Lauren Destino

All Publications

• Parental Perspectives on Continuous Pulse Oximetry Use in Bronchiolitis Hospitalizations. Pediatrics Chi, K. W., Coon, E. R., Destino, L., Schroeder, A. R. 2020

  Abstract

  BACKGROUND: Because of the impact of continuous pulse oximetry (CPOX) on the overdiagnosis of hypoxemia in bronchiolitis, the American Academy of Pediatrics and the Choosing Wisely campaign have issued recommendations for intermittent monitoring. Parental preferences for monitoring may impact adoption of these recommendations, but these perspectives are poorly understood.METHODS: Using this cross-sectional survey, we explored parental perspectives on CPOX monitoring before discharge and 1 week after bronchiolitis hospitalizations. During the 1-week call, half of the participants were randomly assigned to receive a verbal statement on the potential harms of CPOX to determine if conveying the concept of overdiagnosis can change parental preferences on monitoring frequency. An aggregate variable measuring favorable perceptions of CPOX was created to determine CPOX affinity predictors.RESULTS: In-hospital interviews were completed on 357 patients, of which 306 (86%) completed the 1-week follow-up. Although 25% of parents agreed or strongly agreed that hospital monitors made them feel anxious, 98% agreed that the monitors were helpful. Compared to other vital signs, respiratory rate (87%) and oxygen saturation (84%) were commonly rated as "extremely important." Providing an educational statement on CPOX comparatively decreased parental desire for continuous monitoring (40% vs 20%; P < .001). Although there were no significant predictors of CPOX affinity, the effect size of the educational intervention was higher in college-educated parents.CONCLUSIONS: Parents find security in CPOX. A brief statement on the potential harms of CPOX use had an impact on stated monitoring preferences. Parental perspectives are important to consider because they may influence the adoption of intermittent monitoring.

  View details for DOI 10.1542/peds.2020-0130

  View details for PubMedID 32675334

• Comparison of As-Needed and Scheduled Posthospitalization Follow-up for Children Hospitalized for Bronchiolitis: The Bronchiolitis Follow-up Intervention Trial (BeneFIT) Randomized Clinical Trial. JAMA pediatrics Coon, E. R., Destino, L. A., Greene, T. H., Vukin, E., Stoddard, G., Schroeder, A. R. 2020: e201937

  Abstract

  Importance: Posthospitalization follow-up visits are prescribed frequently for children with bronchiolitis. The rationale for this practice is unclear, but prior work has indicated that families value these visits for the reassurance provided. The overall risks and benefits of scheduled visits have not been evaluated.Objective: To assess whether an as-needed posthospitalization follow-up visit is noninferior to a scheduled posthospitalization follow-up visit with respect to reducing anxiety among parents of children hospitalized for bronchiolitis.Design, Setting, and Participants: This open-label, noninferiority randomized clinical trial, performed between January 1, 2018, and April 31, 2019, assessed children younger than 24 months of age hospitalized for bronchiolitis at 2 children's hospitals (Primary Children's Hospital, Salt Lake City, Utah, and Lucile Packard Children's Hospital, Palo Alto, California) and 2 community hospitals (Intermountain Riverton Hospital, Riverton, Utah, and Packard El Camino Hospital, Mountain View, California). Data analysis was performed in an intention-to-treat manner.Interventions: Randomization (1:1) to a scheduled (n=151) vs an as-needed (n=153) posthospitalization follow-up visit.Main Outcome and Measures: The primary outcome was parental anxiety 7 days after hospital discharge, measured using the anxiety portion of the Hospital Anxiety and Depression Scale, which ranged from 0 to 28 points, with higher scores indicating greater anxiety. Fourteen prespecified secondary outcomes were assessed.Results: Among 304 children randomized (median age, 8 months; interquartile range, 3-14 months; 179 [59%] male), the primary outcome was available for 269 patients (88%). A total of 106 children (81%) in the scheduled follow-up group attended a scheduled posthospitalization visit compared with 26 children (19%) in the as-needed group (absolute difference, 62%; 95% CI, 53%-71%). The mean (SD) 7-day parental anxiety score was 3.9 (3.5) among the as-needed posthospitalization follow-up group and 4.2 (3.5) among the scheduled group (absolute difference, -0.3 points; 95% CI, -1.0 to 0.4 points), with the upper bound of the 95% CI within the prespecified noninferiority margin of 1.1 points. Aside from a decreased mean number of clinic visits (absolute difference, -0.6 visits per patient; 95% CI, -0.4 to -0.8 visits per patient) among the as-needed group, there were no significant between-group differences in secondary outcomes, including readmissions (any hospital readmission before symptom resolution: absolute difference, -1.6%; 95% CI, -5.7% to 2.5%) and symptom duration (time from discharge to cough resolution: absolute difference, -0.6 days; 95% CI, -2.4 to 1.2 days; time from discharge to child reported "back to normal": absolute difference, -0.8 days; 95% CI, -2.7 to 1.0 days; and time from discharge to symptom resolution: absolute difference, -0.6 days; 95% CI, -2.5 to 1.3 days).Conclusions and Relevance: Among parents of children hospitalized for bronchiolitis, an as-needed posthospitalization follow-up visit is noninferior to a scheduled posthospitalization follow-up visit with respect to reducing parental anxiety. These findings support as-needed follow-up as an effective posthospitalization follow-up strategy.Trial Registration: ClinicalTrials.gov Identifier: NCT03354325.

