk, H. T., Scheinker, D., Yeverino, C., Tweedy, M., Maheru, M., Sharek, P. J. 2017; 27 (7): 702-710

  Abstract

  The risk of surgical site infections is reduced with appropriate timing and dosing of preoperative antimicrobials. Based on evolving national guidelines, we increased the preoperative dose of cefazolin from 25 to 30 mg·kg(-1) . This quality improvement project describes an improvement initiative to develop standard work processes to ensure appropriate dosing.The primary aim was to deliver cefazolin 30 mg·kg(-1) to at least 90% of indicated patients. The secondary aim was to determine differences between accuracy of cefazolin doses when given as an electronic order compared to a verbal order.Data were collected from January 1, 2012 to May 31, 2016. A quality improvement team of perioperative physicians, nurses, and pharmacists implemented a series of interventions including new electronic medical record order sets, personal provider antibiotic dose badges, and utilization of pharmacists to prepare antibiotics to increase compliance with the recommended dose. Process compliance was measured using a statistical process control chart, and dose compliance was measured through electronic analysis of the electronic medical record. Secondary aim data were displayed as percentage of dose compliance. An unpaired t-test was used to determine differences between groups.Between January 1, 2012 and May 31, 2016, cefazolin was administered to 9086 patients. The mean compliance of cefazolin at 30 mg·kg(-1) from May 2013 to March 2014 was 40%, which prompted initiation of this project. From April 2014 to May 2016, a series of interventions were deployed. The mean compliance from September 2015 to May 2016 was 93% with significantly reduced variation and no special cause variation, indicating that the process was in control at the target primary aim. There were 649 cefazolin administrations given verbally and 1929 given with an electronic order between October 1, 2014 and May 31, 2016. During this time period, the rate of compliance of administering cefazolin at 30 mg·kg(-1) was significantly higher when given after an electronic order than when given verbally, 94% vs 76%.This comprehensive quality improvement project improved practitioner compliance with evidence-based preoperative antimicrobial dosing recommendations to reduce the risk of surgical site infections.

  View details for DOI 10.1111/pan.13137

  View details for PubMedID 28321988

• Standardized ICU to OR handoff increases communication without delaying surgery. International journal of health care quality assurance Caruso, T. J., Marquez, J. L., Gipp, M. S., Kelleher, S. P., Sharek, P. J. 2017; 30 (4): 304-311

  Abstract

  Purpose No studies have examined preoperative handoffs from the intensive care unit (ICU) to OR. Given the risk of patient harm, the authors developed a standardized ICU to OR handoff using a previously published handoff model. The purpose of this paper is to determine whether a standardized ICU to OR handoff process would increase the number of team handoffs and improve patient transport readiness. Design/methodology/approach The intervention consisted of designing a multidisciplinary, face-to-face handoff between sending ICU providers and receiving anesthesiologist and OR nurse, verbally presented in the I-PASS format. Anticipatory calls from the OR nurse to the ICU nurse were made to prepare the patient for transport. Data collected included frequency of handoff, patient transport readiness, turnover time between OR cases, and anesthesia provider satisfaction. Findings In total, 57 audits were completed. The frequency of handoffs increased from 25 to 86 percent ( p<0.0001) and the frequency of patient readiness increased from 61 to 97 percent ( p=0.001). There were no changes in timeliness of first start cases and no significant change in turnover times between cases. Anesthesia provider satisfaction scores increased significantly. Practical implications A standardized, team based ICU to OR handoff increased the frequency of face-to-face handoffs, patient readiness and anesthesia provider satisfaction within increasing turnover between cases. Originality/value Although studies have identified the transition of patients from the ICU to the OR as a period of increased harm, the development of a preoperative ICU to OR handoff had not been described. This intervention may be used in other institutions to design ICU to OR transitions of care.

  View details for DOI 10.1108/IJHCQA-02-2016-0015

  View details for PubMedID 28470134

• Factors Associated With Provider Burnout in the NICU PEDIATRICS Tawfik, D. S., Phibbs, C. S., Sexton, J. B., Kan, P., Sharek, P. J., Nisbet, C. C., Rigdon, J., Trockel, M., Profit, J. 2017; 139 (5)

  Abstract

  NICUs vary greatly in patient acuity and volume and represent a wide array of organizational structures, but the effect of these differences on NICU providers is unknown. This study sought to test the relation between provider burnout prevalence and organizational factors in California NICUs.Provider perceptions of burnout were obtained from 1934 nurse practitioners, physicians, registered nurses, and respiratory therapists in 41 California NICUs via a validated 4-item questionnaire based on the Maslach Burnout Inventory. The relations between burnout and organizational factors of each NICU were evaluated via t-test comparison of quartiles, univariable regression, and multivariable regression.Overall burnout prevalence was 26.7% ± 9.8%. Highest burnout prevalence was found among NICUs with higher average daily admissions (32.1% ± 6.4% vs 17.2% ± 6.7%, P < .001), higher average occupancy (28.1% ± 8.1% vs 19.9% ± 8.4%, P = .02), and those with electronic health records (28% ± 11% vs 18% ± 7%, P = .03). In sensitivity analysis, nursing burnout was more sensitive to organizational differences than physician burnout in multivariable modeling, significantly associated with average daily admissions, late transfer proportion, nursing hours per patient day, and mortality per 1000 infants. Burnout prevalence showed no association with proportion of high-risk patients, teaching hospital distinction, or in-house attending presence.Burnout is most prevalent in NICUs with high patient volume and electronic health records and may affect nurses disproportionately. Interventions to reduce burnout prevalence may be of greater importance in NICUs with ≥10 weekly admissions.

  View details for DOI 10.1542/peds.2016-4134

  View details for Web of Science ID 000400371500040

  View details for PubMedID 28557756

• Teamwork in the NICU Setting and Its Association with Health Care-Associated Infections in Very Low-Birth-Weight Infants. American journal of perinatology Profit, J., Sharek, P. J., Kan, P., Rigdon, J., Desai, M., Nisbet, C. C., Tawfik, D. S., Thomas, E. J., Lee, H. C., Sexton, J. B. 2017

  Abstract

  Background and Objective Teamwork may affect clinical care in the neonatal intensive care unit (NICU) setting. The objective of this study was to assess teamwork climate across NICUs and to test scale-level and item-level associations with health care-associated infection (HAI) rates in very low-birth-weight (VLBW) infants. Methods Cross-sectional study of the association between HAI rates, defined as any bacterial or fungal infection during the birth hospitalization, among 6,663 VLBW infants cared for in 44 NICUs between 2010 and 2012. NICU HAI rates were correlated with teamwork climate ratings obtained in 2011 from 2,073 of 3,294 eligible NICU health professionals (response rate 63%). The relation between HAI rates and NICU teamwork climate was assessed using logistic regression models including NICU as a random effect. Results Across NICUs, 36 to 100% (mean 66%) of respondents reported good teamwork. HAI rates were significantly and independently associated with teamwork climate (odds ratio, 0.82; 95% confidence interval, 0.73-0.92, p = 0.005), such that the odds of an infant contracting a HAI decreased by 18% with each 10% rise in NICU respondents reporting good teamwork. Conclusion Improving teamwork may be an important element in infection control efforts.

  View details for DOI 10.1055/s-0037-1601563

  View details for PubMedID 28395366

• Effects of delivery room quality improvement on premature infant outcomes JOURNAL OF PERINATOLOGY Lapcharoensap, W., Bennett, M. V., Powers, R. J., Finer, N. N., Halamek, L. P., Gould, J. B., Sharek, P. J., Lee, H. C. 2017; 37 (4): 349-354

  Abstract

  Delivery room management interventions have been successfully implemented via collaborative quality improvement (QI) projects. However, it is unknown whether these successes translate to reductions in neonatal morbidity and mortality.This was a prospective pre-post intervention study of three nonrandomized hospital groups within the California Perinatal Quality Care Collaborative. A collaborative QI model (Collaborative QI) was compared with a single-site QI model (NICU QI) and a non-participant population when implementing evidence-based delivery room practices. The intervention period was between June 2011 and May 2012. Infants born with gestational age between 22 weeks 0 days and 29 weeks 6 days and birth weight ⩽1500 g were included. Outcomes were mortality and select morbidities (bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH), retinopathy of prematurity (ROP) and necrotizing enterocolitis (NEC)). Outcomes were compared between the baseline (January 2010 to May 2011) and post-intervention period (June 2012 to May 2013) within each comparison group.Ninety-five hospitals were included with 4222 infants in the baseline period and 4186 infants in the post-intervention period. The Collaborative QI group had significantly reduced odds of developing BPD post-intervention (odds ratio (OR) 0.8, 95% confidence interval (CI) 0.65 to 0.99) or composite BPD-death (OR 0.83, 95% CI 0.69 to 1.00). In both the Collaborative QI and non-participants there were also reductions in IVH, severe IVH, composite severe IVH-death, severe ROP and composite severe ROP-death.Hospitals dedicated to improving delivery room practices can impact neonatal outcomes.Journal of Perinatology advance online publication, 22 December 2016; doi:10.1038/jp.2016.237.

  View details for DOI 10.1038/jp.2016.237

  View details for Web of Science ID 000399264800007

• Burnout in the neonatal intensive care unit and its relation to healthcare-associated infections. Journal of perinatology Tawfik, D. S., Sexton, J. B., Kan, P., Sharek, P. J., Nisbet, C. C., Rigdon, J., Lee, H. C., Profit, J. 2017; 37 (3): 315-320

  Abstract

  To examine burnout prevalence among California neonatal intensive care units (NICUs) and to test the relation between burnout and healthcare-associated infection (HAI) rates in very low birth weight (VLBW) neonates.Retrospective observational study of provider perceptions of burnout from 2073 nurse practitioners, physicians, registered nurses and respiratory therapists, using a validated four-item questionnaire based on the Maslach Burnout Inventory. The relation between burnout and HAI rates among VLBW (<1500 g) neonates from each NICU was evaluated using multi-level logistic regression analysis with patient-level factors as fixed effects.We found variable prevalence of burnout across the NICUs surveyed (mean 25.2±10.1%). Healthcare-associated infection rates were 8.3±5.1% during the study period. Highest burnout prevalence was found among nurses, nurse practitioners and respiratory therapists (non-physicians, 28±11% vs 17±19% physicians), day shift workers (30±3% vs 25±4% night shift) and workers with 5 or more years of service (29±2% vs 16±6% in fewer than 3 years group). Overall burnout rates showed no correlation with risk-adjusted rates of HAIs (r=-0.133). Item-level analysis showed positive association between HAIs and perceptions of working too hard (odds ratio 1.15, 95% confidence interval 1.04-1.28). Sensitivity analysis of high-volume NICUs suggested a moderate correlation between burnout prevalence and HAIs (r=0.34).Burnout is most prevalent among non-physicians, daytime workers and experienced workers. Perceptions of working too hard associate with increased HAIs in this cohort of VLBW infants, but overall burnout prevalence is not predictive.Journal of Perinatology advance online publication, 17 November 2016; doi:10.1038/jp.2016.211.

  View details for DOI 10.1038/jp.2016.211

  View details for PubMedID 27853320

• Pediatric Postoperative Pulse Oximetry Monitoring During Transport to the Postanesthesia Care Unit Reduces Frequency of Hypoxemia. Joint Commission journal on quality and patient safety Caruso, T. J., Mokhtari, T. E., Coughlan, M. J., Wu, D. S., Marquez, J. L., Duan, M., Freeman, H., Giustini, A., Tweedy, M., Sharek, P. J. 2017; 43 (3): 146–50

  Abstract

  The standard use of pulse oximetry during the transport of postoperative patients from the operating room (OR) to the postanesthesia care unit (PACU) is not routinely practiced. A study was conducted to determine if the frequency of hypoxemia on admission to the PACU decreased after implementation of routine use of transport pulse oximeters for postoperative patients being transferred to the PACU.In this prospective cohort study, which was conducted at an academic pediatric hospital, the primary outcome measure was the frequency of hypoxemic events on arrival to the PACU.A total of 506 patients in the preintervention phase and 597 in the postintervention phase met the inclusion criteria. Six hypoxemic events on arrival to the PACU were identified in preintervention phase versus zero in the postintervention period, p = 0.009. Use of oxygen monitors during transport from the OR to the PACU increased from 0% to 100%, p < 0.0001, in the postintervention phase. The median duration of unmonitored time during transport decreased from 272 seconds to 13 seconds, p < 0.0001. Of the 605 patients who met the inclusion criteria for sustainment audits-conducted 18 months after the postimplementation evaluation-99.8% were transported to the PACU with a pulse oximeter, and there were zero reported hypoxemic patients on PACU admission.The routine use of portable oxygen monitoring when transferring patients from the OR to the PACU is a low-cost, noninvasive safety measure that should be considered at any institution performing pediatric general anesthesia.

