Browsing by Author "McLean, Heather S"

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    A Respiratory Therapist-Driven Asthma Pathway Reduced Hospital Length of Stay in the Pediatric Intensive Care Unit.
    (Respiratory care, 2019-11) Miller, Andrew G; Haynes, Kaitlyn E; Gates, Rachel M; Zimmerman, Kanecia O; Heath, Travis S; Bartlett, Kathleen W; McLean, Heather S; Rehder, Kyle J
    BACKGROUND:Asthma is a common reason for admissions to the pediatric intensive care unit (PICU). Since June 2014, our institution has used a pediatric asthma clinical pathway for all patients, including those in PICU. The pathway promotes respiratory therapist-driven bronchodilator weaning based on the Modified Pulmonary Index Score (MPIS). This pathway was associated with decreased hospital length of stay (LOS) for all pediatric asthma patients; however, the effect on PICU patients was unclear. We hypothesized that the implementation of a pediatric asthma pathway would reduce hospital LOS for asthmatic patients admitted to the PICU. METHODS:We retrospectively reviewed the medical records of all pediatric asthma subjects 2-17 y old admitted to our PICU before and after pathway initiation. Primary outcome was hospital LOS. Secondary outcomes were PICU LOS and time on continuous albuterol. Data were analyzed using the chi-square test for categorical data, the t test for normally distributed data, and the Mann-Whitney test for nonparametric data. RESULTS:A total of 203 eligible subjects (49 in the pre-pathway group, 154 in the post group) were enrolled. There were no differences between groups for age, weight, gender, home medications, cause of exacerbation, medical history, or route of admission. There were significant decreases in median (interquartile range) hospital LOS (4.4 [2.9-6.6] d vs 2.7 [1.6-4.0] d, P < .001), median PICU LOS (2.1 [1.3-4.0] d vs 1.6 [0.8-2.4] d, P = .003), and median time on continuous albuterol (39 [25-85] h vs 27 [13-42] h, P = .001). Significantly more subjects in the post-pathway group were placed on high-flow nasal cannula (32% vs 6%, P = .001) or noninvasive ventilation (10% vs 4%, P = .02). CONCLUSION:The implementation of an asthma pathway was associated with decreased hospital LOS, PICU LOS, and time on continuous albuterol. There was also an increase in the use of high-flow nasal cannula and noninvasive ventilation after the implementation of this clinical pathway.
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    Choosing wisely in pediatric hospital medicine: five opportunities for improved healthcare value.
    (Journal of hospital medicine, 2013-09) Quinonez, Ricardo A; Garber, Matthew D; Schroeder, Alan R; Alverson, Brian K; Nickel, Wendy; Goldstein, Jenna; Bennett, Jeffrey S; Fine, Bryan R; Hartzog, Timothy H; McLean, Heather S; Mittal, Vineeta; Pappas, Rita M; Percelay, Jack M; Phillips, Shannon C; Shen, Mark; Ralston, Shawn L
    BACKGROUND: Despite estimates that waste constitutes up to 20% of healthcare expenditures in the United States, overuse of tests and therapies is significantly under-recognized in medicine, particularly in pediatrics. The American Board of Internal Medicine Foundation developed the Choosing Wisely campaign, which challenged medical societies to develop a list of 5 things physicians and patients should question. The Society of Hospital Medicine (SHM) joined this effort in the spring of 2012. This report provides the pediatric work group's results. METHODS: A work group of experienced and geographically dispersed pediatric hospitalists was convened by the Quality and Safety Committee of the SHM. This group developed an initial list of 20 recommendations, which was pared down through a modified Delphi process to the final 5 listed below. RESULTS: The top 5 recommendations proposed for pediatric hospital medicine are: (1) Do not order chest radiographs in children with asthma or bronchiolitis. (2) Do not use systemic corticosteroids in children under 2 years of age with a lower respiratory tract infection. (3) Do not use bronchodilators in children with bronchiolitis. (4) Do not treat gastroesophageal reflux in infants routinely with acid suppression therapy. (5) Do not use continuous pulse oximetry routinely in children with acute respiratory illness unless they are on supplemental oxygen. CONCLUSION: We recommend that pediatric hospitalists use this list to prioritize quality improvement efforts and include issues of waste and overuse in their efforts to improve patient care.
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    Differences in Safety Report Event Types Submitted by Graduate Medical Education Trainees Compared With Other Healthcare Team Members.