  View details for DOI 10.1001/jamapediatrics.2020.1937

  View details for PubMedID 32628250

• An Improvement Effort to Optimize Electronically Generated Hospital Discharge Instructions. Hospital pediatrics Chadwick, W., Bassett, H., Hendrickson, S., Slonaker, K., Perales, S., Pantaleoni, J., Srinivas, N., Platchek, T., Destino, L. 2019

  Abstract

  OBJECTIVES: The purpose of hospital discharge instructions (HDIs) is to facilitate safe patient transitions home, but electronic health records can generate lengthy documents filled with irrelevant information. When our institution changed electronic health records, a cumbersome electronic discharge workflow produced low-value HDI and contributed to a spike in discharge delays. Our aim was to decrease these delays while improving family and provider satisfaction with HDI.METHODS: We used quality improvement methodology to redesign the electronic discharge navigator and HDI to address the following issues: (1) difficulty preparing discharge instructions before time of discharge, (2) suboptimal formatting of HDI, (3) lack of standard templates and language within HDI, and (4) difficulties translating HDI into non-English languages. Discharge delays due to HDI were tracked before and after the launch of our new discharge workflow. Parents and providers evaluated HDI and the electronic discharge workflow, respectively, before and after our intervention. Providers audited HDI for content.RESULTS: Discharge delays due to HDI errors decreased from a mean of 3.4 to 0.5 per month after our intervention. Parents' ratings of how understandable our HDIs were improved from 2.35 to 2.74 postintervention (P = .05). Pediatric resident agreement that the electronic discharge process was easy to use increased from 9% to 67% after the intervention (P < .001).CONCLUSIONS: Through multidisciplinary collaboration we facilitated advance preparation of more standardized HDI and decreased related discharge delays from the acute care units at a large tertiary care hospital.

  View details for DOI 10.1542/hpeds.2018-0251

  View details for PubMedID 31243058

• Family-Centered Rounds: Past, Present, and Future. Pediatric clinics of North America Destino, L. A., Shah, S. S., Good, B. 2019; 66 (4): 827?37

  Abstract

  Bedside rounds have evolved concurrently with hospitalist medicine and patient-centered care. Family-centered rounds are the foundation of effective communication in the in-patient pediatric setting. Participant perspectives (family members, patients, nurses, faculty, and trainees) on family-centered rounds differ and goals may not always align. Further, the practical components of how rounds are conducted varies and have continued opportunities for improvement. This article summarizes the most recent experience with rounds in an attempt to identify unified and effective strategies moving forward.

  View details for DOI 10.1016/j.pcl.2019.03.008

  View details for PubMedID 31230625

• Improving Patient Flow: Analysis of an Initiative to Improve Early Discharge JOURNAL OF HOSPITAL MEDICINE Destino, L., Bennett, D., Wood, M., Acuna, C., Goodman, S., Asch, S. M., Platchek, T. 2019; 14 (1): 22?27

  View details for DOI 10.12788/jhm.3133

  View details for Web of Science ID 000457470100004

• Patient safety after implementation of a coproduced family centered communication programme: multicenter before and after intervention study. BMJ (Clinical research ed.) Khan, A., Spector, N. D., Baird, J. D., Ashland, M., Starmer, A. J., Rosenbluth, G., Garcia, B. M., Litterer, K. P., Rogers, J. E., Dalal, A. K., Lipsitz, S., Yoon, C. S., Zigmont, K. R., Guiot, A., O'Toole, J. K., Patel, A., Bismilla, Z., Coffey, M., Langrish, K., Blankenburg, R. L., Destino, L. A., Everhart, J. L., Good, B. P., Kocolas, I., Srivastava, R., Calaman, S., Cray, S., Kuzma, N., Lewis, K., Thompson, E. D., Hepps, J. H., Lopreiato, J. O., Yu, C. E., Haskell, H., Kruvand, E., Micalizzi, D. A., Alvarado-Little, W., Dreyer, B. P., Yin, H. S., Subramony, A., Patel, S. J., Sectish, T. C., West, D. C., Landrigan, C. P. 2018; 363: k4764