  View details for DOI 10.1016/j.jcjq.2016.12.001

  View details for PubMedID 28334593

• Effects of delivery room quality improvement on premature infant outcomes. Journal of perinatology Lapcharoensap, W., Bennett, M. V., Powers, R. J., Finer, N. N., Halamek, L. P., Gould, J. B., Sharek, P. J., Lee, H. C. 2016

  Abstract

  Delivery room management interventions have been successfully implemented via collaborative quality improvement (QI) projects. However, it is unknown whether these successes translate to reductions in neonatal morbidity and mortality.This was a prospective pre-post intervention study of three nonrandomized hospital groups within the California Perinatal Quality Care Collaborative. A collaborative QI model (Collaborative QI) was compared with a single-site QI model (NICU QI) and a non-participant population when implementing evidence-based delivery room practices. The intervention period was between June 2011 and May 2012. Infants born with gestational age between 22 weeks 0 days and 29 weeks 6 days and birth weight ⩽1500 g were included. Outcomes were mortality and select morbidities (bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH), retinopathy of prematurity (ROP) and necrotizing enterocolitis (NEC)). Outcomes were compared between the baseline (January 2010 to May 2011) and post-intervention period (June 2012 to May 2013) within each comparison group.Ninety-five hospitals were included with 4222 infants in the baseline period and 4186 infants in the post-intervention period. The Collaborative QI group had significantly reduced odds of developing BPD post-intervention (odds ratio (OR) 0.8, 95% confidence interval (CI) 0.65 to 0.99) or composite BPD-death (OR 0.83, 95% CI 0.69 to 1.00). In both the Collaborative QI and non-participants there were also reductions in IVH, severe IVH, composite severe IVH-death, severe ROP and composite severe ROP-death.Hospitals dedicated to improving delivery room practices can impact neonatal outcomes.Journal of Perinatology advance online publication, 22 December 2016; doi:10.1038/jp.2016.237.

  View details for DOI 10.1038/jp.2016.237

  View details for PubMedID 28005062

• Comparing NICU teamwork and safety climate across two commonly used survey instruments BMJ QUALITY & SAFETY Profit, J., Lee, H. C., Sharek, P. J., Kan, P., Nisbet, C. C., Thomas, E. J., Etchegaray, J. M., Sexton, B. 2016; 25 (12): 954-961

  Abstract

  Measurement and our understanding of safety culture are still evolving. The objectives of this study were to assess variation in safety and teamwork climate and in the neonatal intensive care unit (NICU) setting, and compare measurement of safety culture scales using two different instruments (Safety Attitudes Questionnaire (SAQ) and Hospital Survey on Patient Safety Culture (HSOPSC)).Cross-sectional survey study of a voluntary sample of 2073 (response rate 62.9%) health professionals in 44 NICUs. To compare survey instruments, we used Spearman's rank correlation coefficients. We also compared similar scales and items across the instruments using t tests and changes in quartile-level performance.We found significant variation across NICUs in safety and teamwork climate scales of SAQ and HSOPSC (p<0.001). Safety scales (safety climate and overall perception of safety) and teamwork scales (teamwork climate and teamwork within units) of the two instruments correlated strongly (safety r=0.72, p<0.001; teamwork r=0.67, p<0.001). However, the means and per cent agreements for all scale scores and even seemingly similar item scores were significantly different. In addition, comparisons of scale score quartiles between the two instruments revealed that half of the NICUs fell into different quartiles when translating between the instruments.Large variation and opportunities for improvement in patient safety culture exist across NICUs. Important systematic differences exist between SAQ and HSOPSC such that these instruments should not be used interchangeably.

  View details for DOI 10.1136/bmjqs-2014-003924

  View details for Web of Science ID 000388323100010

  View details for PubMedID 26700545

• Safety Analysis of Proposed Data-Driven Physiologic Alarm Parameters for Hospitalized Children JOURNAL OF HOSPITAL MEDICINE Goel, V. V., Poole, S. F., Longhurst, C. A., Platchek, T. S., Pageler, N. M., Sharek, P. J., Palma, J. P. 2016; 11 (12): 817-823

  Abstract

  Modification of alarm limits is one approach to mitigating alarm fatigue. We aimed to create and validate heart rate (HR) and respiratory rate (RR) percentiles for hospitalized children, and analyze the safety of replacing current vital sign reference ranges with proposed data-driven, age-stratified 5th and 95th percentile values.In this retrospective cross-sectional study, nurse-charted HR and RR data from a training set of 7202 hospitalized children were used to develop percentile tables. We compared 5th and 95th percentile values with currently accepted reference ranges in a validation set of 2287 patients. We analyzed 148 rapid response team (RRT) and cardiorespiratory arrest (CRA) events over a 12-month period, using HR and RR values in the 12 hours prior to the event, to determine the proportion of patients with out-of-range vitals based upon reference versus data-driven limits.There were 24,045 (55.6%) fewer out-of-range measurements using data-driven vital sign limits. Overall, 144/148 RRT and CRA patients had out-of-range HR or RR values preceding the event using current limits, and 138/148 were abnormal using data-driven limits. Chart review of RRT and CRA patients with abnormal HR and RR per current limits considered normal by data-driven limits revealed that clinical status change was identified by other vital sign abnormalities or clinical context.A large proportion of vital signs in hospitalized children are outside presently used norms. Safety evaluation of data-driven limits suggests they are as safe as those currently used. Implementation of these parameters in physiologic monitors may mitigate alarm fatigue. Journal of Hospital Medicine 2015;11:817-823. © 2015 Society of Hospital Medicine.

  View details for DOI 10.1002/jhm.2635

  View details for Web of Science ID 000389420100001

  View details for PubMedID 27411896

• Implementing Delivery Room Checklists and Communication Standards in a Multi-Neonatal ICU Quality Improvement Collaborative. Joint Commission journal on quality and patient safety / Joint Commission Resources Bennett, S. C., Finer, N., Halamek, L. P., Mickas, N., Bennett, M. V., Nisbet, C. C., Sharek, P. J. 2016; 42 (8): 369-376

  Abstract

  The 2015 American Academy of Pediatrics Neonatal Resuscitation Program (NRP) and International Liaison Committee on Resuscitation (ILCOR) resuscitation guidelines state, "It is still suggested that briefing and debriefing techniques be used whenever possible for neonatal resuscitation." Effective communication and reliable delivery of evidence-based best practices are critical aspects of the 2015 NRP guidelines. To promote optimal communication and best practice-focused checklists use during active neonatal resuscitation, the Readiness Bundle (RB) was integrated within the larger change package deployed in the California Perinatal Quality Care Collaborative's (CPQCC) 12-month Delivery Room Management Quality Improvement Collaborative.The RB consisted of (1) a checklist for high-risk neonatal resuscitations and (2) briefings and debriefings to improve teamwork and communication in the delivery room (DR). Implementation of the RB was encouraged, compliance with the RB was tracked monthly up through 6 months after the completion of the collaborative, and satisfaction with the RB was evaluated.Twenty-four neonatal intensive care units (NICUs) participated in the CPQCCDR collaborative. Before the initiation of the collaborative, the elements of the RB were complied with in 0 of 740 reported deliveries (0%). During the 12-month collaborative, compliance with the RB improved to a median of 71%, which was surpassed in the 6-month period after the collaborative ended (80%). One-hundred percent of responding NICUs would recommend the RB to other NICUs working on improving DR management.The RB was rapidly adopted, with compliance sustained for 6 months after completion of the collaborative. Inclusion of the RB in the next generation of the NRP guidelines is encouraged.

  View details for PubMedID 27456419

• Perceived Factors Associated with Sustained Improvement Following Participation in a Multicenter Quality Improvement Collaborative. Joint Commission journal on quality and patient safety / Joint Commission Resources Stone, S., Lee, H. C., Sharek, P. J. 2016; 42 (7): 309-315

  Abstract

  The California Perinatal Quality Care Collaborative led the Breastmilk Nutrition Quality Improvement Collaborative from October 2009 to September 2010 to increase the percentage of very low birth weight infants receiving breast milk at discharge in 11 collaborative neonatal ICUs (NICUs). Observed increases in breast milk feeding and decreases in necrotizing enterocolitis persisted for 6 months after the collaborative ended. Eighteen to 24 months after the end of the collaborative, some sites maintained or further increased their gains, while others trended back toward baseline. A study was conducted to assess the qualitative factors that affect sustained improvement following participation.Collaborative leaders at each of the 11 NICUs that participated in the Breastmilk Nutrition Quality Improvement Collaborative were invited to participate in a site-specific one-hour phone interview. Interviews were recorded and transcribed and then analyzed using qualitative research analysis software to identify themes associated with sustained improvement.Eight of 11 invited centers agreed to participate in the interviews. Thematic saturation was achieved by the sixth interview, so further interviews were not pursued. Factors contributing to sustainability included physician involvement within the multidisciplinary teams, continuous education, incorporation of interventions into the daily work flow, and integration of a data-driven feedback system.Early consideration by site leaders of how to integrate best-practice interventions into the daily work flow, and ensuring physician commitment and ongoing education based in continuous data review, should enhance the likelihood of sustaining improvements. To maximize sustained success, future collaborative design should consider proactively identifying and supporting these factors at participating sites.

  View details for PubMedID 27301834

• Performance of the Global Assessment of Pediatric Patient Safety (GAPPS) Tool PEDIATRICS Landrigan, C. P., Stockwell, D., Toomey, S. L., Loren, S., Tracy, M., Jang, J., Quinn, J. A., Ashrafzadeh, S., Wang, M., Sharek, P. J., Parry, G., Schuster, M. A. 2016; 137 (6)

  Abstract

  Efforts to advance patient safety have been hampered by the lack of high quality measures of adverse events (AEs). This study's objective was to develop and test the Global Assessment of Pediatric Patient Safety (GAPPS) trigger tool, which measures hospital-wide rates of AEs and preventable AEs.Through a literature review and expert panel process, we developed a draft trigger tool. Tool performance was tested in 16 academic and community hospitals across the United States. At each site, a primary reviewer (nurse) reviewed ∼240 randomly selected medical records; 10% of records underwent an additional primary review. Suspected AEs were subsequently evaluated by 2 secondary reviewers (physicians). Ten percent of records were also reviewed by external expert reviewers. Each trigger's incidence and positivity rates were assessed to refine GAPPS.In total, 3814 medical records were reviewed. Primary reviewers agreed 92% of the time on presence or absence of a suspected AE (κ = 0.69). Secondary reviewers verifying AE presence or absence agreed 92% of the time (κ = 0.81). Using expert reviews as a standard for comparison, hospital-based primary reviewers had a sensitivity and specificity of 40% and 91%, respectively. As primary reviewers gained experience, their agreement with expert reviewers improved significantly. After removing low-yield triggers, 27 and 30 (of 54) triggers met inclusion criteria to form final manual and automated trigger lists, respectively.GAPPS reliably identifies AEs and can be used to guide and monitor quality improvement efforts. Ongoing refinement may facilitate future interhospital comparisons.

  View details for DOI 10.1542/peds.2015-4076

  View details for Web of Science ID 000378520100028

  View details for PubMedID 27221286

• HARMFUL DIAGNOSTIC ERRORS OCCUR FREQUENTLY IN PEDIATRIC CARDIAC INTENSIVE CARE: A MULTI-SITE SURVEY Bhat, P. N., Costello, J., Aiyagari, R., Sharek, P., Mazwi, M., Roth, S., Shin, A. ELSEVIER SCIENCE INC. 2016: 1001

  View details for DOI 10.1016/S0735-1097(16)31002-6

  View details for Web of Science ID 000375188701845

• Changes in Efficiency and Safety Culture After Integration of an I-PASS-Supported Handoff Process. Pediatrics Sheth, S., McCarthy, E., Kipps, A. K., Wood, M., Roth, S. J., Sharek, P. J., Shin, A. Y. 2016; 137 (2): 1-9

  Abstract

  Recent publications have shown improved outcomes associated with resident-to-resident handoff processes. However, the implementation of similar handoff processes for patients moving between units and teams with expansive responsibilities presents unique challenges. We sought to determine the impact of a multidisciplinary standardized handoff process on efficiency, safety culture, and satisfaction.A prospective improvement initiative to standardize handoffs during patient transitions from the cardiovascular ICU to the acute care unit was implemented in a university-affiliated children's hospital.Time between verbal handoff and patient transfer decreased from baseline (397 ± 167 minutes) to the postintervention period (24 ± 21 minutes) (P < .01). Percentage positive scores for the handoff/transitions domain of a national culture of safety survey improved (39.8% vs 15.2% and 38.8% vs 19.6%; P = .005 and 0.03, respectively). Provider satisfaction improved related to the information conveyed (34% to 41%; P = .03), time to transfer (5% to 34%; P < .01), and overall experience (3% to 24%; P < .01). Family satisfaction improved for several questions, including: "satisfaction with the information conveyed" (42% to 70%; P = .02), "opportunities to ask questions" (46% to 74%; P < .01), and "Acute Care team's knowledgeabout my child's issues" (50% to 73%; P = .04). No differences in rates of readmission, rapid response team calls, or mortality were observed.Implementation of a multidisciplinary I-PASS-supported handoff process for patients transferring from the cardiovascular ICU to the acute care unit resulted in improved transfer efficiency, safety culture scores, and satisfaction of providers and families.

