K N Shaw

The Children's Hospital of Philadelphia, Philadelphia, PA, United States

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Publications (64)230.52 Total impact

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    ABSTRACT: A formal emergency care system for children in the United States began in the 1980s with the establishment of specialized training programs in academic children's hospitals. The ensuing three decades have witnessed the establishment of informal regional networks for clinical care and a federally funded research consortium that allows for multisite research on evidence-based practices. However, pediatric emergency care suffers from problems common to emergency departments (EDs) in general, which include misaligned incentives for care, overcrowding, and wide variation in the quality of care. In pediatric emergency care specifically, there are problems with low-volume EDs that have neither the experience nor the equipment to treat children, poor adherence to clinical guidelines, lack of resources for mental health patients, and a lack of widely accepted performance metrics. We call for policies to address these issues, including providing after-hours care in other settings and restructuring payment and reimbursement policies to better address patients' needs.
    Health Affairs 12/2013; 32(12):2109-15. · 4.64 Impact Factor
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    ABSTRACT: A unit-based Patient Safety Leadership Walkrounds (PSWR) model was deployed in six medical/surgical units at The Children's Hospital of Philadelphia to identify patient safety issues in the clinical microsystem. Specific objectives of PSWR were to (1) provide a forum for frontline staff to freely report and discuss patient safety problems with unit local leaders, (2) improve teamwork and communication within and across units, and (3) develop a supportive environment in which staff and leaders brainstorm on potential solutions. Baseline data collection and discussion with leaders and staff from the pilot units were used to create a standard set of safety tools and questions. Through multiple Plan-Do-Study-Act cycles, safety tools and questions were refined, while the process of walkrounds in each of the six pilot units was customized. Leaders in all six pilot units indicated that PSWR helped them to uncover previously unidentified safety concerns. Top-impact areas included nurse-medical team relationship, work-flow flaws, equipment defects, staff education, and medication safety. The project engaged 149 individuals across all disciplines, including 33 physicians, and entailed 34 PSWR in its first year. Information from these pilot units initiated safety changes that spread across multiple units, with identification of hospital-wide quality and patient safety issues. For participating units, the PSWR process is a situational awareness tool that helps management periodically assess new or unresolved vulnerabilities that may affect safety and care quality on the unit. Unit-based PSWR help identify safety concerns at the microsystem level while improving communication about safety events across units and to hospital leaders in the macrosystem.
    Joint Commission journal on quality and patient safety / Joint Commission Resources 09/2013; 39(9):396-403.
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    ABSTRACT: OBJECTIVE: Hospital incident reporting is widely used but has had limited effectiveness for improving patient safety nationally. We describe the process of establishing a multi-institutional safety event reporting system. METHODS: A descriptive study in The Pediatric Emergency Care Applied Research Network of 22 hospital emergency departments was performed. An extensive legal analysis addressed investigators' concerns about sharing confidential incident reports (IRs): (1) the ability to identify sites and (2) potential loss of peer review statute protection. Of the 22 Pediatric Emergency Care Applied Research Network sites, 19 received institutional approval to submit deidentified IRs to the data center. Incident reports were randomly assigned to independent review; discordance was resolved by consensus. Incident reports were categorized by type, subtype, severity, staff involved, and contributing factors. RESULTS: A total of 3,106 IRs were submitted by 18 sites in the first year. Reporting rates ranged more than 50-fold from 0.12 to 6.13 per 1000 patients. Data were sufficient to determine type of error (90% of IRs), severity (79%), staff involved (82%), and contributing factors (82%). However, contributing factors were clearly identified in only 44% of IRs and required extrapolation by investigators in 38%. The most common incidents were related to laboratory specimens (25.5%), medication administration (19.3%), and process variance, such as delays in care (14.4%). CONCLUSIONS: Incident reporting provides qualitative data concerning safety events. Perceived legal barriers to sharing confidential data can be addressed. Large variability in reporting rates and low rates of providing contributing factors suggest a need for standardization and improvement of safety event reporting.