  Abstract

  OBJECTIVE: To determine whether medical errors, family experience, and communication processes improved after implementation of an intervention to standardize the structure of healthcare provider-family communication on family centered rounds.DESIGN: Prospective, multicenter before and after intervention study.SETTING: Pediatric inpatient units in seven North American hospitals, 17 December 2014 to 3 January 2017.PARTICIPANTS: All patients admitted to study units (3106 admissions, 13171 patient days); 2148 parents or caregivers, 435 nurses, 203 medical students, and 586 residents.INTERVENTION: Families, nurses, and physicians coproduced an intervention to standardize healthcare provider-family communication on ward rounds ("family centered rounds"), which included structured, high reliability communication on bedside rounds emphasizing health literacy, family engagement, and bidirectional communication; structured, written real-time summaries of rounds; a formal training programme for healthcare providers; and strategies to support teamwork, implementation, and process improvement.MAIN OUTCOME MEASURES: Medical errors (primary outcome), including harmful errors (preventable adverse events) and non-harmful errors, modeled using Poisson regression and generalized estimating equations clustered by site; family experience; and communication processes (eg, family engagement on rounds). Errors were measured via an established systematic surveillance methodology including family safety reporting.RESULTS: The overall rate of medical errors (per 1000 patient days) was unchanged (41.2 (95% confidence interval 31.2 to 54.5) pre-intervention v 35.8 (26.9 to 47.7) post-intervention, P=0.21), but harmful errors (preventable adverse events) decreased by 37.9% (20.7 (15.3 to 28.1) v 12.9 (8.9 to 18.6), P=0.01) post-intervention. Non-preventable adverse events also decreased (12.6 (8.9 to 17.9) v 5.2 (3.1 to 8.8), P=0.003). Top box (eg, "excellent") ratings for six of 25 components of family reported experience improved; none worsened. Family centered rounds occurred more frequently (72.2% (53.5% to 85.4%) v 82.8% (64.9% to 92.6%), P=0.02). Family engagement 55.6% (32.9% to 76.2%) v 66.7% (43.0% to 84.1%), P=0.04) and nurse engagement (20.4% (7.0% to 46.6%) v 35.5% (17.0% to 59.6%), P=0.03) on rounds improved. Families expressing concerns at the start of rounds (18.2% (5.6% to 45.3%) v 37.7% (17.6% to 63.3%), P=0.03) and reading back plans (4.7% (0.7% to 25.2%) v 26.5% (12.7% to 7.3%), P=0.02) increased. Trainee teaching and the duration of rounds did not change significantly.CONCLUSIONS: Although overall errors were unchanged, harmful medical errors decreased and family experience and communication processes improved after implementation of a structured communication intervention for family centered rounds coproduced by families, nurses, and physicians. Family centered care processes may improve safety and quality of care without negatively impacting teaching or duration of rounds.TRIAL REGISTRATION: ClinicalTrials.gov NCT02320175.

  View details for DOI 10.1136/bmj.k4764

  View details for PubMedID 30518517

• I-PASS Handoff Program: Use of a Campaign to Effect Transformational Change. Pediatric quality & safety Rosenbluth, G., Destino, L. A., Starmer, A. J., Landrigan, C. P., Spector, N. D., Sectish, T. C., I-PASS Campaign Committee 2018; 3 (4): e088

  Abstract

  Background: Behavior change is notoriously difficult to achieve within health care systems. Successful implementation of the I-PASS handoff bundle with subsequent decreases in medical errors and preventable adverse events represents an example of successful transformational change within academic medical centers.Objective: We designed a campaign to support and enhance uptake of the I-PASS handoff bundle at 9 study sites from 2011 to 2013.Methods: Following Kotter's model of transformational change, we established urgency using local data and institutional mandates, and site leaders built local guiding coalitions with institutional leaders, key faculty, and Chief Residents. We created and communicated our vision using a branded campaign and empowered others to act by soliciting and acting on feedback and supporting systems changes. Site leaders planned for and created short-term wins by recognizing residents who engaged with I-PASS, consolidated improvements, and institutionalized new approaches.Results: Implementation of I-PASS was successful, with achievement of substantial improvements in rates of medical errors and preventable adverse events. Data from the initial I-PASS study have continued to drive a national campaign that has included national recognition by leaders in the field of patient safety and pediatrics. Momentum has increased significantly to support mentored implementation of the I-PASS handoff program at over 35 academic medical centers across North America.Conclusions: I-PASS provides an example of transformational change achieved through a combination of educational interventions and change management to address resistance/barriers, supported by a robust campaign. We encourage others in academic medicine to consider using change models, including campaigns, to support health care improvement programs.

  View details for PubMedID 30229199

• Multisite Emergency Department Inpatient Collaborative to Reduce Unnecessary Bronchiolitis Care PEDIATRICS Mussman, G. M., Lossius, M., Wasif, F., Bennett, J., Shadman, K. A., Walley, S. C., Destino, L., Nichols, E., Ralston, S. L. 2018; 141 (2)

  View details for DOI 10.1542/peds.2017-.0830

  View details for Web of Science ID 000424817500006

• Outcomes of Follow-up Visits After Bronchiolitis Hospitalizations. JAMA pediatrics Schroeder, A. R., Destino, L. A., Brooks, R., Wang, C. J., Coon, E. R. 2018

  View details for PubMedID 29379947

• Implementing Parental Tobacco Dependence Treatment Within Bronchiolitis QI Collaboratives. Pediatrics Walley, S. C., Mussman, G. M., Lossius, M., Shadman, K. A., Destino, L., Garber, M., Ralston, S. L. 2018; 141 (6)

  Abstract

  We sought to implement systematic tobacco dependence interventions for parents and/or caregivers as secondary aims within 2 multisite quality improvement (QI) collaboratives for bronchiolitis. We hypothesized that iterative improvements in tobacco dependence intervention strategies would result in improvement in outcomes between collaboratives.This study involved 2 separate yearlong, multisite QI collaboratives that were focused on care provided to inpatients with a primary diagnosis of bronchiolitis. In each collaborative, we provided tools and training in tobacco dependence treatment and expert coaching on interventions for parents as a secondary aim. Data were collected by chart review and results analyzed by using analysis of means and statistical process control analysis. Outcomes between collaboratives were compared by using relative risks.Between both collaboratives, 56 hospitals participated and 6258 inpatient charts were reviewed. In the first collaborative, 22% of identified parents who smoke received tobacco dependence interventions at baseline. This rate increased to 51% during the postintervention period, with special cause revealed by analysis of means. In the second collaborative, 31% of parents who smoke received baseline interventions. This rate increased to 53% by the conclusion of the collaborative, with special cause revealed by statistical process control analysis. The relative risk for providing any cessation intervention in 1 collaborative versus the other was 0.9 (confidence interval 0.8-1.1).Tobacco dependence treatment of parents and/or caregivers can be integrated into bronchiolitis QI by using relatively low-resource strategies. Using a more intensive QI intervention did not alter the rates of screening or intervention for caregivers who smoke.