  View details for DOI 10.1542/peds.2015-0166

  View details for PubMedID 26743818

• Use of a Checklist and Clinical Decision Support Tool Reduces Laboratory Use and Improves Cost. Pediatrics Algaze, C. A., Wood, M., Pageler, N. M., Sharek, P. J., Longhurst, C. A., Shin, A. Y. 2016; 137 (1): 1-8

  Abstract

  We hypothesized that a daily rounding checklist and a computerized order entry (CPOE) rule that limited the scheduling of complete blood cell counts and chemistry and coagulation panels to a 24-hour interval would reduce laboratory utilization and associated costs.We performed a retrospective analysis of these initiatives in a pediatric cardiovascular ICU (CVICU) that included all patients with congenital or acquired heart disease admitted to the cardiovascular ICU from September 1, 2008, until April 1, 2011. Our primary outcomes were the number of laboratory orders and cost of laboratory orders. Our secondary outcomes were mortality and CVICU and hospital length of stay.We found a reduction in laboratory utilization frequency in the checklist intervention period and additional reduction in the CPOE intervention period [complete blood count: 31% and 44% (P < .0001); comprehensive chemistry panel: 48% and 72% (P < .0001); coagulation panel: 26% and 55% (P < .0001); point of care blood gas: 43% and 44% (P < .0001)] compared with the preintervention period. Projected yearly cost reduction was $717, 538.8. There was no change in adjusted mortality rate (odds ratio 1.1, 95% confidence interval 0.7-1.9, P = .65). CVICU and total length of stay (days) was similar in the pre- and postintervention periods.Use of a daily checklist and CPOE rule reduced laboratory resource utilization and cost without adversely affecting adjusted mortality or length of stay. CPOE has the potential to hardwire resource management interventions to augment and sustain the daily checklist.

  View details for DOI 10.1542/peds.2014-3019

  View details for PubMedID 26681782

• Exploring Value in Congenital Heart Disease: An Evaluation of Inpatient Admissions. Congenital heart disease Shin, A. Y., Hu, Z., Jin, B., Lal, S., Rosenthal, D. N., Efron, B., Sharek, P. J., Sutherland, S. M., Cohen, H. J., McElhinney, D. B., Roth, S. J., Ling, X. B. 2015; 10 (6): E278-87

  Abstract

  Understanding value provides an important context for improvement. However, most health care models fail to measure value. Our objective was to categorize inpatient encounters within an academic congenital heart program based on clinical outcome and the cost to achieve the outcome (value). We aimed to describe clinical and nonclinical features associated with value.We defined hospital encounters based on outcome per resource utilized. We performed principal component and cluster analysis to classify encounters based on mortality, length of stay, hospital cost and revenue into six classes. We used nearest shrunken centroid to identify discriminant features associated with the cluster-derived classes. These features underwent hierarchical clustering and multivariate analysis to identify features associated with each class.We analyzed all patients admitted to an academic congenital heart program between September 1, 2009, and December 31, 2012.A total of 2658 encounters occurred during the study period. Six classes were categorized by value. Low-performing value classes were associated with greater institutional reward; however, encounters with higher-performing value were associated with a loss in profitability. Encounters that included insertion of a pediatric ventricular assist device (log OR 2.5 [95% CI, 1.78 to 3.43]) and acquisition of a hospital-acquired infection (log OR 1.42 [95% CI, 0.99 to 1.87]) were risk factors for inferior health care value.Among the patients in our study, institutional reward was not associated with value. We describe a framework to target quality improvement and resource management efforts that can benefit patients, institutions, and payers alike.

  View details for DOI 10.1111/chd.12290

  View details for PubMedID 26219731

• Exploring Value in Congenital Heart Disease: An Evaluation of Inpatient Admissions CONGENITAL HEART DISEASE Shin, A. Y., Hu, Z., Jin, B., Lal, S., Rosenthal, D. N., Efron, B., Sharek, P. J., Sutherland, S. M., Cohen, H. J., McElhinney, D. B., Roth, S. J., Ling, X. B. 2015; 10 (6): E278-E287

  Abstract

  Understanding value provides an important context for improvement. However, most health care models fail to measure value. Our objective was to categorize inpatient encounters within an academic congenital heart program based on clinical outcome and the cost to achieve the outcome (value). We aimed to describe clinical and nonclinical features associated with value.We defined hospital encounters based on outcome per resource utilized. We performed principal component and cluster analysis to classify encounters based on mortality, length of stay, hospital cost and revenue into six classes. We used nearest shrunken centroid to identify discriminant features associated with the cluster-derived classes. These features underwent hierarchical clustering and multivariate analysis to identify features associated with each class.We analyzed all patients admitted to an academic congenital heart program between September 1, 2009, and December 31, 2012.A total of 2658 encounters occurred during the study period. Six classes were categorized by value. Low-performing value classes were associated with greater institutional reward; however, encounters with higher-performing value were associated with a loss in profitability. Encounters that included insertion of a pediatric ventricular assist device (log OR 2.5 [95% CI, 1.78 to 3.43]) and acquisition of a hospital-acquired infection (log OR 1.42 [95% CI, 0.99 to 1.87]) were risk factors for inferior health care value.Among the patients in our study, institutional reward was not associated with value. We describe a framework to target quality improvement and resource management efforts that can benefit patients, institutions, and payers alike.

  View details for DOI 10.1111/chd.12290

  View details for Web of Science ID 000367379300004

• Utility of Clinical Biomarkers to Predict Central Line-associated Bloodstream Infections After Congenital Heart Surgery. Pediatric infectious disease journal Shin, A. Y., Jin, B., Hao, S., Hu, Z., Sutherland, S., McCammond, A., Axelrod, D., Sharek, P., Roth, S. J., Ling, X. B. 2015; 34 (3): 251-254

  Abstract

  Central line associated bloodstream infections is an important contributor of morbidity and mortality in children recovering from congenital heart surgery. The reliability of commonly used biomarkers to differentiate these patients have not been specifically studied.This was a retrospective cohort study in a university-affiliated children's hospital examining all patients with congenital or acquired heart disease admitted to the cardiovascular intensive care unit following cardiac surgery who underwent evaluation for a catheter-associated bloodstream infection.Among 1260 cardiac surgeries performed, 451 encounters underwent an infection evaluation post-operatively. Twenty-five instances of CLABSI and 227 instances of a negative infection evaluation were the subject of analysis. Patients with CLABSI tended to be younger (1.34 vs 4.56 years, p = 0.011) and underwent more complex surgery (RACHS-1 score 3.79 vs 3.04, p = 0.039). The two groups were indistinguishable in WBC, PMNs and band count at the time of their presentation. On multivariate analysis, CLABSI was associated with fever (adjusted OR 4.78; 95% CI, 1.6 to 5.8) and elevated CRP (adjusted OR 1.28; 95% CI, 1.09 to 1.68) after adjusting for differences between the two groups. Receiver operating characteristic analysis demonstrated the discriminatory power of both fever and CRP (area under curve 0.7247, 95% CI, 0.42 to 0.74 and 0.58, 95% CI 0.4208 to 0.7408). We calculated multilevel likelihood ratios for a spectrum of temperature and CRP values.We found commonly used serum biomarkers such as fever and CRP not to be helpful discriminators in patients following congenital heart surgery.

  View details for DOI 10.1097/INF.0000000000000553

  View details for PubMedID 25232780

• Implementation of Data Drive Heart Rate and Respiratory Rate parameters on a Pediatric Acute Care Unit. Studies in health technology and informatics Goel, V., Poole, S., Kipps, A., Palma, J., Platchek, T., Pageler, N., Longhurst, C., Sharek, P. 2015; 216: 918-?

  Abstract

  The majority of hospital physiologic monitor alarms are not clinically actionable and contribute to alarm fatigue. In 2014, The Joint Commission declared alarm safety as a National Patient Safety Goal and urged prompt action by hospitals to mitigate the issue [1]. It has been demonstrated that vital signs in hospitalized children are quite different from currently accepted reference ranges [2]. Implementation of data-driven, age stratified vital sign parameters (Table 1) for alarms in this patient population could reduce alarm frequency.

  View details for PubMedID 26262220

  View details for PubMedCentralID PMC4824687

• Implementation of a standardized postanesthesia care handoff increases information transfer without increasing handoff duration. Joint Commission journal on quality and patient safety / Joint Commission Resources Caruso, T. J., Marquez, J. L., Wu, D. S., Shaffer, J. A., Balise, R. R., Groom, M., Leong, K., Mariano, K., Honkanen, A., Sharek, P. J. 2015; 41 (1): 35-42

  Abstract

  In the transition of a patient from the operating room (OR) to the postanesthesia care unit (PACU), it was hypothesized that (1) standardizing the members of sending and receiving teams and (2) requiring a structured handoff process would increase the overall amount of patient information transferred in the OR-to-PACU handoff process.A prospective cohort study was conducted at a 311-bed freestanding academic pediatric hospital in Northern California. The intervention, which was conducted in February-March 2013, consisted of (1) requiring the sending team to include a surgeon, an anesthesiologist, and a circulating nurse, and the receiving team to include the PACU nurse; (2) standardizing the content of the handoff on the basis of literature-guided recommendations; and (3) presenting the handoff verbally in the I-PASS format. Data included amount of patient information transferred, duration of handoff, provider presence, and nurse satisfaction.Forty-one audits during the preimplementation phase and 45 audits during the postimplementation phase were analyzed. Overall information transfer scores increased significantly from a mean score of 49% to 83% (p < .0001). Twenty-two PACU nurse satisfaction surveys were completed after the preimplementation phase and 14 surveys were completed in the postimplementation phase. Paired mean total satisfaction scores increased from 36 to 44 (p =. 004). The duration of the handoffs trended downward from 4.1 min to 3.5 min (p = 0.10).A standardized, team-based approach to OR-to-PACU handoffs increased the quantity of patient information transferred, increased PACU nurse satisfaction, and did not increase the handoff duration.

  View details for PubMedID 25976722

• Implementation Methods for Delivery Room Management: A Quality Improvement Comparison Study PEDIATRICS Lee, H. C., Powers, R. J., Bennett, M. V., Finer, N. N., Halamek, L. P., Nisbet, C., Crockett, M., Chance, K., Blackney, D., von Koehler, C., Kurtin, P., Sharek, P. J. 2014; 134 (5): E1378-E1386

  Abstract

  There is little evidence to compare the effectiveness of large collaborative quality improvement versus individual local projects.This was a prospective pre-post intervention study of neonatal resuscitation practice, comparing 3 groups of nonrandomized hospitals in the California Perinatal Quality Care Collaborative: (1) collaborative, hospitals working together through face-to-face meetings, webcasts, electronic mailing list, and data sharing; (2) individual, hospitals working independently; and (3) nonparticipant hospitals. The collaborative and individual arms participated in improvement activities, focusing on reducing hypothermia and invasive ventilatory support.There were 20 collaborative, 31 individual, and 44 nonparticipant hospitals caring for 12 528 eligible infants. Each group had reduced hypothermia from baseline to postintervention. The collaborative group had the most significant decrease in hypothermia, from 39% to 21%, compared with individual hospital efforts of 38% to 33%, and nonparticipants of 42% to 34%. After risk adjustment, the collaborative group had twice the magnitude of decrease in rates of newborns with hypothermia compared with the other groups. Collaborative improvement also led to greater decreases in delivery room intubation (53% to 40%) and surfactant administration (37% to 20%).Collaborative efforts resulted in larger improvements in delivery room outcomes and processes than individual efforts or nonparticipation. These findings have implications for planning quality improvement projects for implementation of evidence-based practices.

  View details for DOI 10.1542/peds.2014-0863

  View details for Web of Science ID 000344385900014

• Implementation methods for delivery room management: a quality improvement comparison study. Pediatrics Lee, H. C., Powers, R. J., Bennett, M. V., Finer, N. N., Halamek, L. P., Nisbet, C., Crockett, M., Chance, K., Blackney, D., von Köhler, C., Kurtin, P., Sharek, P. J. 2014; 134 (5): e1378-86

  Abstract

  There is little evidence to compare the effectiveness of large collaborative quality improvement versus individual local projects.This was a prospective pre-post intervention study of neonatal resuscitation practice, comparing 3 groups of nonrandomized hospitals in the California Perinatal Quality Care Collaborative: (1) collaborative, hospitals working together through face-to-face meetings, webcasts, electronic mailing list, and data sharing; (2) individual, hospitals working independently; and (3) nonparticipant hospitals. The collaborative and individual arms participated in improvement activities, focusing on reducing hypothermia and invasive ventilatory support.There were 20 collaborative, 31 individual, and 44 nonparticipant hospitals caring for 12 528 eligible infants. Each group had reduced hypothermia from baseline to postintervention. The collaborative group had the most significant decrease in hypothermia, from 39% to 21%, compared with individual hospital efforts of 38% to 33%, and nonparticipants of 42% to 34%. After risk adjustment, the collaborative group had twice the magnitude of decrease in rates of newborns with hypothermia compared with the other groups. Collaborative improvement also led to greater decreases in delivery room intubation (53% to 40%) and surfactant administration (37% to 20%).Collaborative efforts resulted in larger improvements in delivery room outcomes and processes than individual efforts or nonparticipation. These findings have implications for planning quality improvement projects for implementation of evidence-based practices.