    Pediatric emergency care 01/2013; · 0.92 Impact Factor
  • Kathy N Shaw
    Annals of emergency medicine 01/2013; · 4.23 Impact Factor
  • Pediatric emergency care 12/2012; 28(12):1406-1408. · 0.92 Impact Factor
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    ABSTRACT: OBJECTIVE: Medication errors are an important cause of preventable morbidity, especially in children in emergency department (ED) settings. Internal use of voluntary incident reporting (IR) is common within hospitals, with little external reporting or sharing of this information across institutions. We describe the analysis of paediatric medication events (ME) reported in 18 EDs in a paediatric research network in 2007-2008. METHODS: Confidential, deidentified incident reports (IRs) were collected, and MEs were independently categorised by two investigators. Discordant responses were resolved by consensus. RESULTS: MEs (597) accounted for 19% of all IRs, with reporting rates varying 25-fold across sites. Anti-infective agents were the most commonly reported, followed by analgesics, intravenous fluids and respiratory medicines. Of the 597 MEs, 94% were medication errors and 6% adverse reactions; further analyses are reported for medication errors. Incorrect medication doses were related to incorrect weight (20%), duplicate doses (21%), and miscalculation (22%). Look-alike/sound-alike MEs were 36% of incorrect medications. Human factors contributed in 85% of reports: failure to follow established procedures (41%), calculation (13%) or judgment (12%) errors, and communication failures (20%). Outcomes were: no deaths or permanent disability, 13% patient harm, 47% reached patient (no harm), 30% near miss or unsafe conditions, and 9% unknown. CONCLUSIONS: ME reporting by the system revealed valuable data across sites on medication categories and potential human factors. Harm was infrequently reported. Our analyses identify trends and latent systems issues, suggesting areas for future interventions to reduce paediatric ED medication errors.
    Emergency Medicine Journal 10/2012; · 1.65 Impact Factor
  • The Journal of pediatrics 09/2012; 161(3):377-378.e1. · 4.02 Impact Factor
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    ABSTRACT: The objectives were to evaluate clinical performance measures used for pediatric emergency medicine (PEM) physicians for reliability, correlation with one another, and relationship with clinical experience. This retrospective cohort study collected performance data for PEM physicians working at an urban children's hospital emergency department (ED) for each of 7 consecutive 6-month periods. Low correlations were seen between patients per hour or admission rate and 72-hour revisit rates. No significant association existed between level of experience and any performance measure. Physician treatment times appeared to be most reliable, and revisit rates were least reliable. Increase in number of patients seen per hour or lower admission rates in the ED are not significantly associated with an increase in revisit rates. Provider experience did not affect performance measures. Physician treatment time, patients per hour, admission rate, and charges per hour are reliable measures to assess the clinical performance of PEM physicians working at a single center.
    American Journal of Medical Quality 06/2012; · 1.47 Impact Factor
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    ABSTRACT: The Institute of Medicine (IOM) has recommended the development of national standards for the measurement of emergency care performance. The authors undertook this study with the goals of enumerating and categorizing existing performance measures relevant to pediatric emergency care. Potential performance measures were identified through a survey of 1) the peer-reviewed literature, 2) websites of organizations and societies pertaining to quality improvement, and 3) emergency department (ED) directors. Performance measures were enumerated and categorized, using consensus methods, on three dimensions: 1) the IOM quality domains; 2) Donabedian's structure/process/outcome framework; and 3) general, cross-cutting, or disease-specific measures. A total of 405 performance measures were found for potential use for pediatric emergency care. When categorized by IOM domain, nearly half of the measures were related to effectiveness, while only 6% of measures addressed patient-centeredness. In the Donabedian dimension, 67% of measures were categorized as process measures, with 29% outcome and 4% structure measures. Finally, 31% of measures were general measures relevant to every ED visit. Although 225 measures (55%) were disease-specific, the majority (56%) of these measures related to only five common conditions. A wide range of performance measures relevant to pediatric emergency care are available. However, measures lack a systematic and comprehensive approach to evaluate the quality of care provided.
    Academic Emergency Medicine 05/2011; 18(5):519-26. · 1.76 Impact Factor
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    ABSTRACT: Objective: Exploring several health and safety practices in child care centers (CCCs) in Pennsylvania (PA). Design and Methods: A prospective observational study of a convenience sample of CCCs was done. On-site evaluations included direct observation of hand washing behaviors, infant sleep position, playground equipment safety, and an assessment of safety policies. Results: Evaluations were done at 134 sites. The director's median time in her current position was 2.5 years; 32% of the providers worked at the site less than one year. Sixteen (12%) sites had consulted a doctor on health policy development. Of 114 food preparation or consumption observations, 88 (77%) of the adults and 100 (92%) of the children washed their hands; and, of 181 diapering or toileting observations, 78 (83%) of the adults and 103 (95%) of the children washed their hands. Staff placed 67% of infants on their backs for sleep. Safe playground surfacing was observed surrounding 10 (21%) indoor and 52 (57%) outdoor equipment areas. Overall, suburban, non-profit, parent funded centers performed better than urban, for profit, state funded centers—except for sleep positioning when the opposite association was observed. Conclusion: Many CCCs lack adequate health and safety practices especially those sites that were urban, for profit, or were predominately state funded. Improving the training of staff, updating or increasing comprehensive and accurate policies, and obtaining input from skilled health professionals may improve safety in CCCs.