  View details for PubMedID 29769242

• Respiratory Scores as a Tool to Reduce Bronchodilator Use in Children Hospitalized With Acute Viral Bronchiolitis. Hospital pediatrics Mussman, G. M., Sahay, R. D., Destino, L., Lossius, M., Shadman, K. A., Walley, S. C. 2017; 7 (5): 279-286

  Abstract

  Adoption of clinical respiratory scoring as a quality improvement (QI) tool in bronchiolitis has been temporally associated with decreased bronchodilator usage. We sought to determine whether documented use of a clinical respiratory score at the patient level was associated with a decrease in either the physician prescription of any dose of bronchodilator or the number of doses, if prescribed, in a multisite QI collaborative.We performed a secondary analysis of data from a QI collaborative involving 22 hospitals. The project enrolled patients aged 1 month to 2 years with a primary diagnosis of acute viral bronchiolitis and excluded those with prematurity, other significant comorbid diseases, and those needing intensive care. We assessed for an association between documentation of any respiratory score use during an episode of care, as well as the method in which scores were used, and physician prescribing of any bronchodilator and number of doses. Covariates considered were phase of the collaborative, hospital length of stay, steroid use, and presence of household smokers.A total of 1876 subjects were included. There was no association between documentation of a respiratory score and the likelihood of physician prescribing of any bronchodilator. Score use was associated with fewer doses of bronchodilators if one was prescribed (P = .05), but this association disappeared with multivariable analysis (P = .73).We found no clear association between clinical respiratory score use and physician prescribing of bronchodilators in a multicenter QI collaborative.

  View details for DOI 10.1542/hpeds.2016-0090

  View details for PubMedID 28442541

• Inpatient Hospital Factors and Resident Time With Patients and Families PEDIATRICS Destino, L. A., Valentine, M., Sheikhi, F. H., Starmer, A. J., Landrigan, C. P., Sanders, L. 2017; 139 (5)

  Abstract

  To define hospital factors associated with proportion of time spent by pediatric residents in direct patient care.We assessed 6222 hours of time-motion observations from a representative sample of 483 pediatric-resident physicians delivering inpatient care across 9 pediatric institutions. The primary outcome was percentage of direct patient care time (DPCT) during a single observation session (710 sessions). We used one-way analysis of variance to assess a significant difference in the mean percentage of DPCT between hospitals. We used the intraclass correlation coefficient analysis to determine within- versus between-hospital variations. We compared hospital characteristics of observation sessions with ?12% DPCT to characteristics of sessions with <12% DPCT (12% is the DPCT in recent resident trainee time-motion studies). We conducted mixed-effects regression analysis to allow for clustering of sessions within hospitals and accounted for correlation of responses across hospital.Mean proportion of physician DPCT was 13.2% (SD = 8.6; range, 0.2%-49.5%). DPCT was significantly different between hospitals (P < .001). The intraclass correlation coefficient was 0.25, indicating more within-hospital than between-hospital variation. Observation sessions with ?12% DPCT were more likely to occur at hospitals with Magnet designation (odds ratio [OR] = 3.45, P = .006), lower medical complexity (OR = 2.57, P = .04), and higher patient-to-trainee ratios (OR = 2.48, P = .05).On average, trainees spend <8 minutes per hour in DPCT. Variation exists in DPCT between hospitals. A less complex case mix, increased patient volume, and Magnet designation were independently associated with increased DPCT.

  View details for DOI 10.1542/peds.2016-3011

  View details for PubMedID 28557735

• Families as Partners in Hospital Error and Adverse Event Surveillance. JAMA pediatrics Khan, A., Coffey, M., Litterer, K. P., Baird, J. D., Furtak, S. L., Garcia, B. M., Ashland, M. A., Calaman, S., Kuzma, N. C., O'Toole, J. K., Patel, A., Rosenbluth, G., Destino, L. A., Everhart, J. L., Good, B. P., Hepps, J. H., Dalal, A. K., Lipsitz, S. R., Yoon, C. S., Zigmont, K. R., Srivastava, R., Starmer, A. J., Sectish, T. C., Spector, N. D., West, D. C., Landrigan, C. P., Allair, B. K., Alminde, C., Alvarado-Little, W., Atsatt, M., Aylor, M. E., Bale, J. F., Balmer, D., Barton, K. T., Beck, C., Bismilla, Z., Blankenberg, R. L., Chandler, D., Choudhary, A., Christensen, E., Coghlan-McDonald, S., Cole, F. S., Corless, E., Cray, S., Da Silva, R., Dahale, D., Dreyer, B., Growdon, A. S., Gubler, L., Guiot, A., Harris, R., Haskell, H., Kocolas, I., Kruvand, E., Lane, M. M., Langrish, K., Ledford, C. J., Lewis, K., Lopreiato, J. O., Maloney, C. G., Mangan, A., Markle, P., Mendoza, F., Micalizzi, D. A., Mittal, V., Obermeyer, M., O'Donnell, K. A., Ottolini, M., Patel, S. J., Pickler, R., Rogers, J. E., Sanders, L. M., Sauder, K., Shah, S. S., Sharma, M., Simpkin, A., Subramony, A., Thompson, E. D., Trueman, L., Trujillo, T., Turmelle, M. P., Warnick, C., Welch, C., White, A. J., Wien, M. F., Winn, A. S., Wintch, S., Wolf, M., Yin, H. S., Yu, C. E. 2017