  View details for DOI 10.1542/peds.2014-0863

  View details for PubMedID 25332503

• Burnout in the NICU setting and its relation to safety culture BMJ QUALITY & SAFETY Profit, J., Sharek, P. J., Amspoker, A. B., Kowalkowski, M. A., Nisbet, C. C., Thomas, E. J., Chadwick, W. A., Sexton, J. B. 2014; 23 (10): 806-813

  Abstract

  Burnout is widespread among healthcare providers and is associated with adverse safety behaviours, operational and clinical outcomes. Little is known with regard to the explanatory links between burnout and these adverse outcomes.(1) Test the psychometric properties of a brief four-item burnout scale, (2) Provide neonatal intensive care unit (NICU) burnout and resilience benchmarking data across different units and caregiver types, (3) Examine the relationships between caregiver burnout and patient safety culture.Cross-sectional survey study.Nurses, nurse practitioners, respiratory care providers and physicians in 44 NICUs.Caregiver assessments of burnout and safety culture.Of 3294 administered surveys, 2073 were returned for an overall response rate of 62.9%. The percentage of respondents in each NICU reporting burnout ranged from 7.5% to 54.4% (mean=25.9%, SD=10.8). The four-item burnout scale was reliable (α=0.85) and appropriate for aggregation (intra-class correlation coefficient-2=0.95). Burnout varied significantly between NICUs, p<0.0001, but was less prevalent in physicians (mean=15.1%, SD=19.6) compared with non-physicians (mean=26.9%, SD=11.4, p=0.0004). NICUs with more burnout had lower teamwork climate (r=-0.48, p=0.001), safety climate (r=-0.40, p=0.01), job satisfaction (r=-0.64, p<0.0001), perceptions of management (r=-0.50, p=0.0006) and working conditions (r=-0.45, p=0.002).NICU caregiver burnout appears to have 'climate-like' features, is prevalent, and associated with lower perceptions of patient safety culture.

  View details for DOI 10.1136/bmjqs-2014-002831

  View details for Web of Science ID 000342375400003

• Exposure to Leadership WalkRounds in neonatal intensive care units is associated with a better patient safety culture and less caregiver burnout. BMJ quality & safety Sexton, J. B., Sharek, P. J., Thomas, E. J., Gould, J. B., Nisbet, C. C., Amspoker, A. B., Kowalkowski, M. A., Schwendimann, R., Profit, J. 2014; 23 (10): 814-822

  Abstract

  Leadership WalkRounds (WR) are widely used in healthcare organisations to improve patient safety. The relationship between WR and caregiver assessments of patient safety culture, and healthcare worker burnout is unknown.This cross-sectional survey study evaluated the association between receiving feedback about actions taken as a result of WR and healthcare worker assessments of patient safety culture and burnout across 44 neonatal intensive care units (NICUs) actively participating in a structured delivery room management quality improvement initiative.Of 3294 administered surveys, 2073 were returned for an overall response rate of 62.9%. More WR feedback was associated with better safety culture results and lower burnout rates in the NICUs. Participation in WR and receiving feedback about WR were less common in NICUs than in a benchmarking comparison of adult clinical areas.WR are linked to patient safety and burnout. In NICUs, where they occurred more often, the workplace appears to be a better place to deliver and to receive care.

  View details for DOI 10.1136/bmjqs-2013-002042

  View details for PubMedID 24825895

• Burnout in the NICU setting and its relation to safety culture. BMJ quality & safety Profit, J., Sharek, P. J., Amspoker, A. B., Kowalkowski, M. A., Nisbet, C. C., Thomas, E. J., Chadwick, W. A., Sexton, J. B. 2014; 23 (10): 806-813

  Abstract

  Burnout is widespread among healthcare providers and is associated with adverse safety behaviours, operational and clinical outcomes. Little is known with regard to the explanatory links between burnout and these adverse outcomes.(1) Test the psychometric properties of a brief four-item burnout scale, (2) Provide neonatal intensive care unit (NICU) burnout and resilience benchmarking data across different units and caregiver types, (3) Examine the relationships between caregiver burnout and patient safety culture.Cross-sectional survey study.Nurses, nurse practitioners, respiratory care providers and physicians in 44 NICUs.Caregiver assessments of burnout and safety culture.Of 3294 administered surveys, 2073 were returned for an overall response rate of 62.9%. The percentage of respondents in each NICU reporting burnout ranged from 7.5% to 54.4% (mean=25.9%, SD=10.8). The four-item burnout scale was reliable (α=0.85) and appropriate for aggregation (intra-class correlation coefficient-2=0.95). Burnout varied significantly between NICUs, p<0.0001, but was less prevalent in physicians (mean=15.1%, SD=19.6) compared with non-physicians (mean=26.9%, SD=11.4, p=0.0004). NICUs with more burnout had lower teamwork climate (r=-0.48, p=0.001), safety climate (r=-0.40, p=0.01), job satisfaction (r=-0.64, p<0.0001), perceptions of management (r=-0.50, p=0.0006) and working conditions (r=-0.45, p=0.002).NICU caregiver burnout appears to have 'climate-like' features, is prevalent, and associated with lower perceptions of patient safety culture.

  View details for DOI 10.1136/bmjqs-2014-002831

  View details for PubMedID 24742780

• Exposure to Leadership WalkRounds in neonatal intensive care units is associated with a better patient safety culture and less caregiver burnout BMJ QUALITY & SAFETY Sexton, J. B., Sharek, P. J., Thomas, E. J., Gould, J. B., Nisbet, C. C., Amspoker, A. B., Kowalkowski, M. A., Schwendimann, R., Profit, J. 2014; 23 (10): 814-822

  Abstract

  Leadership WalkRounds (WR) are widely used in healthcare organisations to improve patient safety. The relationship between WR and caregiver assessments of patient safety culture, and healthcare worker burnout is unknown.This cross-sectional survey study evaluated the association between receiving feedback about actions taken as a result of WR and healthcare worker assessments of patient safety culture and burnout across 44 neonatal intensive care units (NICUs) actively participating in a structured delivery room management quality improvement initiative.Of 3294 administered surveys, 2073 were returned for an overall response rate of 62.9%. More WR feedback was associated with better safety culture results and lower burnout rates in the NICUs. Participation in WR and receiving feedback about WR were less common in NICUs than in a benchmarking comparison of adult clinical areas.WR are linked to patient safety and burnout. In NICUs, where they occurred more often, the workplace appears to be a better place to deliver and to receive care.

  View details for DOI 10.1136/bmjqs-2013-002042

  View details for Web of Science ID 000342375400004

• Optimizing care of adults with congenital heart disease in a pediatric cardiovascular ICU using electronic clinical decision support*. Pediatric critical care medicine May, L. J., Longhurst, C. A., Pageler, N. M., Wood, M. S., Sharek, P. J., Zebrack, C. M. 2014; 15 (5): 428-434

  Abstract

  The optimal location for postoperative cardiac care of adults with congenital heart disease is controversial. Some congenital heart surgeons operate on these adults in children's hospitals with postoperative care provided by pediatric critical care teams who may be unfamiliar with adult national performance measures. This study tested the hypothesis that Clinical Decision Support tools integrated into the clinical workflow would facilitate improved compliance with The Joint Commission Surgical Care Improvement Project performance measures in adults recovering from cardiac surgery in a children's hospital.Retrospective chart review comparing compliance pre- and post-Clinical Decision Support intervention for Surgical Care Improvement Project measures addressed in the critical care unit: appropriate cessation of prophylactic antibiotics; controlled blood glucose; urinary catheter removal; and reinitiation of preoperative β-blocker when indicated.Cardiovascular ICU in a quaternary care freestanding children's hospital.The cohort included 114 adults 18-70 years old recovering from cardiac surgery in our pediatric cardiovascular ICU.Clinical Decision Support tools including data-triggered alerts, smart documentation forms, and order sets with conditional logic were integrated into the workflow.Compliance with antibiotic discontinuation was 100% pre- and postintervention. Compliance rates improved for glucose control (p = 0.007) and urinary catheter removal (p = 0.05). Documentation of β-blocker therapy (nonexistent preintervention) was 100% postintervention. Composite compliance for all measures increased from 53% to 84% (p = 0.002). There were no complications related to institution of the Surgical Care Improvement Project measures. There was no in-hospital mortality.Compliance with the national adult postoperative performance measures can be excellent in a children's hospital with the help of Clinical Decision Support tools. This represents an important step toward providing high-quality care to a growing population of adults with congenital heart disease who may receive care in a pediatric center.

  View details for DOI 10.1097/PCC.0000000000000124

  View details for PubMedID 24732291

• Use of electronic medical record-enhanced checklist and electronic dashboard to decrease CLABSIs. Pediatrics Pageler, N. M., Longhurst, C. A., Wood, M., Cornfield, D. N., Suermondt, J., Sharek, P. J., Franzon, D. 2014; 133 (3): e738-46

  Abstract

  We hypothesized that a checklist enhanced by the electronic medical record and a unit-wide dashboard would improve compliance with an evidence-based, pediatric-specific catheter care bundle and decrease central line-associated bloodstream infections (CLABSI).We performed a cohort study with historical controls that included all patients with a central venous catheter in a 24-bed PICU in an academic children's hospital. Postintervention CLABSI rates, compliance with bundle elements, and staff perceptions of communication were evaluated and compared with preintervention data.CLABSI rates decreased from 2.6 CLABSIs per 1000 line-days before intervention to 0.7 CLABSIs per 1000 line-days after intervention. Analysis of specific bundle elements demonstrated increased daily documentation of line necessity from 30% to 73% (P < .001), increased compliance with dressing changes from 87% to 90% (P = .003), increased compliance with cap changes from 87% to 93% (P < .001), increased compliance with port needle changes from 69% to 95% (P < .001), but decreased compliance with insertion bundle documentation from 67% to 62% (P = .001). Changes in the care plan were made during review of the electronic medical record checklist on 39% of patient rounds episodes.Use of an electronic medical record-enhanced CLABSI prevention checklist coupled with a unit-wide real-time display of adherence was associated with increased compliance with evidence-based catheter care and sustained decrease in CLABSI rates. These data underscore the potential for computerized interventions to promote compliance with proven best practices and prevent patient harm.

  View details for DOI 10.1542/peds.2013-2249

  View details for PubMedID 24567021

• Use of Electronic Medical Record-Enhanced Checklist and Electronic Dashboard to Decrease CLABSIs. Pediatrics Pageler, N. M., Longhurst, C. A., Wood, M., Cornfield, D. N., Suermondt, J., Sharek, P. J., Franzon, D. 2014; 133 (3): e738-46

  Abstract

  We hypothesized that a checklist enhanced by the electronic medical record and a unit-wide dashboard would improve compliance with an evidence-based, pediatric-specific catheter care bundle and decrease central line-associated bloodstream infections (CLABSI).We performed a cohort study with historical controls that included all patients with a central venous catheter in a 24-bed PICU in an academic children's hospital. Postintervention CLABSI rates, compliance with bundle elements, and staff perceptions of communication were evaluated and compared with preintervention data.CLABSI rates decreased from 2.6 CLABSIs per 1000 line-days before intervention to 0.7 CLABSIs per 1000 line-days after intervention. Analysis of specific bundle elements demonstrated increased daily documentation of line necessity from 30% to 73% (P < .001), increased compliance with dressing changes from 87% to 90% (P = .003), increased compliance with cap changes from 87% to 93% (P < .001), increased compliance with port needle changes from 69% to 95% (P < .001), but decreased compliance with insertion bundle documentation from 67% to 62% (P = .001). Changes in the care plan were made during review of the electronic medical record checklist on 39% of patient rounds episodes.Use of an electronic medical record-enhanced CLABSI prevention checklist coupled with a unit-wide real-time display of adherence was associated with increased compliance with evidence-based catheter care and sustained decrease in CLABSI rates. These data underscore the potential for computerized interventions to promote compliance with proven best practices and prevent patient harm.

  View details for DOI 10.1542/peds.2013-2249

  View details for PubMedID 24567021

• Exemplar Pediatric Collaborative Improvement Networks: Achieving Results PEDIATRICS Billett, A. L., Colletti, R. B., Mandel, K. E., Miller, M., Muething, S. E., Sharek, P. J., Lannon, C. M. 2013; 131: S196-S203

  Abstract

  A number of pediatric collaborative improvement networks have demonstrated improved care and outcomes for children. Regionally, Cincinnati Children's Hospital Medical Center Physician Hospital Organization has sustained key asthma processes, substantially increased the percentage of their asthma population receiving "perfect care," and implemented an innovative pay-for-performance program with a large commercial payor based on asthma performance measures. The California Perinatal Quality Care Collaborative uses its outcomes database to improve care for infants in California NICUs. It has achieved reductions in central line-associated blood stream infections (CLABSI), increased breast-milk feeding rates at hospital discharge, and is now working to improve delivery room management. Solutions for Patient Safety (SPS) has achieved significant improvements in adverse drug events and surgical site infections across all 8 Ohio children's hospitals, with 7700 fewer children harmed and >$11.8 million in avoided costs. SPS is now expanding nationally, aiming to eliminate all events of serious harm at children's hospitals. National collaborative networks include ImproveCareNow, which aims to improve care and outcomes for children with inflammatory bowel disease. Reliable adherence to Model Care Guidelines has produced improved remission rates without using new medications and a significant increase in the proportion of Crohn disease patients not taking prednisone. Data-driven collaboratives of the Children's Hospital Association Quality Transformation Network initially focused on CLABSI in PICUs. By September 2011, they had prevented an estimated 2964 CLABSI, saving 355 lives and $103,722,423. Subsequent improvement efforts include CLABSI reductions in additional settings and populations.

  View details for DOI 10.1542/peds.2012-3786F

  View details for Web of Science ID 000321674900003

  View details for PubMedID 23729760

• A clinical case of electronic health record drug alert fatigue: consequences for patient outcome. Pediatrics Carspecken, C. W., Sharek, P. J., Longhurst, C., Pageler, N. M. 2013; 131 (6): e1970-3

  Abstract

  Despite advances in electronic medication order entry systems, it has been well established that clinicians override many drug allergy alerts generated by the electronic health record. The direct clinical consequences of overalerting clinicians in a pediatric setting have not been well demonstrated in the literature. We observed a patient in the PICU who experienced complications as a result of an extended series of non-evidence-based alerts in the electronic health record. Subsequently, evidence-based allergy alerting changes were made to the hospital's system. Incorporating clinical evidence in electronic drug allergy alerting systems remains challenging, especially in pediatric settings.