    The Open Pediatric Medicine Journal 01/2010; 4:14-22.
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    ABSTRACT: Studies in urban emergency departments (EDs) have found poor quality of chronic asthma care and identified beliefs and barriers associated with low rates of follow-up with a primary care provider (PCP). To develop an ED-based intervention including asthma symptom screening, a video addressing beliefs and a mailed reminder; and measure the effect on PCP follow-up and asthma-related outcomes. This randomized, controlled trial enrolled children aged 1 to 18 years who were discharged after asthma treatment in an urban pediatric ED. Control subjects received instructions to follow-up with a PCP within 3 to 5 days. In addition, intervention subjects (1) received a letter to take to their PCP if they screened positive for persistent asthma symptoms, (2) viewed a video featuring families and providers discussing the importance of asthma control, and (3) received a mailed reminder to follow-up with a PCP. All subjects were contacted by telephone 1, 3, and 6 months after the ED visit, and follow-up was confirmed by PCP record review. Asthma-related quality of life (AQoL), symptoms, and beliefs about asthma care were assessed by using validated surveys. A total of 433 subjects were randomly assigned, and baseline measures were similar between study groups. After the intervention and before ED discharge, intervention subjects were more likely to endorse beliefs about the benefits of follow-up than controls. However, rates of PCP follow-up during the month after the ED visit (44.5%) were similar to control subjects (43.8%) as were AQoL, medication use, and ED visits. An ED-based intervention influenced beliefs but did not increase PCP follow-up or asthma-related outcomes.
    PEDIATRICS 10/2009; 124(4):1135-42. · 4.47 Impact Factor
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    ABSTRACT: The goals were (1) to describe emergency department (ED) characteristics thought to be related to patient safety within the Pediatric Emergency Care Applied Research Network, (2) to measure staff perceptions of the climate of safety in EDs, and (3) to measure associations between ED characteristics and a climate of safety. Twenty-one EDs were surveyed to assess physical structure, staffing patterns, overcrowding, medication administration, teamwork, and methods for promoting patient safety. A validated survey on the climate of safety was administered to all emergency department staff members. Safety climate scores were compared to evaluate associations with ED characteristics. A total of 1747 staff members (49%) responded to the survey on the climate of safety. A minority of EDs had organized safety activities such as safety committees (48%) or walk-rounds (38%), used computerized physician order entry (38%), had ED pharmacists (19%), or had formal physician/registered nurse teams (38%). The majority (67%) treated patients in hallways. Most (67%) varied staffing on the basis of seasonal patient volume. Of the 1747 ED staff members (49%) responding to the survey, there was a wide range (28%-82%) in the proportion reporting a positive safety climate. Physicians' ratings of the climate of safety were higher than nurses' ratings, and perceptions varied according to work experience. Characteristics associated with an improved climate of safety were a lack of ED overcrowding, a sick call back-up plan for physicians, and the presence of an ED safety committee. Large variability existed among EDs in structures and processes thought to be associated with patient safety and in staff perception of the safety climate. Several ED characteristics were associated with a positive climate of safety.