  Abstract

  Medical errors and adverse events (AEs) are common among hospitalized children. While clinician reports are the foundation of operational hospital safety surveillance and a key component of multifaceted research surveillance, patient and family reports are not routinely gathered. We hypothesized that a novel family-reporting mechanism would improve incident detection.To compare error and AE rates (1) gathered systematically with vs without family reporting, (2) reported by families vs clinicians, and (3) reported by families vs hospital incident reports.We conducted a prospective cohort study including the parents/caregivers of 989 hospitalized patients 17 years and younger (total 3902 patient-days) and their clinicians from December 2014 to July 2015 in 4 US pediatric centers. Clinician abstractors identified potential errors and AEs by reviewing medical records, hospital incident reports, and clinician reports as well as weekly and discharge Family Safety Interviews (FSIs). Two physicians reviewed and independently categorized all incidents, rating severity and preventability (agreement, 68%-90%; ?, 0.50-0.68). Discordant categorizations were reconciled. Rates were generated using Poisson regression estimated via generalized estimating equations to account for repeated measures on the same patient.Error and AE rates.Overall, 746 parents/caregivers consented for the study. Of these, 717 completed FSIs. Their median (interquartile range) age was 32.5 (26-40) years; 380 (53.0%) were nonwhite, 566 (78.9%) were female, 603 (84.1%) were English speaking, and 380 (53.0%) had attended college. Of 717 parents/caregivers completing FSIs, 185 (25.8%) reported a total of 255 incidents, which were classified as 132 safety concerns (51.8%), 102 nonsafety-related quality concerns (40.0%), and 21 other concerns (8.2%). These included 22 preventable AEs (8.6%), 17 nonharmful medical errors (6.7%), and 11 nonpreventable AEs (4.3%) on the study unit. In total, 179 errors and 113 AEs were identified from all sources. Family reports included 8 otherwise unidentified AEs, including 7 preventable AEs. Error rates with family reporting (45.9 per 1000 patient-days) were 1.2-fold (95% CI, 1.1-1.2) higher than rates without family reporting (39.7 per 1000 patient-days). Adverse event rates with family reporting (28.7 per 1000 patient-days) were 1.1-fold (95% CI, 1.0-1.2; P?=?.006) higher than rates without (26.1 per 1000 patient-days). Families and clinicians reported similar rates of errors (10.0 vs 12.8 per 1000 patient-days; relative rate, 0.8; 95% CI, .5-1.2) and AEs (8.5 vs 6.2 per 1000 patient-days; relative rate, 1.4; 95% CI, 0.8-2.2). Family-reported error rates were 5.0-fold (95% CI, 1.9-13.0) higher and AE rates 2.9-fold (95% CI, 1.2-6.7) higher than hospital incident report rates.Families provide unique information about hospital safety and should be included in hospital safety surveillance in order to facilitate better design and assessment of interventions to improve safety.

  View details for DOI 10.1001/jamapediatrics.2016.4812

  View details for PubMedID 28241211

• Improving Communication with Primary Care Physicians at the Time of Hospital Discharge. Joint Commission journal on quality and patient safety Destino, L. A., Dixit, A., Pantaleoni, J. L., Wood, M. S., Pageler, N. M., Kim, J., Platchek, T. S. 2017; 43 (2): 80-88

  Abstract

  Communication with primary care physicians (PCPs) at the time of a patient's hospital discharge is important to safely transition care to home. The goal of this quality improvement initiative was to increase discharge communication to PCPs at an academic children's hospital.A multidisciplinary team at Lucile Packard Children's Hospital Stanford used Lean A3 problem solving methodology to address the problem of inadequate discharge communication with PCPs. Emphasis was placed on frontline provider (resident physicians) involvement in the improvement process, creating standards, and error proofing. Root cause analysis identified several key drivers of the problem, and successive countermeasures were implemented beginning in August 2013 aimed at achieving the target of 80% attempted verbal communication within seven days before or after (usually 24-48 hours) on the pediatric medical services. Run charts were generated tracking the outcome of PCP communication.On the pediatric medical services, the goal of 80% communication was met and sustained during a seven-month period starting October 2013, a statistically significant improvement. In the eight months prior to October 2013, hospitalwide PCP communication prior to discharge averaged 59.1% (n?=?5,397) and improved to 76.7% (n?=?4,870) in the seven months after (p?<0.001). Fifteen of 19 specialty services had a significant increase in discharge communication after October 2013.Lean improvement methodology (including structured problem solving using A3 thinking), intensive frontline provider involvement, and process-oriented electronic health record work flow redesign led to increased verbal PCP communication at around the time of a patient's discharge.