  View details for DOI 10.1542/peds.2012-3252

  View details for PubMedID 23713099

• A clinical case of electronic health record drug alert fatigue: consequences for patient outcome. Pediatrics Carspecken, C. W., Sharek, P. J., Longhurst, C., Pageler, N. M. 2013; 131 (6): e1970-3

  Abstract

  Despite advances in electronic medication order entry systems, it has been well established that clinicians override many drug allergy alerts generated by the electronic health record. The direct clinical consequences of overalerting clinicians in a pediatric setting have not been well demonstrated in the literature. We observed a patient in the PICU who experienced complications as a result of an extended series of non-evidence-based alerts in the electronic health record. Subsequently, evidence-based allergy alerting changes were made to the hospital's system. Incorporating clinical evidence in electronic drug allergy alerting systems remains challenging, especially in pediatric settings.

  View details for DOI 10.1542/peds.2012-3252

  View details for PubMedID 23713099

• Using an Evidence-Based Approach to EMR Implementation to Optimize Outcomes and Avoid Unintended Consequences. Journal of healthcare information management : JHIM Longhurst, C. A., Palma, J. P., Grisim, L. M., Widen, E., Chan, M., Sharek, P. J. 2013; 27 (3): 79-83

  Abstract

  Implementation of an electronic medical record (EMR) with computerized physician order entry (CPOE) can provide an important foundation for preventing harm and improving outcomes. Incentivized by the recent economic stimulus initiative, healthcare systems are implementing vendor-based EMR systems at an unprecedented rate. Accumulating evidence suggests that local implementation decisions, rather than the specific EMR product or technology selected, are the primary drivers of the quality improvement performance of these systems. However, limited attention has been paid to effective approaches to EMR implementation. In this case report, we outline the evidence-based approach we used to make EMR implementation decisions in a pragmatic structure intended for replication at other sites.

  View details for PubMedID 24771994

• Reducing Mortality Related to Adverse Events in Children PEDIATRIC CLINICS OF NORTH AMERICA Shin, A. Y., Longhurst, C. A., Sharek, P. J. 2012; 59 (6): 1293-?

  Abstract

  Since the launch of the 100,000 Lives Campaign by the Institute for Healthcare Improvement (IHI), preventing medical adverse events to reduce avoidable mortality has emerged as a central focus for health care providers, institutions, regulators, insurance companies, and patients. Evidence-based interventions targeting the 6 interventions in the campaign have been associated with a reduction in preventable hospital deaths in the United States. The generalizability of the IHI's campaign to the pediatric population is only partly applicable. Pediatric experiences with rapid response teams and preventing central-line infections parallel the published experience of adults, with promise to significantly reduce preventable pediatric mortality.

  View details for DOI 10.1016/j.pcl.2012.09.002

  View details for Web of Science ID 000312618600007

  View details for PubMedID 23116526

• A Quality Improvement Project to Increase Breast Milk Use in Very Low Birth Weight Infants PEDIATRICS Lee, H. C., Kurtin, P. S., Wight, N. E., Chance, K., Cucinotta-Fobes, T., Hanson-Timpson, T. A., Nisbet, C. C., Rhine, W. D., Risingsun, K., Wood, M., Danielsen, B. H., Sharek, P. J. 2012; 130 (6): E1679-E1687

  Abstract

  To evaluate a multihospital collaborative designed to increase breast milk feeding in premature infants.Eleven NICUs in the California Perinatal Quality of Care Collaborative participated in an Institute for Healthcare Improvement-style collaborative to increase NICU breast milk feeding rates. Multiple interventions were recommended with participating sites implementing a self-selected combination of these interventions. Breast milk feeding rates were compared between baseline (October 2008-September 2009), implementation (October 2009-September 2010), and sustainability periods (October 2010-March 2011). Secondary outcome measures included necrotizing enterocolitis (NEC) rates and lengths of stay. California Perinatal Quality of Care Collaborative hospitals not participating in the project served as a control population.The breast milk feeding rate in the intervention sites improved from baseline (54.6%) to intervention period (61.7%; P = .005) with sustained improvement over 6 months postintervention (64.0%; P = .003). NEC rates decreased from baseline (7.0%) to intervention period (4.3%; P = .022) to sustainability period (2.4%; P < .0001). Length of stay increased during the intervention but returned to baseline levels in the sustainability period. Control hospitals had higher rates of breast milk feeding at baseline (64.2% control vs 54.6% participants, P < .0001), but over the course of the implementation (65.7% vs 61.7%, P = .049) and sustainability periods (67.7% vs 64.0%, P = .199), participants improved to similar rates as the control group.Implementation of a breast milk/nutrition change package by an 11-site collaborative resulted in an increase in breast milk feeding and decrease in NEC that was sustained over an 18-month period.

  View details for DOI 10.1542/peds.2012-0547

  View details for Web of Science ID 000314802000033

  View details for PubMedID 23129071

  View details for PubMedCentralID PMC3507251

• Integrating the home management plan of care for children with asthma into an electronic medical record. Joint Commission journal on quality and patient safety / Joint Commission Resources Patel, S. J., Longhurst, C. A., Lin, A., Garrett, L., Gillette-Arroyo, J., Mark, J. D., Wood, M. S., Sharek, P. J. 2012; 38 (8): 359-365

  Abstract

  Asthma exacerbation is one of the most common causes for pediatric hospitalization. One of the three Joint Commission quality measures--which has proven the most challenging--addresses the provision of a home management plan of care (HMPC) for discharge of pediatric inpatients with a primary diagnosis of asthma. A user-friendly electronic medical record (EMR)-generated HMPC was developed and implemented at Lucile Packard Children's Hospital (LPCH) Palo Alto, California, an HPMC needed to be completed before entry of an inpatient discharge order.A cohort study using historical controls was conducted in 2010-2011. Patients were eligible to receive an HMPC if they were between the ages of 2 and 17 years old at discharge, had a length of stay < 120 days, were not enrolled in clinical trials, and had the primary discharge diagnosis of asthma. These patients were identified by the EMR if this diagnosis was listed in the diagnosis list or problem list or if the asthma admit/discharge order set was initiated.Compliance with the HMPC increased from 65.3% for the 39 months (April 1, 2007-June 30, 2010) before integration of the HMPC into EMR to 93.7% for the 18 months after integration (July 1, 2010, through December 31, 2011); p < .0001. Users of the EMR-integrated HMPC found it to be significantly easier to complete, less time-consuming, and less prone to potential errors or omission.Lessons learned at LPCH included the need for a continuous surveillance and improvement model, which resulted in several iterations of the HMPC; the importance of soliciting user input, which resulted in improvements in work flow; and consistent support from the quality management and information technology departments, which are crucial to eliminating barriers and facilitating improvement.

  View details for PubMedID 22946253

• The Emergence of the Trigger Tool as the Premier Measurement Strategy for Patient Safety. AHRQ WebM&M : morbidity & mortality rounds on the Web Sharek, P. J. 2012; 2012 (5)

  View details for PubMedID 23667349

  View details for PubMedCentralID PMC3648871

• Rapid Response Team Implementation in a Children's Hospital ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE Sharek, P. J., Parast, L. M., Roth, S. J. 2011; 165 (12): 1139-1139

  View details for Web of Science ID 000297638100016

  View details for PubMedID 22147784

• Impact of electronic medical record integration of a handoff tool on sign-out in a newborn intensive care unit JOURNAL OF PERINATOLOGY Palma, J. P., Sharek, P. J., Longhurst, C. A. 2011; 31 (5): 311-317

  Abstract

  Objective:To evaluate the impact of integrating a handoff tool into the electronic medical record (EMR) on sign-out accuracy, satisfaction and workflow in a neonatal intensive care unit (NICU).Study Design:Prospective surveys of neonatal care providers in an academic children's hospital 1 month before and 6 months following EMR integration of a standalone Microsoft Access neonatal handoff tool.Result:Providers perceived sign-out information to be somewhat or very accurate at a rate of 78% with the standalone handoff tool and 91% with the EMR-integrated tool (P < 0.01). Before integration of neonatal sign-out into the EMR, 35% of providers were satisfied with the process of updating sign-out information and 71% were satisfied with the printed sign-out document; following EMR integration, 92% of providers were satisfied with the process of updating sign-out information (P < 0.01) and 98% were satisfied with the printed sign-out document (P<0.01). Neonatal care providers reported spending a median of 11 to 15 min/day updating the standalone sign-out and 16 to 20 min/day updating the EMR-integrated sign-out (P = 0.026). The median percentage of total sign-out preparation time dedicated to transcribing information from the EMR was 25 to 49% before and <25% after EMR integration of the handoff tool (P < 0.01).Conclusion:Integration of a NICU-specific handoff tool into an EMR resulted in improvements in perceived sign-out accuracy, provider satisfaction and at least one aspect of workflow.

  View details for DOI 10.1038/jp.2010.202

  View details for Web of Science ID 000289982300003

  View details for PubMedID 21273990

• Neonatal Informatics: Computerized Physician Order Entry. NeoReviews Palma, J. P., Sharek, P. J., Classen, D. C., Longhurst, C. A. 2011; 12: 393-396

  Abstract

  Computerized physician order entry (CPOE) is the feature of electronic medical record (EMR) implementation that arguably offers the greatest quality and patient safety benefits. The gains are potentially greater for critically ill neonates, but the effect of CPOE on quality and safety is dependent upon local implementation decisions. OBJECTIVES: After completing this article, readers should be able to: Define the basic aspects of CPOE and clinical decision support (CDS) systems.Describe the potential benefits of implementing CPOE associated with CDS in a neonatal intensive care unit (NICU).

  View details for PubMedID 21804768

  View details for PubMedCentralID PMC3146345

• NICU Practices and Outcomes Associated With 9 Years of Quality Improvement Collaboratives PEDIATRICS Payne, N. R., Finkelstein, M. J., Liu, M., Kaempf, J. W., Sharek, P. J., Olsen, S. 2010; 125 (3): 437-446

  Abstract

  Quality improvement collaboratives (QICs) can improve short-term outcomes, but few have examined their long-term results. This study evaluated the changes in treatment practices and outcomes associated with participation in multiple sequential QICs.This retrospective, 9-year, pre-post study of very low birth weight infants, we assessed treatment and outcomes from the 8 NICUs of the Reduce Lung Injury (ReLI) group of a QIC sponsored by the Vermont Oxford Network (VON). We analyzed data from 1998 (pre-ReLI), 2001 (last ReLI year), and 2006 (5 years after ReLI) by using univariate and multiple regression.A total of 4065 very low birth weight infants were treated in ReLI NICUs in 1998, 2001, and 2006. From 1998 to 2006, the ReLI group decreased delivery room intubation (70% vs 52%; adjusted odds ratio [aOR]: 0.2 [95% confidence interval (CI): 0.2-0.3]; P < .001), conventional ventilation (75% vs 62%; aOR: 0.3 [95% CI: 0.2-0.4]; P < .001), and postnatal steroids for BPD (35% vs 10%; aOR: 0.09 [95% CI: 0.07-0.1]; P < .001). They increased the use of nasal continuous positive airway pressure (57% vs 78%; aOR: 3.3 [95% CI: 2.7-3.9]; P < .001). BPD-free survival remained unchanged (68% vs 66%; aOR: 0.9 [95% CI: 0.7-1.1]; P = .16), the BPD rate increased (25% vs 29%; aOR: 1.3 [95% CI: 1.1-1.6]; P = .017), survival to discharge increased (90% vs 93%; aOR: 1.5 [95% CI: 1.1-2.2]; P < .001), and nosocomial infections decreased (18% vs 15%; aOR: 0.8 [95% CI: 0.6-0.99]; P = .045).Participation in VON-sponsored QICs was associated with sustained implementation of potentially better respiratory practices, increased survival, and reduced nosocomial infections. The BPD-free survival rate did not change, and the BPD rate increased. Implemented changes endured for at least 5 years after the QIC.

  View details for DOI 10.1542/peds.2009-1272

  View details for Web of Science ID 000275945700004

  View details for PubMedID 20123773

• Improved physician work flow after integrating sign-out notes into the electronic medical record. Joint Commission journal on quality and patient safety / Joint Commission Resources Bernstein, J. A., Imler, D. L., Sharek, P., Longhurst, C. A. 2010; 36 (2): 72-78

  Abstract

  In recent years, electronic sign-out notes have been identified as a means of enhancing the effective transfer of patient care between providers. Such a tool was developed and implemented within the electronic medical record (EMR) system, and its impact on physician work flow was assessed.A printable sign-out report was implemented within the EMR system at a tertiary academic children's hospital. Month 1 post go-live survey data were collected in June and July 2006, and 6-month post go-live survey data were collected in November and December 2006. Use of the sign-out form to document handoff data between go-live and Month 16 (September 2007) was measured using log data from the EMR. Housestaff physicians were asked to report the impact of the tool on their work flow and satisfaction with the sign-out process through a Web-based survey.The sign-out report was steadily adopted following its introduction. Between the first and second surveys, use of EMR-integrated sign-out increased from 37% to 81% of respondents for day-to-night sign-out (chi2 = 12.79, p < .001) and from 14% to 39% for night-to-day sign-out (chi 2 = 5.08, p < .05). With increased use of the report, housestaff reported less time devoted to redundant data entry and increased satisfaction with the sign-out process.EMR-integrated sign-out documents offer the advantages of other electronic network-accessible systems and can also incorporate information already in the medical record in an automated manner. Although the primary motivation for introducing standardized, EMR-integrated sign-out documents is to enhance the safety of patient handoffs, the perception of improved physician work flow is also a benefit of such an intervention.