    PEDIATRICS 09/2009; 124(2):485-93. · 4.47 Impact Factor
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    ABSTRACT: Short-Stay Emergency Department Observation Units (OU) are an alternative to hospitalization, but data on OU care of pediatric poisoning exposures is limited. We report the experience of a pediatric OU with this population. We retrospectively reviewed the charts of children with poison exposure admitted to a pediatric OU during a 30-month period. Data was collected pertaining to demographics, type of exposure, clinical presentation, and rate of hospitalization, and was compared to nonpoisoned OU patients. Of the 91 pediatric patients with poison exposure, 86 complete charts were available for review (94.5%). Of these patients, 49.5% were female, and 82.4% were <6 years of age (range 1.5 months to 16.6 years). There were a total of 98 toxicants implicated, the most common of which were psychoactive drugs (25%) and cardiovascular agents (19%). At OU admission, 33 of 88 patients (38%) had altered mental status or abnormal vital signs. Only 2 of the 53 remaining patients developed abnormal vital signs within the OU. Two patients were hospitalized unexpectedly with respiratory distress due to hydrocarbon and charcoal aspiration pneumonitis, respectively; the unexpected hospitalization rate was 2.2%. Three more planned hospitalizations for endoscopy or psychiatric evaluation led to a total hospitalization rate of 5.4%. This hospitalization rate is significantly lower (RR=0.26, 95% CI=0.11-0.62) than the hospitalization rate from the OU for nonpoisoned patients (20.3%) during that time. Mean OU length of stay for nonadmitted poisoned patients was 14.35 hours. There were no adverse events noted as a result of OU placement. Select poisoned pediatric patients appear suitable for OU management and had less frequent unexpected hospitalization from the OU than other diagnoses.
    Journal of medical toxicology: official journal of the American College of Medical Toxicology 03/2009; 5(1):15-9.
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    ABSTRACT: The 23-hour observation units (OUs) may be used to avoid unnecessary hospital admissions. However, unexpected hospitalizations from the 23-hour OUs involve transfer of care and may decrease the efficiency and safety of care of the patient and the unit itself. The primary objective of this study was to determine the predictors of unexpected hospitalization for admissions to a pediatric 23-hour OU. This is an observational prospective cohort study of patients admitted to a pediatric 23-hour OU. Bivariate and multivariate regression analyses identify factors associated with unexpected hospitalization. There were 4453 patients admitted to the 23-hour OU during the study. The overall rate of unexpected hospitalization was 20.3%; the mean 23-hour OU stay was 15 hours. Age, sex, race/ethnicity, and insurance status were not associated with increased unexpected hospitalization rates. Multivariate regression modeling revealed that unexpected hospitalization was associated with subgroups of resources used (intravenous medications and fluids, cardiorespiratory monitoring, respiratory therapist use, and supplemental oxygen), of subspecialty consultation, and of diagnosis categories (including asthma, adenitis, cellulitis, bronchiolitis, and esophageal foreign body ingestions). Experience of the health care provider involved in the care of the patient was not associated with increased unexpected hospitalization. Most of the patients (80%) were successfully discharged from the 23-hour OU. Demographics of the patient and practitioner characteristics did not influence the risk of unexpected hospitalizations; however, certain patient diagnoses, use of resources,and subspecialty consultation did increase the risk of unexpected hospitalization and, therefore, may guide future admission criteria for pediatric 23-hour OU.
    Pediatric emergency care 10/2008; 24(9):589-94. · 0.92 Impact Factor
  • Pediatric emergency care 09/2008; 24(8):582-5. · 0.92 Impact Factor
  • Angela M Ellison, Kathy Shaw
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    ABSTRACT: Pain is the clinical hallmark of sickle cell disease (SCD). Vasoocclusive pain events (VOEs) are the primary cause of morbidity and account for most emergency department visits and hospitalizations for patients with SCD in the United States and Europe. The nature of VOE makes its management extremely challenging. There are no large controlled trials of analgesic regimens for VOE, and smaller trials have generally failed to produce an optimal course of therapy. Therefore, treatment recommendations are largely based on expert opinion and anecdotal experience. Although VOEs are not life-threatening, inadequate treatment may result in unnecessary morbidity and life-threatening complications. Health care providers caring for patients with SCD must be well informed about the management of VOE. This continuing medical education article will provide a summary of the management of acute pain events in SCD with particular emphasis on adequate analgesia.
    Pediatric emergency care 12/2007; 23(11):832-8; quiz 838-41. · 0.92 Impact Factor
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    ABSTRACT: The benefits of family presence (FP) during resuscitation have been well documented in the literature for the past 20 years. However, many hospitals lack written guidelines to direct staff members during a resuscitation event. A structured approach affords staff a uniform and organized way to offering FP, avoiding any interference with patient care. The purpose of this paper is to provide evidence-based practice guidelines to offering FP during resuscitation in the emergency department. The guidelines illustrate a practical step-by-step approach that staff members can follow every time a patient is being evaluated and/or treated in the resuscitation room.