  View details for DOI 10.1016/j.jcjq.2016.11.005

  View details for PubMedID 28334566

• Integrating Research, Quality Improvement, and Medical Education for Better Handoffs and Safer Care: Disseminating, Adapting, and Implementing the I-PASS Program. Joint Commission journal on quality and patient safety Starmer, A. J., Spector, N. D., West, D. C., Srivastava, R., Sectish, T. C., Landrigan, C. P. 2017; 43 (7): 319?29

  Abstract

  In 2009 the I-PASS Study Group was formed by patient safety, medical education, health services research, and clinical experts from multiple institutions in the United States and Canada. When the I-PASS Handoff Program, which was developed by the I-PASS Study Group, was implemented in nine hospitals, it was associated with a 30% reduction in injuries due to medical errors and significant improvements in handoff processes, without any adverse effects on provider work flow.To effectively disseminate and adapt I-PASS for use across specialties and disciplines, a series of federally and privately funded dissemination and implementation projects were carried out following the publication of the initial study. The results of these efforts have informed ongoing initiatives intended to continue adapting and scaling the program.As of this writing, I-PASS Study Group members have directly worked with more than 50 hospitals to facilitate implementation of I-PASS. To further disseminate I-PASS, Study Group members delivered hundreds of academic presentations, including plenaries at scientific meetings, workshops, and institutional Grand Rounds. Some 3,563 individuals, representing more than 500 institutions in the 50 states in the United States, the District of Columbia, Puerto Rico, and 57 other countries, have requested access to I-PASS materials. Most recently, the I-PASS(SM) Patient Safety Institute has developed a virtual immersion training platform, mobile handoff observational tools, and processes to facilitate further spread of I-PASS.Implementation of I-PASS has been associated with substantial improvements in patient safety and can be applied to a variety of disciplines and types of patient handoffs. Widespread implementation of I-PASS has the potential to substantially improve patient safety in the United States and beyond.

  View details for DOI 10.1016/j.jcjq.2017.04.001

  View details for PubMedID 28648217

• Expanding the phenotype of hawkinsinuria: new insights from response to N-acetyl-L-cysteine. Journal of inherited metabolic disease Gomez-Ospina, N., Scott, A. I., Oh, G. J., Potter, D., Goel, V. V., Destino, L., Baugh, N., Enns, G. M., Niemi, A., Cowan, T. M. 2016; 39 (6): 821-829

  Abstract

  Hawkinsinuria is a rare disorder of tyrosine metabolism that can manifest with metabolic acidosis and growth arrest around the time of weaning off breast milk, typically followed by spontaneous resolution of symptoms around 1 year of age. The urinary metabolites hawkinsin, quinolacetic acid, and pyroglutamic acid can aid in identifying this condition, although their relationship to the clinical manifestations is not known. Herein we describe clinical and laboratory findings in two fraternal twins with hawkinsinuria who presented with failure to thrive and metabolic acidosis. Close clinical follow-up and laboratory testing revealed previously unrecognized hypoglycemia, hypophosphatemia, combined hyperlipidemia, and anemia, along with the characteristic urinary metabolites, including massive pyroglutamic aciduria. Treatment with N-acetyl-L-cysteine (NAC) restored normal growth and normalized or improved most biochemical parameters. The dramatic response to NAC therapy supports the idea that glutathione depletion plays a key role in the pathogenesis of hawkinsinuria.

  View details for PubMedID 27488560

• Engaging Pediatric Resident Physicians in Quality Improvement Through Resident-Led Morbidity and Mortality Conferences. Joint Commission journal on quality and patient safety / Joint Commission Resources Destino, L. A., Kahana, M., Patel, S. J. 2016; 42 (3): 99-106

  Abstract

  Increasingly, medical disciplines have used morbidity and mortality conferences (MMCs) to address quality improvement and patient safety (QI/PS), as well as teach systems-based improvement to graduate trainees. The goal of this educational intervention was to establish a pediatric resident physician?led MMC that not only focused on QI/PS principles but also engaged resident physicians in QI/ PS endeavors in their clinical learning environments.Following a needs assessment, pediatric resident physicians at the Stanford University School of Medicine (Stanford, California) established a new MMC model in February 2010 as part of a required QI rotation. Cases were identified, explored, analyzed, and presented by resident physicians using the Johns Hopkins Learning from Defects tool. Discussions during the MMCs were resident physician? directed and systems-based, and resulted in projects to address care delivery. Faculty advisors assessed resident physician comprehension of QI/PS. Conferences were evaluated through the end of the 2012?2013 academic year and outcomes tracked through the 2013?2014 academic year to determine trainee involvement in systems change resulting from the MMCs.The MMC was well received and the number of MMCs increased over time. By the end of the 2013?2014 academic year, resident physicians were involved in address ing 14 systems-based issues resulting from 25 MMCs. Examples of the resident physician?initiated improvement work included increasing use of the rapid response team, institution of a gastrostomy (g)-tube order set, and establishing a face-to-face provider handoff for pediatric ICU?to-acute-care-floor transfers.A resident physician?run MMC exposes resident physicians to QI/PS concepts and principles, enables direct faculty assessment of QI/PS knowledge, and can propel resident physicians into real-time engagement in the culture of safety in a complex hospital environment.