  View details for PubMedID 20180439

• Implementation of a two-specimen requirement for verification of ABO/Rh for blood transfusion TRANSFUSION Goodnough, L. T., Viele, M., Fontaine, M. J., Jurado, C., Stone, N., Quach, P., Chua, L., Chin, M., Scott, R., Tokareva, I., Tabb, K., Sharek, P. J. 2009; 49 (7): 1321-1328

  Abstract

  This study presents our implementation of a two-specimen requirement with no prior record of ABO/Rh to verify patients' blood type before transfusion.Blood type verification was introduced, discussed, approved, and implemented over a 12-month period (May 2007 to May 2008). Potential barriers and impact on benchmark indicators were identified and tracked.Inpatient identification and/or specimen labeling for nursing and laboratory phlebotomists baseline corrected error rates were 1:467 and 1:5555, respectively. This study therefore sought and obtained approval to initiate a new policy of blood type verification before blood transfusion. Compliance in turnaround time (TAT) before and after implementation for completion of STAT type and screen/crossmatch within 60 minutes worsened marginally, from 90% to 80%. The impact on use of O-, uncrossmatched blood was found to be manageable. Seven (of 25 total) recorded electronic complaints were received after implementation. The corrected error rate for nurse phlebotomy draws after implementation was 1:630.Despite the lack of an instigating event, verification of blood type before blood transfusion was successfully implemented. An impact on resources and benchmark indicators such as TAT can be anticipated and managed. Further process improvement efforts will be needed to ensure safety (e.g., at time of blood transfusion) for patients receiving blood transfusions. ABO/Rh verification may be necessary even after future implementation of bar coding and/or RFID chips, because human errors continue to occur even with systems improvements.

  View details for DOI 10.1111/j.1537-2995.2009.02157.x

  View details for Web of Science ID 000267715300010

  View details for PubMedID 19389026

• An intervention to decrease narcotic-related adverse drug events in children's hospitals PEDIATRICS Sharek, P. J., McClead, R. E., Taketomo, C., Luria, J. W., Takata, G. S., Walti, B., Tanski, M., Nelson, C., Logsdon, T. R., Thurm, C., Federico, F. 2008; 122 (4): E861-E866

  Abstract

  Narcotic-related adverse drug events are the most common adverse drug events in hospitalized children. Despite multiple published studies describing interventions that decrease adverse drug events from narcotics, large-scale collaborative quality improvement efforts to address narcotic-related adverse drug events in pediatrics have not been described. The purpose of this study was to evaluate collaborative-wide narcotic-related adverse drug event rates after a collection of expert panel-defined best practices was implemented.All 42 children's hospitals in the Child Health Corporation of America were invited to participate in the Institute for Healthcare Improvement-style quality improvement collaborative aimed at reducing narcotic-related adverse drug events. A collection of interventions known or suspected to reduce narcotic-related adverse drug events was recommended by an expert panel, with each site implementing >or=1 of these best practices on the basis of local need. Narcotic-related adverse drug event rates were compared between the baseline (December 1, 2004, to March 31, 2005) and postimplementation periods (January 1, 2006, to March 31, 2006) after an a priori-defined intervention ramp-up time (April 1, 2005, and December 31, 2005). Secondary outcome measures included constipation rates and narcotic-related automated drug-dispensing-device override percentages.Median narcotic-related adverse drug event rates decreased 67% between the baseline and postimplementation time frames across the 14-site collaborative. Constipation rates decreased 68.9%, and automated drug-dispensing-device overrides decreased from 10.18% to 5.91% of all narcotic doses administered.Implementation of >or=1 expert panel-recommended interventions at each participating site resulted in a significant decrease in narcotic-related adverse drug events, constipation, and automated drug-dispensing-device overrides in a 12-month, 14-site children's hospital quality collaborative.

  View details for DOI 10.1542/peds.2008-1011

  View details for Web of Science ID 000259812600053

  View details for PubMedID 18829784

• Effects of the Accreditation Council for Graduate Medical Education duty hour limits on sleep, work hours, and safety PEDIATRICS Landrigan, C. P., Fahrenkopf, A. M., Lewin, D., Sharek, P. J., Barger, L. K., Eisner, M., Edwards, S., Chiang, V. W., Wiedermann, B. L., Sectish, T. C. 2008; 122 (2): 250-258

  Abstract

  To mitigate the risks of fatigue-related medical errors, the Accreditation Council for Graduate Medical Education introduced work hour limits for resident physicians in 2003. Our goal was to determine whether work hours, sleep, and safety changed after implementation of the Accreditation Council for Graduate Medical Education standards.We conducted a prospective cohort study in which residents from 3 large pediatric training programs provided daily reports of work hours and sleep. In addition, they completed reports of near-miss and actual motor vehicle crashes, occupational exposures, self-reported medical errors, and ratings of educational experience. They were screened for depression and burnout. Concurrently, at 2 of the centers, data on medication errors were collected prospectively by using an established active surveillance method.A total of 220 residents provided 6007 daily reports of their work hours and sleep, and 16 158 medication orders were reviewed. Although scheduling changes were made in each program to accommodate the standards, 24- to 30-hour shifts remained common, and the frequency of residents' call remained largely unchanged. There was no change in residents' measured total work hours or sleep hours. There was no change in the overall rate of medication errors, and there was a borderline increase in the rate of resident physician ordering errors, from 1.06 to 1.38 errors per 100 patient-days. Rates of motor vehicle crashes, occupational exposures, depression, and self-reported medical errors and overall ratings of work and educational experiences did not change. The mean length of extended-duration (on-call) shifts decreased 2.7% to 28.5 hours, and rates of resident burnout decreased significantly (from 75.4% to 57.0%).Total hours of work and sleep did not change after implementation of the duty hour standards. Although fewer residents were burned out, rates of medication errors, resident depression, and resident injuries and educational ratings did not improve.

  View details for DOI 10.1542/peds.2007-2306

  View details for Web of Science ID 000258142500004

  View details for PubMedID 18676540

• Improving communication in a pediatric intensive care unit using daily patient goal sheets JOURNAL OF CRITICAL CARE Agarwal, S., Frankel, L., Tourner, S., McMillan, A., Sharek, P. J. 2008; 23 (2): 227-235

  Abstract

  The aim of the study was to determine if a pediatric intensive care unit (PICU) daily patient goal sheet would improve communication between health care providers and decrease length of stay (LOS).We evaluated a daily patient goal sheet's impact on questionnaire-based measures of effectiveness of communication, nurses' knowledge of physicians in charge, and on LOS in the PICU.Four hundred nineteen questionnaires were completed by nurses and physicians before goal sheet implementation and 387 after implementation. Nurses and physicians perceived an improved understanding of patient care goals (P < .001), reported increased comfort in explaining patient care goals to parents (P < .001), and listed a higher number of patient care goals after goal sheet implementation (P < .01). Nurses identified the patient's attending physician and fellow with increased accuracy after goal sheet implementation (P < .001). Median PICU LOS was unchanged; however, mean LOS trended toward a reduction after goal sheet implementation (4.1 vs 3.7 days, P = .36). Seventy-six percent of respondents found the goal sheets helpful.Using a PICU daily patient goal sheet can improve communication between health care providers, help nurses identify the in-charge physicians, and be helpful for patient care. By explicitly documenting patient care goals, there is enhanced clarity of patient care plans between health care providers.

  View details for DOI 10.1016/j.jcrc.2007.07.001

  View details for Web of Science ID 000256890800013

  View details for PubMedID 18538216

• Neonatal heparin overdose-a multidisciplinary team approach to medication error prevention. The journal of pediatric pharmacology and therapeutics : JPPT : the official journal of PPAG Arimura, J., Poole, R. L., Jeng, M., Rhine, W., Sharek, P. 2008; 13 (2): 96-98

  Abstract

  Despite the efforts of many hospitals, system failures can result in medication errors that may be life threatening. During 2006 and 2007, nine neonates received potentially fatal doses of heparin. This paper will review contributing factors to the heparin medication errors and ways to minimize the risk of heparin overdose.

  View details for DOI 10.5863/1551-6776-13.2.96

  View details for PubMedID 23055872

  View details for PubMedCentralID PMC3462065

• Cardiorespiratory arrests and rapid response teams in pediatrics - Reply JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Sharek, P., Roth, S. J. 2008; 299 (12): 1424-1424

  View details for Web of Science ID 000254292200012

• Rates of medication errors among depressed and burnt out residents: prospective cohort study BRITISH MEDICAL JOURNAL Fahrenkopf, A. M., Sectish, T. C., Barger, L. K., Sharek, P. J., Lewin, D., Chiang, V. W., Edwards, S., Wiedermann, B. L., Landrigan, C. P. 2008; 336 (7642): 488-491

  Abstract

  To determine the prevalence of depression and burnout among residents in paediatrics and to establish if a relation exists between these disorders and medication errors.Prospective cohort study.Three urban freestanding children's hospitals in the United States.123 residents in three paediatric residency programmes.Prevalence of depression using the Harvard national depression screening day scale, burnout using the Maslach burnout inventory, and rate of medication errors per resident month.24 (20%) of the participating residents met the criteria for depression and 92 (74%) met the criteria for burnout. Active surveillance yielded 45 errors made by participants. Depressed residents made 6.2 times as many medication errors per resident month as residents who were not depressed: 1.55 (95% confidence interval 0.57 to 4.22) compared with 0.25 (0.14 to 0.46, P<0.001). Burnt out residents and non-burnt out residents made similar rates of errors per resident month: 0.45 (0.20 to 0.98) compared with 0.53 (0.21 to 1.33, P=0.2).Depression and burnout are major problems among residents in paediatrics. Depressed residents made significantly more medical errors than their non-depressed peers; however, burnout did not seem to correlate with an increased rate of medical errors.

  View details for DOI 10.1136/bmj.39469.763218.BE

  View details for Web of Science ID 000253997500041

  View details for PubMedID 18258931

  View details for PubMedCentralID PMC2258399

• The use of telemedicine access to schools to facilitate expert assessment of children with asthma. International journal of telemedicine and applications Bergman, D. A., Sharek, P. J., Ekegren, K., Thyne, S., Mayer, M., Saunders, M. 2008: 159276-?

  Abstract

  Research has shown that access to an asthma specialist improves asthma outcomes. We hypothesized that we could improve access to expert asthma care through a telemedicine link between an asthma specialist and a school-based asthma program. We conducted a prospective cohort study in 3 urban schools to ascertain the feasibility of using an asthma-focused telemedicine solution. Each subject was seen by an asthma expert at 0, 8, and 32 weeks. The assessment and recommendations for care were sent to the primary care physician (PCP) and parents were told to contact their physician for follow-up care. Eighty three subjects participated in the study. Subjects experienced improvement (P < .05) in family social activities and the number of asthma attacks. Ninety four percent of subjects rated the program as good or excellent. This study demonstrates the feasibility and acceptance of a school-based asthma program using a telemedicine link to an asthma specialist.

  View details for DOI 10.1155/2008/159276

  View details for PubMedID 18369409

  View details for PubMedCentralID PMC2271044

• Best practice implementation: lessons learned from 20 partnerships. Joint Commission journal on quality and patient safety / Joint Commission Resources Sharek, P. J., Mullican, C., Lavanderos, A., Palmer, C., Snow, V., Kmetik, K., Antman, M., Knutson, D., Dembry, L. M. 2007; 33 (12): 16-26

  Abstract

  Partnerships can facilitate effective implementation of best practices, but literature describing effective and ineffective strategies to address barriers to implementation in partnerships is lacking.Principal investigators (PIs) were surveyed to identify barriers to best practice implementation, rank their significance, and articulate the success and failure of solutions attempted.The top four categories of barriers to implementation were partnership challenges, practitioner/local organization variables, time frame challenges, and financial concerns. Ninety-eight effective and 38 ineffective solutions used to overcome these barriers were identified. The most common categories of successful solutions were flexibility of interventions to align with unique local characteristics, schedules, and budgets (36.7% of listed successful solutions); communication strategies that emphasize frequent bidirectional information exchange in person (26.5%); and thoughtful use of personnel emphasizing sites' senior leadership and centralized quality and analytic content expertise (16.3%).Despite substantial partnership diversity, consistent themes related to barriers to implementation and solutions to these barriers emerged. The successful and unsuccessful solutions provided should be proactively assessed to enhance the likelihood of future partnership success.