    Pediatric emergency care 09/2007; 23(8):587-91. · 0.92 Impact Factor
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    ABSTRACT: Bronchiolitis, the most common infection of the lower respiratory tract in infants, is a leading cause of hospitalization in childhood. Corticosteroids are commonly used to treat bronchiolitis, but evidence of their effectiveness is limited. We conducted a double-blind, randomized trial comparing a single dose of oral dexamethasone (1 mg per kilogram of body weight) with placebo in 600 children (age range, 2 to 12 months) with a first episode of wheezing diagnosed in the emergency department as moderate-to-severe bronchiolitis (defined by a Respiratory Distress Assessment Instrument score > or =6). We enrolled patients at 20 emergency departments during the months of November through April over a 3-year period. The primary outcome was hospital admission after 4 hours of emergency department observation. The secondary outcome was the Respiratory Assessment Change Score (RACS). We also evaluated later outcomes: length of hospital stay, later medical visits or admissions, and adverse events. Baseline characteristics were similar in the two groups. The admission rate was 39.7% for children assigned to dexamethasone, as compared with 41.0% for those assigned to placebo (absolute difference, -1.3%; 95% confidence interval [CI], -9.2 to 6.5). Both groups had respiratory improvement during observation; the mean 4-hour RACS was -5.3 for dexamethasone, as compared with -4.8 for placebo (absolute difference, -0.5; 95% CI, -1.3 to 0.3). Multivariate adjustment did not significantly alter the results, nor were differences detected in later outcomes. In infants with acute moderate-to-severe bronchiolitis who were treated in the emergency department, a single dose of 1 mg of oral dexamethasone per kilogram did not significantly alter the rate of hospital admission, the respiratory status after 4 hours of observation, or later outcomes. (ClinicalTrials.gov number, NCT00119002 [ClinicalTrials.gov].).
    New England Journal of Medicine 07/2007; 357(4):331-9. · 54.42 Impact Factor
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    ABSTRACT: An abstract is unavailable. This article is available as HTML full text and PDF.
    Pediatric Emergency Care 08/2006; 22(9):683. · 0.89 Impact Factor
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    ABSTRACT: Unscheduled revisits (URVs) may serve as markers of quality of care and may be costly both in financial terms as well as in limitations they place on primary care. We performed this study to examine the association between characteristics easily obtainable during an emergency department (ED) visit and URV to identify a subpopulation of children who may warrant interventions to decrease URV. This is a case-control study of patients visiting an urban tertiary care pediatric ED for a fever or infectious disease-related complaint. Cases were defined as patients who had URVs that occurred within 72 hours of an initial ED visit. Control patients were selected by simple random sampling of an enumerated computerized list of all ED visits. Data on independent variables of interest were collected from a chart review and telephone interview with the patient's caregiver. Bivariate and multivariate analyses were performed to determine factors associated with URV. Seventy-five percent of cases and controls participated in the study. Logistic regression analysis revealed 3 factors independently associated with URV for fever or infectious disease-related complaints in children. These included presence of chronic disease (adjusted odds ratio 1.75, 95% confidence interval 1.01-3.03), Medicaid insurance (adjusted odds ratio 1.86, 95% confidence interval 1.04-3.32) and acute triage category (adjusted odds ratio 1.83, 95% confidence interval 1.08-3.10). These factors may be used to identify children in the ED at greater risk for URV and may point to a need for improved discharge instructions and enhanced communication with primary care and systems to arrange follow-up. Results of this work may also identify at-risk populations for future qualitative research or intervention studies on URV to EDs.
    Pediatric emergency care 01/2006; 21(12):816-21. · 0.92 Impact Factor

Publication Stats

2k Citations
230.52 Total Impact Points


  • 1988–2013
    • The Children's Hospital of Philadelphia
      • • Department of Pediatrics
      • • Department of Emergency Medicine
      Philadelphia, PA, United States
  • 2011
    • Cincinnati Children's Hospital Medical Center
      • Department of Pediatrics
      Cincinnati, OH, United States
  • 2007
    • University of Utah
      Salt Lake City, Utah, United States
  • 1997–2007
    • Hospital of the University of Pennsylvania
      • Department of Pediatrics
      Philadelphia, Pennsylvania, United States
  • 2003
    • Medical College of Wisconsin
      • Department of Pediatrics
      Milwaukee, WI, United States
  • 1999–2000
    • Nemours
      Jacksonville, Florida, United States