  View details for PubMedID 26892704

• Intern and Resident Workflow Patterns on Pediatric Inpatient Units: A Multicenter Time-Motion Study JAMA PEDIATRICS Starmer, A. J., Destino, L., Yoon, C. S., Landrigan, C. P. 2015; 169 (12): 1175-1177

  View details for DOI 10.1001/jamapediatrics.2015.2471

  View details for PubMedID 26501753

• Variation in printed handoff documents: Results and recommendations from a multicenter needs assessment JOURNAL OF HOSPITAL MEDICINE Rosenbluth, G., Bale, J. F., Starmer, A. J., Spector, N. D., Srivastava, R., West, D. C., Sectish, T. C., Landrigan, C. P. 2015; 10 (8): 517-524

  Abstract

  Handoffs of patient care are a leading root cause of medical errors. Standardized techniques exist to minimize miscommunications during verbal handoffs, but studies to guide standardization of printed handoff documents are lacking.To determine whether variability exists in the content of printed handoff documents and to identify key data elements that should be uniformly included in these documents.Pediatric hospitalist services at 9 institutions in the United States and Canada.Sample handoff documents from each institution were reviewed, and structured group interviews were conducted to understand each institution's priorities for written handoffs. An expert panel reviewed all handoff documents and structured group-interview findings, and subsequently made consensus-based recommendations for data elements that were either essential or recommended, including best overall printed handoff practices.Nine sites completed structured group interviews and submitted data. We identified substantial variation in both the structure and content of printed handoff documents. Only 4 of 23 possible data elements (17%) were uniformly present in all sites' handoff documents. The expert panel recommended the following as essential for all printed handoffs: assessment of illness severity, patient summary, action items, situation awareness and contingency plans, allergies, medications, age, weight, date of admission, and patient and hospital service identifiers. Code status and several other elements were also recommended.Wide variation exists in the content of printed handoff documents. Standardizing printed handoff documents has the potential to decrease omissions of key data during patient care transitions, which may decrease the risk of downstream medical errors.

  View details for DOI 10.1002/jhm.2380

  View details for Web of Science ID 000358693600007

  View details for PubMedID 26014471

• Changes in Medical Errors after Implementation of a Handoff Program NEW ENGLAND JOURNAL OF MEDICINE Starmer, A. J., Spector, N. D., Srivastava, R., West, D. C., Rosenbluth, G., Allen, A. D., NOBLE, E. L., Tse, L. L., Dalal, A. K., Keohane, C. A., Lipsitz, S. R., Rothschild, J. M., Wien, M. F., Yoon, C. S., Zigmont, K. R., Wilson, K. M., O'Toole, J. K., Solan, L. G., Aylor, M., Bismilla, Z., Coffey, M., Mahant, S., Blankenburg, R. L., Destino, L. A., EVERHART, J. L., Patel, S. J., Bale, J. F., Spackman, J. B., Stevenson, A. T., Calaman, S., Cole, F. S., Balmer, D. F., Hepps, J. H., Lopreiato, J. O., Yu, C. E., Sectish, T. C., Landrigan, C. P. 2014; 371 (19): 1803-1812

  Abstract

  Miscommunications are a leading cause of serious medical errors. Data from multicenter studies assessing programs designed to improve handoff of information about patient care are lacking.We conducted a prospective intervention study of a resident handoff-improvement program in nine hospitals, measuring rates of medical errors, preventable adverse events, and miscommunications, as well as resident workflow. The intervention included a mnemonic to standardize oral and written handoffs, handoff and communication training, a faculty development and observation program, and a sustainability campaign. Error rates were measured through active surveillance. Handoffs were assessed by means of evaluation of printed handoff documents and audio recordings. Workflow was assessed through time-motion observations. The primary outcome had two components: medical errors and preventable adverse events.In 10,740 patient admissions, the medical-error rate decreased by 23% from the preintervention period to the postintervention period (24.5 vs. 18.8 per 100 admissions, P<0.001), and the rate of preventable adverse events decreased by 30% (4.7 vs. 3.3 events per 100 admissions, P<0.001). The rate of nonpreventable adverse events did not change significantly (3.0 and 2.8 events per 100 admissions, P=0.79). Site-level analyses showed significant error reductions at six of nine sites. Across sites, significant increases were observed in the inclusion of all prespecified key elements in written documents and oral communication during handoff (nine written and five oral elements; P<0.001 for all 14 comparisons). There were no significant changes from the preintervention period to the postintervention period in the duration of oral handoffs (2.4 and 2.5 minutes per patient, respectively; P=0.55) or in resident workflow, including patient-family contact and computer time.Implementation of the handoff program was associated with reductions in medical errors and in preventable adverse events and with improvements in communication, without a negative effect on workflow. (Funded by the Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, and others.).

  View details for DOI 10.1056/NEJMsa1405556

  View details for Web of Science ID 000344170300009

• Development, Implementation, and Dissemination of the I-PASS Handoff Curriculum: A Multisite Educational Intervention to Improve Patient Handoffs ACADEMIC MEDICINE Starmer, A. J., O'Toole, J. K., Rosenbluth, G., Calaman, S., Balmer, D., West, D. C., Bale, J. F., Yu, C. E., Noble, E. L., Tse, L. L., Srivastava, R., Landrigan, C. P., Sectish, T. C., Spector, N. D. 2014; 89 (6): 876-884