  View details for PubMedID 18277636

• Simulation-based medical error disclosure training for pediatric healthcare professionals. Journal for healthcare quality : official publication of the National Association for Healthcare Quality Wayman, K. I., Yaeger, K. A., Sharek, P. J., Trotter, S., Wise, L., Flora, J. A., Halamek, L. P. 2007; 29 (4): 12-19

  Abstract

  Ethical and regulatory guidelines recommend disclosure of medical errors to patients and families. Yet few studies examine how to effectively train healthcare professionals to deliver communications about adverse events to family members of affected pediatric patients. This pilot study uses a preintervention-postintervention study design to investigate the effects of medical error disclosure training in a simulated setting for pediatric oncology nurses (N=16). The results of a paired t test showed statistically significant increases in nurses' communication self-efficacy to carry out medical disclosure (t = 6.68, p < .001). Ratings of setting "realism" and simulation effectiveness were high (21 out of 25 composite score). Findings provide preliminary support for further research on simulation-based disclosure training for healthcare professionals.

  View details for PubMedID 17849675

• The incidence of adverse events and medical error in pediatrics PEDIATRIC CLINICS OF NORTH AMERICA Sharek, P. J., Classen, D. 2006; 53 (6): 1067-?

  Abstract

  In its 2000 report, To Err is Human, the Institute of Medicine concluded that between 44,000 and 98,000 deaths per year occur in United States hospitals as a result of error. These data have resulted in calls for further research, regulatory interventions, third-party payer involvement, and health care organization initiatives to improve this situation. Studies of pediatric inpatients suggest that medication-related harm occurs at a rate as high as 11.1 per 100 admissions, and hospital-related harm occurs in high risk neonatal ICUs at a rate of 74 per 100 admissions. This article discusses differences between error and harm, methods used to measure harm, and available evidence that identifies the incidence of adverse events in pediatric inpatients and outpatients.

  View details for DOI 10.1016/j.pcl.2006.09.011

  View details for Web of Science ID 000243305100003

  View details for PubMedID 17126682

• Evaluation and development of potentially better practices to improve pain management of neonates PEDIATRICS Sharek, P. J., Powers, R., Koehn, A., Anand, K. J. 2006; 118: S78-S86

  Abstract

  Despite increased knowledge, improved options, and regulatory mandates, pain management of neonates remains inadequate, promoted by the ineffective translation of research data into clinical practice. The Neonatal Intensive Care Quality Improvement Collaborative 2002 was created to provide participating NICUs the tools necessary to translate research, related to prevention and treatment of neonatal pain, into practice. The objective for this study was to use proven quality improvement methods to develop a process to improve neonatal pain management collaboratively.Twelve members of the Neonatal Intensive Care Quality Improvement Collaborative 2002 formed an exploratory group to improve neonatal pain management. The exploratory group established group and site-specific goals and outcome measures for this project. Group members crafted a list of potentially better practices on the basis of the available literature, encouraged implementation of the potentially better practices at individual sites, developed a database for sharing information, and measured baseline outcomes.The goal "improve the assessment and management of infants experiencing pain in the NICU" was established. In addition, each site within the group identified local goals for improvement in neonatal pain management. Data from 7 categories of neonates (N = 277) were collected within 48 hours of NICU admission to establish baseline data for clinical practices. Ten potentially better practices were developed for prioritized pain conditions, and 61 potentially better practices were newly implemented at the 12 participating sites. Various methods were used for pain assessment at the participating centers. At baseline, heel sticks were used more frequently than peripheral intravenous insertions or venipunctures, with substantial variability in the number of avoidable procedures between centers. Pain was assessed in only 17% of procedures, and analgesic interventions were performed in 19% of the procedures at baseline.Collaborative use of quality improvement methods resulted in the creation of self-directed, efficient, and effective processes to improve neonatal pain management. Group establishment of potentially better practices, collective and site-specific goals, and extensive baseline data resulted in accelerated implementation of clinical practices that would not likely occur outside a collaborative setting.

  View details for DOI 10.1542/peds.2006-0913D

  View details for Web of Science ID 000243201000004

  View details for PubMedID 17079627

• Implementation and case-study results of potentially better practices to improve pain management of neonates PEDIATRICS Dunbar, A. E., Sharek, P. J., Mickas, N. A., Coker, K. L., Duncan, J., McLendon, D., Pagano, C., Puthoff, T. D., Reynolds, N. L., Powers, R. J., Johnston, C. C. 2006; 118: S87-S94

  Abstract

  Collaborative quality improvement techniques were used to facilitate local quality improvement in the management of pain in infants. Several case studies are presented to highlight this process.Twelve NICUs in the Neonatal Intensive Care Quality Improvement Collaborative 2002 focused on improving neonatal pain management and sedation practices. These centers developed and implemented evidence-based potentially better practices for pain management and sedation in neonates. The group introduced changes through plan-do-study-act cycles and tracked performance measures throughout the process.Strategies for implementing potentially better practices varied between centers on the basis of local characteristics. Individual centers identified barriers to implementation, developed tools for improvement, and shared their experience with the collaborative. Baseline data from the 12 sites revealed substantial opportunities for improved pain management, and local potentially better practice implementation resulted in measurable improvements in pain management at participating centers.The use of collaborative quality improvement techniques enhanced local quality improvement efforts and resulted in effective implementation of potentially better practices at participating centers.

  View details for DOI 10.1542/peds.2006-0913E

  View details for Web of Science ID 000243201000005

  View details for PubMedID 17079628

• Perceived increase in mortality after process and policy changes implemented with computerized physician order entry PEDIATRICS Longhurst, C., Sharek, P., Hahn, J., Sullivan, J., Classen, D. 2006; 117 (4): 1450-1451

  View details for DOI 10.1542/peds.2005-3048

  View details for Web of Science ID 000236540500088

  View details for PubMedID 16585351

• Improved pain management in pediatric postoperative liver transplant patients using parental education and non-pharmacologic interventions PEDIATRIC TRANSPLANTATION Sharek, P. J., Wayman, K., Lin, E., Strichartz, D., Sentivany-Collins, S., Good, J., Esquivel, C., Brown, M., Cox, K. 2006; 10 (2): 172-177

  Abstract

  A pain management intervention, consisting of pretransplant parental education and support, pre- and postoperative behavioral pediatrics consultation, postoperative physical and occupational therapy consultation, and implementation of non-pharmacologic pain management strategies, was introduced to all pediatrics patients receiving liver transplants at Lucile Packard Children's Hospital beginning August 2001. Children receiving transplants pre-intervention (May, 2000 to February, 2001) and post-intervention (August, 2001 to March, 2002) were compared using pain scores, parent perception of pain ratings, length of stay, ventilator days, total cost, and opioid use. A total of 27 children were evaluated (13 historical control, 14 intervention). The two populations did not differ on age at transplant (mean age 53.8 vs. 63.6 months), sex (46.1% vs. 50% male), ethnicity (53.8% vs. 57.1% white, non-Hispanic) weight at transplant (17.5 vs. 24.7 kg), percent with biliary atresia as the primary reason for transplant (42.9% vs. 69.2%), percent with status 1 transplant listing score (38.5% vs. 50.0%), or public insurance status (30.8 vs. 57.2% with Medicaid). No differences were found in mean pediatric intensive care unit (PICU) postoperative length of stay (6.7 vs. 5.3 days), total postoperative length of stay (17.5 vs. 17.5 days), total inpatient length of stay (27.0 vs. 24.4 days), time to extubation (30 vs. 24.3 h), total cost (dollar 147,983 vs. dollar 157,882) or opioid use through postoperative day (POD) 6 (0.24 vs. 0.25 mg/kg/day morphine equivalent). A decrease in mean pain score between POD 0 and 6 (2.82 vs. 2.12; p = 0.047), a decrease in mean parental pain perception score (3.1 vs. 2.1; p = 0.001), and an increase in number of pain assessments per 12 h shift (3.43 vs. 6.79; p < 0.005) were seen. A comprehensive non-pharmacologic postoperative pain management program in children receiving a liver transplant was associated with decreased pain scores, improved parent perception of pain, and an increased number of pain assessments per 12 h shift. No increases in lengths of stay (PICU, postoperative, total), time to extubation, or total cost were found.

  View details for DOI 10.1111/j.1399-3046.2005.00438.x

  View details for Web of Science ID 000236026400011

  View details for PubMedID 16573603

• Comparing the utility of a standard pediatric resuscitation cart with a pediatric resuscitation cart based on the Broselow tape: A randomized, controlled, crossover trial involving simulated resuscitation scenarios PEDIATRICS Agarwal, S., Swanson, S., Murphy, A., Yaeger, K., Sharek, P., Halamek, L. P. 2005; 116 (3): E326-E333

  Abstract

  Access to resuscitation equipment is a critical component in delivering optimal care in pediatric arrest situations. Historically, children's hospitals and clinics have used a standard pediatric resuscitation cart ("standard cart") in which drawers are organized by intervention (eg, intubation module, intravenous module), requiring multiple drawers to be opened during a code. Many emergency departments, however, use a pediatric resuscitation cart based on the Broselow tape ("Broselow cart") in which each drawer is color coded and organized by patient length and weight ranges; each drawer contains all necessary equipment for resuscitation of a patient in that specific length/weight range. A literature review has revealed no studies examining the utility of either cart.To compare which resuscitation cart organization (standard versus Broselow) allows for faster access to equipment, more accurate selection of appropriately sized equipment, and better user satisfaction. Methodology. We performed a prospective, randomized, controlled, crossover trial in which 21 pediatric health care providers were assigned the role of obtaining the appropriate equipment during 2 standardized, simulated codes alternately using either a standard or Broselow cart. Time to and accuracy of the selection of appropriate medical equipment along with posttesting satisfaction were measured. All simulations were performed in the Center for Advanced Pediatric Education at Stanford University Medical Center (Stanford, CA), a training facility designed to replicate the real medical environment with the technology to allow for videotaping of scenarios.Of the 21 subjects, 62% found the Broselow cart "easy" or "very easy" to use versus 33% for the standard cart. Of the 21 subjects, 67% preferred the Broselow cart, 10% preferred the standard cart, and 23% indicated no preference. Intubation supplies and nasogastric tubes were found significantly faster when using the Broselow cart (mean time: 29.1 and 20 seconds, respectively) versus the standard cart (mean time: 38.7 and 38.2 seconds, respectively). Correct equipment was provided a statistically significant 99% of the time with the Broselow cart versus 83% of the time with the standard cart. Ten percent of the subjects had prior experience with the Broselow cart versus 62% having experience with the standard cart.Despite less prior experience with the Broselow cart, subjects in this study found it easier to use and preferred it over the standard cart. In addition, subjects located intubation equipment and nasogastric tubes significantly faster when using the Broselow cart, and correct equipment was provided significantly more often with the Broselow cart. These data suggest that sites caring for pediatric patients should consider modeling their resuscitation carts after the Broselow cart to enhance provider confidence and patient safety.

  View details for DOI 10.1542/peds.2005-0320

  View details for Web of Science ID 000231576600001

  View details for PubMedID 16061568

• Effectiveness of a multicomponent self-management program in at-risk, school-aged children with asthma ANNALS OF ALLERGY ASTHMA & IMMUNOLOGY Shames, R. S., Sharek, P., Mayer, M., Robinson, T. N., Hoyte, E. G., Gonzalez-Hensley, F., Bergman, D. A., Umetsu, D. T. 2004; 92 (6): 611-618

  Abstract

  Improving asthma knowledge and self-management is a common focus of asthma educational programs, but most programs have had little influence on morbidity outcomes. We developed a novel multiple-component intervention that included the use of an asthma education video game intended to promote adoption of asthma self-management behaviors and appropriate asthma care.To determine the effectiveness of an asthma education video game in reducing morbidity among high-risk, school-aged children with asthma.We enrolled 119 children aged 5 to 12 years from low-income, urban areas in and around San Francisco, CA, and San Jose, CA. Children with moderate-to-severe asthma and parental reports of significant asthma health care utilization were randomized to participate in the disease management intervention or to receive their usual care (control group). Patients were evaluated for clinical and quality-of-life outcomes at weeks 8, 32, and 52 of the study.Compared with controls, the intervention group had significant improvements in the physical domain (P = .04 and P = .01 at 32 and 52 weeks, respectively) and social activity domain (P = .02 and P = .05 at 32 and 52 weeks, respectively) of asthma quality of life on the Child Health Survey for Asthma and child (P = .02 at 8 weeks) and parent (P = .04 and .004 at 32 and 52 weeks, respectively) asthma self-management knowledge. There were no significant differences between groups on clinical outcome variables.A multicomponent educational, behavioral, and medical intervention targeted at high-risk, inner-city children with asthma can improve asthma knowledge and quality of life.

  View details for Web of Science ID 000222121500007

  View details for PubMedID 15237762

• The use of telemedicine access to schools to facilitate expert assessment of children with asthma Annual Meeting of the Pediatric-Academic-Societies/Society-for-Pediatric-Research Bergman, D. A., Sharek, P. J., Ekegren, K., Saunders, M. NATURE PUBLISHING GROUP. 2004: 203A–203A

  View details for Web of Science ID 000220591101198

• Evaluation and development of potentially better practices to prevent chronic lung disease and reduce lung injury in neonates PEDIATRICS Sharek, P. J., Baker, R., Litman, F., Kaempf, J., Burch, K., Schwarz, E., Sun, S. Y., Payne, N. R. 2003; 111 (4)

  Abstract

  Despite increased knowledge and improving technology, chronic lung disease (CLD) rates in extremely low birth weight infants have remained constant for 20 years. One reason for this is an ineffective translation of research-proven improvements into practice. The Neonatal Intensive Care Quality Improvement Collaborative Year 2000 (NIC/Q 2000) was created to provide participating nurseries the tools necessary to effect change. The objective of this study was to develop and implement a process that uses quality improvement techniques to collaboratively improve CLD rates.Nine member hospitals of the NIC/Q 2000 collaborative formed a focus group aiming to decrease CLD rates. The focus group established goals and outcome measures, created a list of potentially better practices (PBPs) based on available literature, benchmarked and performed site visits, encouraged individual site implementation of PBPs, developed a database, and measured outcomes.The goal "decrease CLD rates in extremely low birth weight infants" was established. Nine PBPs were identified, and 57 PBPs were implemented by the 9 participating sites. Twelve site visits were conducted, and a 435-patient database of infants with a mean birth weight of 789 g was established.Collaborative use of quality improvement techniques resulted in creation of a logical, efficient, and effective process to improve CLD rates. Group creation of PBPs, based on literature review and reinforced with site visits, internal data analysis, and improved individual site outcomes, resulted in accelerated and effective change, unlikely to occur if attempted outside of the collaborative.

