Rebecca Hehn’s research while affiliated with Boston Children's Hospital and other places

Background and objective Handoff communication errors are a leading source of sentinel events. We sought to determine the impact of a handoff improvement programme for nurses. Methods We conducted a prospective pre-post intervention study on a paediatric intensive care unit in 2011–2012. The I-PASS Nursing Handoff Bundle intervention consisted of educational training, verbal handoff I-PASS mnemonic implementation, and visual materials to provide reinforcement and sustainability. We developed handoff direct observation and time motion workflow assessment tools to measure: (1) quality of the verbal handoff, including interruption frequency and presence of key handoff data elements; and (2) duration of handoff and other workflow activities. Results I-PASS implementation was associated with improvements in verbal handoff communications, including inclusion of illness severity assessment (37% preintervention vs 67% postintervention, p=0.001), patient summary (81% vs 95%, p=0.05), to do list (35% vs 100%, p<0.001) and an opportunity for the receiving nurse to ask questions (34% vs 73%, p<0.001). Overall, 13/21 (62%) of verbal handoff data elements were more likely to be present following implementation whereas no data elements were less likely present. Implementation was associated with a decrease in interruption frequency pre versus post intervention (67% vs 40% of handoffs with interruptions, p=0.005) without a change in the median handoff duration (18.8 min vs 19.9 min, p=0.48) or changes in time spent in direct or indirect patient care activities. Conclusions Implementation of the I-PASS Nursing Handoff Bundle was associated with widespread improvements in the verbal handoff process without a negative impact on nursing workflow. Implementation of I-PASS for nurses may therefore have the potential to significantly reduce medical errors and improve patient safety.

Purpose Data from low-weight patients with restrictive eating disorders (EDs) treated in outpatient adolescent medicine-based ED treatment programs were analyzed to determine whether there was an association between hospitalization and gain to at least 90% median body mass index (mBMI) at 1-year follow-up. Methods Data were retrospectively collected for 322 low-weight (<85% mBMI at intake) patients aged 9–21 years, who presented with restrictive EDs to 14 adolescent medicine-based ED programs in 2010. Positive outcome was defined as being at least 90% mBMI (%mBMI = patient's body mass index/mBMI for age × 100) at 1-year follow-up. Association between treatment at a higher level of care and gain to at least 90% mBMI was analyzed for 140 patients who were <85% mBMI at the time of presentation, had not been previously hospitalized, and had 1-year follow-up data available. Results For patients presenting at <85% mBMI, those who were hospitalized in the year following intake had 4.0 (95% confidence interval: 1.6–10.1) times the odds of gain to at least 90% mBMI, compared with patients who were not hospitalized, when controlling for baseline %mBMI. Conclusion In this national cohort of patients with restrictive EDs presenting to adolescent medicine-based ED programs at <85% mBMI, those who were hospitalized had greater odds of being at least 90% mBMI at 1-year follow-up.

Background 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. Methods 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. Results 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 Institute has developed a virtual immersion training platform, mobile handoff observational tools, and processes to facilitate further spread of I-PASS. Conclusion 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.

Innovative approaches within primary care are needed to reduce fragmented care, increase continuity of care, and improve asthma outcomes in children with asthma. Our objective was to assess the impact of coordinated team-based asthma care on unplanned asthma-related health care utilization. A multidisciplinary asthma team was developed to provide coordinated care to high-risk asthma patients. Patients received an in-depth diagnostic and family needs assessment, asthma education, and coordinated referral to social and community services. Over a 2-year period, 141 patients were followed. At both 1 and 2 years postintervention, there was a significant decrease from preintervention rates in urgent care visits (40%, P = .002; 50%, P < .0001), emergency department visits (63%, P < .0001; 70%, P < .0001), and inpatient hospitalization (69%, P = .002; 54%, P = .04). Our coordinated asthma care program was associated with a reduction in urgent care visits, emergency department visits, and inpatient hospitalizations among high-risk children with asthma.

Objectives: 1. To determine rates of histologically positive, negative and inconclusive rectal suction biopsies in post-pull-through patients with Hirschsprung disease evaluated for potential residual aganglionosis at our institution. 2. To determine how patients were managed after a post-pull-through rectal suction biopsy. Methods: Thirty-nine post-pull-through suction biopsies from our institution were reviewed. Samples, stained with H&E and often acetylcholinesterase and/or calretinin, were categorized as "histologically" positive, negative or inconclusive for aganglionosis. Subsequent clinical action was categorized as bowel resection, no further procedure, or re-biopsy. Agreement between histologic diagnosis and clinical action was assessed. Results: Histologically, all biopsies were inconclusive (46%) or negative (54%) for residual aganglionosis. Post-biopsy clinical action included re-do pull-through (5%), no further procedure (59%), or re-biopsy (36%). Re-biopsy was sought in 2 of 21 histologically negative patients and in only 12 of 18 histologically indeterminate patients. Eventual re-do pull-through procedures in 6 of 39 patients showed 4 with residual aganglionosis and 2 with abnormalities suggesting residual "transition zone." Conclusions: Our findings show that suction biopsy after pull-through was frequently histologically indeterminate and never definitively positive for residual aganglionosis. When biopsy was histologically indeterminate, re-biopsy was pursued less commonly than might be expected. Our findings emphasize that suction biopsy examination is not a "gold standard" for residual aganglionosis, but instead a component of a diagnosis that ultimately combines clinicopathologic factors, the constellation of which can sometimes spare patients from a more invasive full-thickness biopsy.