    (Journal of patient safety, 2020-03-24) Cohen, Sarah P; McLean, Heather S; Milne, Judy; Parente, Victoria
    OBJECTIVES:Graduate medical education (GME) trainees have a unique perspective from which to identify and report patient safety concerns. However, it is not known how safety reports submitted by GME trainees differ from those submitted by other clinical staff. We hypothesized that GME trainees were more likely to submit safety reports regarding transitions of care, delays in care, and lapses in communication, and reports of higher severity compared with other frontline staff such as nurses, pharmacists, and other providers. METHODS:Patient safety reports submitted by clinical staff for 1 year at an academic tertiary care children's hospital were retrospectively reviewed and categorized by reporter type. Severity level and event type were analyzed by reporter type, and repeat χ tests were used to compare the percentage of reports at each severity level and in each event type submitted by GME trainees compared with each other reporter type. RESULTS:Graduate medical education trainees submitted reports of greater severity (level E/F/G) compared with nurses (10% versus 5%, P = 0.021) and pharmacists (10% versus 2%, P = 0.001). A greater percent of GME trainees' reports were categorized as errors in transitions of care, diagnosis, ordering, laboratory collection, and care delays compared with several other reporter types. CONCLUSIONS:Graduate medical education trainees identify system vulnerabilities not detected by other personnel, supporting efforts to increase safety reporting by GME trainees.
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    Good to Great: Quality-Improvement Initiative Increases and Sustains Pediatric Health Care Worker Hand Hygiene Compliance.
    (Hospital pediatrics, 2017-04) McLean, Heather S; Carriker, Charlene; Bordley, William Clay
    The Joint Commission, the Centers for Disease Control and Prevention, and the World Health Organization challenge hospitals to achieve and sustain compliance with effective hand hygiene (HH) practice; however, many inpatient units fail to achieve a high level of reliability. The aim of the project was to increase and sustain health care worker (HCW) compliance with HH protocols from 87% (level of reliability [LOR] 1) to ≥95% (LOR 2) within 9 months on 2 pediatric inpatient units in an academic children's hospital.This study was a time-series, quality-improvement project. Interventions were tested through multiple plan-do-study-act cycles on 2 pediatric inpatient units. HH compliance audits of HCWs on these units were performed randomly each week by the hospital infection prevention program. Control charts of percentages of HCW HH compliance were constructed with 3-σ (data within 3 SDs from a mean) control limits. These control limits were adjusted after achieving significant improvements in performance over time. Charts were annotated with interventions including (1) increasing awareness, (2) providing timely feedback, (3) empowering patients and families to participate in mitigation, (4) providing focused education, and (5) developing interdisciplinary HH champions.HH compliance rates improved from an average of 87% (LOR 1) to ≥95% (LOR 2) within 9 months, and this improvement has been sustained for >2 years on both pediatric inpatient units.Significant and sustained gains in HH compliance rates of ≥95% (LOR 2) can be achieved by applying high-reliability human-factor interventions.
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    Improving the Efficiency of Care for Pediatric Patients Hospitalized With Asthma.
    (Hospital pediatrics, 2017-01) Bartlett, Kathleen W; Parente, Victoria M; Morales, Vanessa; Hauser, Jillian; McLean, Heather S
    Asthma exacerbations are a leading cause of hospitalization among children. Despite the existence of national pediatric asthma guidelines, significant variation in care persists. At Duke Children's Hospital, we determined that our average length of stay (ALOS) and cost for pediatric asthma admissions exceeded that of our peers. Our aim was to reduce the ALOS of pediatric patients hospitalized with asthma from 2.9 days to 2.6 days within 12 months by implementing an asthma pathway within our new electronic health record.We convened a multidisciplinary committee charged with reducing variability in practice, ALOS, and cost of inpatient pediatric asthma care, while adhering to evidence-based guidelines. Interventions were tested through multiple "plan-do-study-act" cycles. Control charts of the ALOS were constructed and annotated with interventions, including testing of an asthma score, implementation of order sets, use of a respiratory therapy-driven albuterol treatment protocol, and provision of targeted education. Order set usage was audited as a process measure. Readmission rates were monitored as a balancing measure.The ALOS of pediatric patients hospitalized with asthma decreased significantly from 2.9 days to 2.3 days. Comparing baseline with intervention variable direct cost data revealed a savings of $1543 per case. Improvements occurred in the context of high compliance with the asthma pathway order sets. Readmission rates remained stable throughout the study period.Implementation of an asthma care pathway based on the electronic health record improved the efficiency and variable direct costs of hospital care, reduced variability in practice, and ensured adherence to high-quality national guidelines.
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    Use of ketamine during procedural sedation: indications, controversies, and side effects.
    (Journal of infusion nursing : the official publication of the Infusion Nurses Society, 2012-11) Jolly, Tonya; McLean, Heather S
    Ketamine is a well-described anesthetic and analgesic, unique in its ability to preserve laryngeal reflexes and airway protection, and offered to a wide range of patients, although not necessarily widely used. Because it is considered an anesthetic, widespread use by all sedation providers is often limited despite its long history as a safe sedative. Because of its sympathomimetic effects, ketamine may be used in patients who are hypovolemic, including those who are experiencing traumatic or obstetric emergencies. The use of ketamine in patients with epilepsy or traumatic brain injury is more controversial. This article will explore the side effects of ketamine and current research that support or discourage its use in a variety of settings.