  View details for Web of Science ID 000181960900005

  View details for PubMedID 12671162

• Implementing potentially better practices to reduce lung injury in neonates PEDIATRICS Burch, K., Rhine, W., Baker, R., Litman, F., Kaempf, J. W., Schwarz, E., Sun, S. Y., Payne, N. R., Sharek, P. J. 2003; 111 (4)

  Abstract

  Adherence to basic quality improvement principles enhances the implementation of potentially better practices (PBPs) and requires extensive planning and education. Even after PBPs have been identified and acknowledged as desirable, effective implementation of these practices does not occur easily. The objective of this study was to identify and assess implementation strategies that facilitate quality improvements in the respiratory care of extremely low birth weight infants.The 9 members of the Neonatal Intensive Care Quality Improvement Collaborative Year 2000 Reducing Lung Injury focus group identified 9 PBPs in a evidence-based manner to decrease chronic lung disease in extremely low birth weight newborns. Each site implemented several or all PBPs based on a site-specific selection process. Each site was asked to submit 1 or more examples of experiences that highlighted effective implementation strategies. This article reports these examples and emphasizes the principles on which they are based.The 9 participating institutions implemented a total of 57 PBPs (range: 1-9; median: 5). Including previous implementation, the 9 participating institutions implemented a total of 70 of a possible 81 PBPs before or during the study period (range: 5-9; median: 8). We report 7 approaches that facilitated PBP implementation: information availability, feedback, perseverance, collaboration, imitation, recognition of implementation complexity, and tracking of process indicators.Quality improvement efforts are enhanced by identifying and then implementing PBPs. In our experience, implementation of these PBPs can be difficult. Implementation strategies, such as those identified in this article, can improve the chances that quality improvement efforts will be effective.

  View details for Web of Science ID 000181960900006

  View details for PubMedID 12671163

• Agreement among measures of asthma status: A prospective study of low-income children with moderate to severe asthma PEDIATRICS Sharek, P. J., Mayer, M. L., Loewy, L., Robinson, T. N., Shames, R. S., Umetsu, D. T., Bergman, D. A. 2002; 110 (4): 797-804

  Abstract

  Because no validated "gold standard" for measuring asthma outcomes exists, asthma interventions are often evaluated using a large number of disease status measures. Some of these measures may be redundant, whereas others may be complementary. Use of multiple outcomes may lead to ambiguous results, increased type I error rates, and be an inefficient use of resources including caregiver and patient/participant time and effort. Understanding the relationship between these measures may facilitate more parsimonious and valid evaluation strategies without loss of information.To assess the relationships between multiple measures of asthma disease status over time.We used data from a randomized, controlled trial of a comprehensive disease management program involving 119 disadvantaged inner-city children aged 5 to 12 years with moderate to severe asthma. Spearman correlations were calculated between the following asthma disease status measures: parent-reported disease symptoms, parent-reported health care utilization, functional health status using the American Academy of Pediatrics' validated Child Health Survey for Asthma (CHSA), diary data (symptom scores, night wakings, and bronchodilator use), and pulmonary function tests at baseline, 32 weeks, 52 weeks, and changes from baseline to 52 weeks.Ninety-four (79%) of randomized patients participated at baseline and 52 weeks. Completion rates for outcome measures ranged from 79% (CHSA, spirometry data) to 64% (diary data). At baseline, asthma symptoms, health care utilization, and individual domains from the CHSA were significantly correlated (r = 0.21-0.53). These correlations were stable over the 52-week follow-up. Forced expiratory volume in 1 second and diary data did not correlate to any other measures at baseline, and these measures correlated only inconsistently with other measures at 32 weeks and 52 weeks. Baseline to 52-week changes in asthma symptoms, utilization, and the CHSA domains were significantly correlated (0.22-0.56), as were baseline to 52-week changes in symptom days, night wakings, and the CHSA domains (r = 0.24-0.64). Baseline to 52-week changes in forced expiratory volume in 1 second and diary data did not correlate with other measures.These results suggest that asthma status and change in asthma status over time after introduction of a disease management intervention are best characterized by parent-reported symptoms, parent-reported utilization, and functional health status measures. Asthma diaries and pulmonary function tests did not seem to provide additional benefit, although they may play an important role in individual patient management. Our findings suggest a parsimonious evaluation strategy would include collection of key data elements regarding symptoms, utilization, and functional health status only, without loss of vital response information.

  View details for Web of Science ID 000178330200033

  View details for PubMedID 12359798

• Effect of an evidence-based hand washing policy on hand washing rates and false-positive coagulase negative staphylococcus blood and cerebrospinal fluid culture rates in a level III NICU. Journal of perinatology Sharek, P. J., Benitz, W. E., Abel, N. J., Freeburn, M. J., Mayer, M. L., Bergman, D. A. 2002; 22 (2): 137-143

  Abstract

  To determine the effect of implementing an evidence-based hand washing policy on between-patient hand washing compliance and on blood and cerebrospinal fluid (CSF) culture rates in a level III neonatal intensive care unit (NICU).An evidence-based hand washing policy, supported by an intensive education program, was introduced in a regional NICU. A total of 2009 preintervention neonates (16,168 patient days) over 17 months were compared to 676 postintervention neonates (5779 patient days) over 6 months. Hand washing compliance and rates of blood and CSF cultures yielding coagulase negative staphylococci (CONS) were compared before and after intervention.Compliance with appropriate between-patient hand washing improved (from 47.4% to 85.4%, p=0.001) after the hand washing policy was introduced. The rate of cultures positive for CONS declined from 6.1+/-2.3 to 3.2+/-1.6 per 1000 patient days (p=0.005). Most of this reduction was attributable to a reduction in false-positive cultures, from 4.2+/-2.4 to 1.9+/-1.8 per 1000 patient days (p=0.042), but there was a trend toward decreased true-positive cultures (from 2.1+/-1.2 to 1.2+/-1.0 per 1000 patient days, p=0.074) as well. Potential confounders and demographics factors were similar between the control and intervention subjects.Implementation of an evidence-based hand washing policy resulted in a significant increase in hand washing compliance and a significant decrease in false-positive coagulase negative staphylococcal blood and CSF culture rates. Exploratory data analysis revealed a possible effect on true-positive coagulase negative staphylococcal blood and CSF culture rates, but these results need to be confirmed in future studies.

  View details for PubMedID 11896519

• Environmental exposure and sensitization to cockroach, dust mite, and cat allergen: Correlation with asthma symptoms in a population of disadvantaged, inner-city children in the San Francisco Bay Area Taylor, K. L., Hoyte, E. G., Taylor, S. N., Mayer, M. L., Biederman, K. T., Sharek, P. J., Robinson, T. N., Bergman, D. A., Shames, R. S., Umetsu, D. T. MOSBY-ELSEVIER. 2002: S88–S88

  View details for Web of Science ID 000173744800231

• Effect of inhaled corticosteroids on growth - Reply PEDIATRICS Sharek, P. J., Bergman, D. A. 2001; 108 (5): 1235-1236

  View details for Web of Science ID 000171925200054

• The effect of inhaled steroids on the linear growth of children with asthma: A meta-analysis PEDIATRICS Sharek, P. J., Bergman, D. A. 2000; 106 (1)

  Abstract

  To determine whether inhaled steroid therapy causes delayed linear growth in children with asthma.Medline (1966-1998), Embase (1980-1998), and Cinahl (1982-1998) databases and bibliographies of included studies were searched for randomized, controlled trials of inhaled steroid therapy in children with asthma that evaluated linear growth.Studies were included if they met the following criteria: subjects 0 to 18 years of age with the clinical diagnosis of asthma; subjects randomized to inhaled beclomethasone, budesonide, flunisolide, fluticasone, or triamcinolone versus a nonsteroidal inhaled control for a minimum of 3 months; single- or double-blind; and outcome convertible to linear growth velocity. English- and non-English-language trials were included.Data were extracted using a priori guidelines. Methodologic quality was assessed independently by both authors. Outcome was extracted as linear growth velocity.Included trials were subgrouped by inhaled steroid. The beclomethasone subgroup, with 4 studies and 450 subjects, showed a decrease in linear growth velocity of 1.51 cm/year (95% confidence interval: 1.15,1.87). The fluticasone subgroup, with 1 study and 183 subjects, showed a decrease in linear growth velocity of.43 cm/year (95% confidence interval:.01,.85). Sensitivity analysis in the beclomethasone subgroup, which evaluated study quality, mode of medication delivery, control medication, and statistical model, showed similar results.This meta-analysis suggests that moderate doses of beclomethasone and fluticasone in children with mild to moderate asthma cause a decrease in linear growth velocity of 1.51 cm/year and.43 cm/year, respectively. The effects of inhaled steroids when given for >54 weeks, or on final adult height, remain unknown.

  View details for Web of Science ID 000087990400013

  View details for PubMedID 10878177

• Beclomethasone for asthma in children: effects on linear growth. Cochrane database of systematic reviews Sharek, P. J., Bergman, D. A. 2000: CD001282-?

  Abstract

  Inhaled steroids play a central role in the management of childhood asthma. There is concern about their side effects, especially on growth. However asthma may also cause growth retardation. Growth rates are not stable, so randomised controlled parallel group studies are needed to assess the impact of inhaled steroids on growth. This review is confine to one inhaled steroid, beclomethasone, that is known to have significant levels of systemic absorption.To determine whether inhaled beclomethasone cause significant delay in the linear growth of children with asthma.The Cochrane Airways Group asthma register was searched. Bibliographies from included studies, and known reviews were searched for additional citations. Personal contact with colleagues and researchers working in the field of asthma were made to identify potentially relevant trials.Randomized, controlled trials comparing the effects of beclamethasone to non-steroidal medication (placebo or non-steroidal therapy) on the linear growth of children with asthma.Data related to the clinical outcome "change in growth" were extracted by two reviewers working independentlyOne hundred and fifty-nine citations were identified by the search strategy and bibliography review. Three studies met the inclusion criteria. All used beclomethasone 200 mcg twice daily delivered by dry powder Diskhaler to treat children with mild-moderate asthma. Study duration was 7-12 months. In all three studies, a significant decrease in linear growth occurred in children treated with beclomethasone compared to those receiving placebo or non-steroidal asthma therapy. The average decrease, calculated through meta-analysis, was -1.54 cm per year (95% CI -1.15, -1.94).In children with mild-moderate asthma, beclomethasone 200 mcg twice daily caused a decrease in linear growth of -1.54 cm per year. These studies lasted a maximum of 54 weeks, so it remains unclear whether the decrease in growth is sustained or whether it reverses with 'catch up' after therapy is discontinued. We are unable to comment on growth effects of other inhaled steroids that have potentially less systemic effects. If inhaled steroids are required to control a child's asthma, we recommend using the minimum dose that effectively controls the child's asthma and closely following growth.

  View details for PubMedID 10796632

• THE EFFECT OF HOME OR NOVEL ENVIRONMENT ON THE FACILITATION OF PASSIVE-AVOIDANCE BY POST-TRAINING ETHANOL BEHAVIORAL AND NEURAL BIOLOGY COLBERN, D. L., Sharek, P., ZIMMERMANN, E. G. 1986; 46 (1): 1-12

  Abstract

  Passive avoidance behavior of mice is improved when mice are injected with ethanol immediately after footshock training. Further study has shown that avoidance can be affected by ethanol injections given within 1 h, but not at 90 or 180 min, after training. The present study was conducted to investigate the possibility that events which occur in the homecage during this sensitive period may influence the effect of ethanol on subsequent avoidance. Male Swiss-Webster mice were housed either singly in a novel environment for 90 min or returned to their (group) homecage following one-trial, step-through, passive avoidance training (0.1 mA footshock) and intraperitoneal injection of 3.0 g/kg ethanol (15% v/v) or saline. As in previous studies, when ethanol-treated mice were returned to their homecage, avoidance was significantly increased at 24 h compared to the behavior of saline-treated mice. However, when mice were isolated in the novel environment for 90 min immediately following treatment, the memory facilitating effects of ethanol were not observed. The avoidance behavior of mice injected with saline was the same regardless of their post-training environment. Also, the number of mice (6 or 10) housed per homecage did not significantly influence the effects of ethanol or post-training environment on avoidance. These findings indicate that environmental factors may interact with the effects of ethanol to modify avoidance behavior. The possible influence of variables such as aggression, thermoregulation, and behavioral arousal on the effects of ethanol in this paradigm are discussed.

  View details for Web of Science ID A1986C750000001

  View details for PubMedID 3729894