Objectives In patients with systemic right ventricles (RVs) in a biventricular circulation, exercise capacity and RV function often deteriorate over time and echocardiographic assessment of systemic RV function is difficult. The purpose of this study was to examine the relationship between exercise capacity and RV function and to determine which noninvasive imaging parameters correlate most closely with exercise capacity.DesignPatients with a systemic RV (D-loop transposition of the great arteries [TGA] after atrial switch procedure or physiologically “corrected” TGA) who underwent cardiopulmonary exercise testing (CPX) and noninvasive imaging (cardiac magnetic resonance [CMR] and echocardiography [echo]) within 1 year of CPX were identified. Regression analysis was used to evaluate the relationship between exercise variables and noninvasive indices of ventricular function.ResultsWe identified 92 patients with 149 encounters (mean age 31.0 years, 61% men, 70% D-loop TGA) meeting inclusion criteria. Statistically significant correlations between % predicted peak oxygen uptake (%pVO2) and RV ejection fraction (EF) (r = 0.29, P = .0007), indexed RV end-systolic volume (r = −0.25, P = .002), and Tei index (r = −0.22, P = .03) were found. In patients without additional hemodynamically significant lesions, the correlations between %pVO2 and RV EF (r = 0.37, P = .0007) and the Tei index (r = −0.28, P = .03) strengthened and a correlation emerged between %pVO2 and dP/dtic (r = 0.31, P = .007). On multivariable analysis, Tei index was the only statistically significant correlate of %pVO2 (P = .04).Conclusions In patients with systemic RVs in a biventricular circulation, CMR-derived RVEF and echo-derived Tei index correlate with %pVO2. On multivariable analysis, the Tei index was the strongest predictor of peak %pVO2 response.

Background Multicenter studies on idiopathic or viral pericarditis and pericardial effusion (PPE) have not been reported in children. Colchicine use for PPE in adults is supported. We explored epidemiology and management for inpatient hospitalizations for PPE in US children and risk factors for readmission. Methods and Results We analyzed patients in the Pediatric Health Information System database for (1) a code for PPE; (2) absence of codes for underlying systemic disease (eg, neoplastic, cardiac, rheumatologic, renal); (3) age ≥30 days and <21 years; and (4) discharge between January 1, 2007, and December 31, 2012, from 38 hospitals contributing complete data for each year of the study period. Among 11 364 hospitalizations with PPE codes during the study period, 543 (4.8%) met entry criteria for idiopathic or viral PPE. Significantly more boys were noted, especially among adolescents. No temporal trends were noted. Median age was 14.5 years (interquartile range 7.3 to 16.6 years); 78 patients (14.4%) underwent pericardiocentesis, 13 (2.4%) underwent pericardiotomy, and 11 (2.0%) underwent pericardiectomy; 157 (28.9%) had an intensive care unit stay, including 2.0% with tamponade. Median hospitalization was 3 days (interquartile range 2 to 4 days). Medications used at initial admission were nonsteroidal anti‐inflammatory drugs (71.3%), corticosteroids (22.7%), aspirin (7.0%), and colchicine (3.9%). Readmissions within 1 year of initial admission occurred in 46 of 447 patients (10.3%), mostly in the first 3 months. No independent predictors of readmission were noted, but our statistical power was limited. Practice variation was noted in medical management and pericardiocentesis. Conclusions Our report provides the first large multicenter description of idiopathic or viral PPE in children. Idiopathic or viral PPE is most common in male adolescents and is treated infrequently with colchicine.

Purpose: The National Eating Disorders Quality Improvement Collaborative evaluated data of patients with restrictive eating disorders to analyze demographics of diagnostic categories and predictors of weight restoration at 1 year. Methods: Fourteen Adolescent Medicine eating disorder programs participated in a retrospective review of 700 adolescents aged 9-21 years with three visits, with DSM-5 categories of restrictive eating disorders including anorexia nervosa (AN), atypical AN, and avoidant/restrictive food intake disorder (ARFID). Data including demographics, weight and height at intake and follow-up, treatment before intake, and treatment during the year of follow-up were analyzed. Results: At intake, 53.6% met criteria for AN, 33.9% for atypical AN, and 12.4% for ARFID. Adolescents with ARFID were more likely to be male, younger, and had a longer duration of illness before presentation. All sites had a positive change in mean percentage median body mass index (%MBMI) for their population at 1-year follow-up. Controlling for age, gender, duration of illness, diagnosis, and prior higher level of care, only %MBMI at intake was a significant predictor of weight recovery. In the model, there was a 12.7% change in %MBMI (interquartile range, 6.5-19.3). Type of treatment was not predictive, and there were no significant differences between programs in terms of weight restoration. Conclusions: The National Eating Disorders Quality Improvement Collaborative provides a description of the patient population presenting to a national cross-section of 14 Adolescent Medicine eating disorder programs and categorized by DSM-5. Treatment modalities need to be further evaluated to assess for more global aspects of recovery.