  Abstract

  Patient handoffs are a key source of communication failures and adverse events in hospitals. Despite Accreditation Council for Graduate Medical Education requirements for residency training programs to provide formal handoff skills training and to monitor handoffs, well-established curricula and validated skills assessment tools are lacking. Developing a handoff curriculum is challenging because of the need for standardized processes and faculty development, cultural resistance to change, and diverse institution- and unit-level factors. In this article, the authors apply a logic model to describe the process they used from June 2010 to February 2014 to develop, implement, and disseminate an innovative, comprehensive handoff curriculum in pediatric residency training programs as a fundamental component of the multicenter Initiative for Innovation in Pediatric Education-Pediatric Research in Inpatient Settings Accelerating Safe Sign-outs (I-PASS) Study. They describe resources, activities, and outputs, and report preliminary learner outcomes using data from resident and faculty evaluations of the I-PASS Handoff Curriculum: 96% of residents and 97% of faculty agreed or strongly agreed that the curriculum promoted acquisition of relevant skills for patient care activities. They also share lessons learned that could be of value to others seeking to adopt a structured handoff curriculum or to develop large-scale curricular innovations that involve redesigning firmly established processes. These lessons include the importance of approaching curricular implementation as a transformational change effort, assembling a diverse team of junior and senior faculty to provide opportunities for mentoring and professional development, and linking the educational intervention with the direct measurement of patient outcomes.

  View details for DOI 10.1097/ACM.0000000000000264

  View details for PubMedID 24871238

• Placing Faculty Development Front and Center in a Multisite Educational Initiative: Lessons From the I-PASS Handoff Study ACADEMIC PEDIATRICS O'Toole, J. K., West, D. C., Starmer, A. J., Yu, C. E., Calaman, S., Rosenbluth, G., Hepps, J. H., Lopreiato, J. O., Landrigan, C. P., Sectish, T. C., Spector, N. D. 2014; 14 (3): 221-224

  View details for Web of Science ID 000335368000002

  View details for PubMedID 24767774

• Validity of respiratory scores in bronchiolitis. Hospital pediatrics Destino, L., Weisgerber, M. C., Soung, P., Bakalarski, D., Yan, K., Rehborg, R., Wagner, D. R., Gorelick, M. H., Simpson, P. 2012; 2 (4): 202-209

  Abstract

  The primary objective of this study was to establish the validity and reliability of 2 respiratory scores, the Respiratory Distress Assessment Instrument (RDAI) and the Children's Hospital of Wisconsin Respiratory Score (CHWRS), in bronchiolitis. A secondary objective was to identify the respiratory score components that most determine overall respiratory status.This was a prospective cohort study in infants aged < 1 year seen at Children's Hospital of Wisconsin for bronchiolitis. We evaluated: (1) discriminative validity (the score's ability to discriminate between 2 different outcomes) of the respiratory scores to identify emergency department (ED) disposition by using receiver operating characteristic curves; and (2) construct validity (the score's ability to measure what it is thought to measure, overall respiratory status) by using length of stay (LOS) as a proxy for disease severity and comparing correlations between changes in respiratory scores and LOS. Interrater reliability was established by using intraclass correlation. The contribution of individual respiratory score components to determine ED disposition was studied by using multivariate logistic regression.A total of 195 infants were included. The area under the receiver operating characteristic curve was 0.68 for CHWRS versus 0.51 for RDAI in predicting disposition. There was no correlation between initial respiratory scores or change in respiratory scores over the first 24 hours and LOS. Item analysis revealed that oxygen delivery, subcostal retractions, and respiratory rate were independently correlated with ED disposition. The CHWRS was more reliable than the RDAI.The CHWRS had modest discriminative validity in predicting ED disposition. Neither the CHWRS nor the RDAI had good construct validity. Respiratory rate, oxygen need, and presence of retractions were most useful in predicting ED disposition.

  View details for PubMedID 24313026

• I-PASS, a Mnemonic to Standardize Verbal Handoffs PEDIATRICS Starmer, A. J., Spector, N. D., Srivastava, R., Allen, A. D., Landrigan, C. P., Sectish, T. C. 2012; 129 (2): 201-204

  View details for DOI 10.1542/peds.2011-2966

  View details for PubMedID 22232313

• Establishing a Multisite Education and Research Project Requires Leadership, Expertise, Collaboration, and an Important Aim PEDIATRICS Sectish, T. C., Starmer, A. J., Landrigan, C. P., Spector, N. D. 2010; 126 (4): 619-622

  View details for DOI 10.1542/peds.2010-1793

  View details for Web of Science ID 000282526100030

  View details for PubMedID 20876168

• Severe osteomyelitis caused by Myceliophthora thermophila after a pitchfork injury. Annals of clinical microbiology and antimicrobials Destino, L., Sutton, D. A., Helon, A. L., Havens, P. L., Thometz, J. G., Willoughby, R. E., Chusid, M. J. 2006; 5: 21-?

  Abstract

  Traumatic injuries occurring in agricultural settings are often associated with infections caused by unusual organisms. Such agents may be difficult to isolate, identify, and treat effectively.A 4-year-old boy developed an extensive infection of his knee and distal femur following a barnyard pitchfork injury. Ultimately the primary infecting agent was determined to be Myceliophthora thermophila, a thermophilic melanized hyphomycete, rarely associated with human infection, found in animal excreta. Because of resistance to standard antifungal agents including amphotericin B and caspofungin, therapy was instituted with a prolonged course of terbinafine and voriconazole. Voriconazole blood levels demonstrated that the patient required a drug dosage (13.4 mg/kg) several fold greater than that recommended for adults in order to attain therapeutic blood levels.Unusual pathogens should be sought following traumatic farm injuries. Pharmacokinetic studies may be of critical importance when utilizing antifungal therapy with agents for which little information exists regarding drug metabolism in children.

  View details for PubMedID 16961922