MCHB Conference Webcasts
2005 EMSC Annual Grantee Meeting
April 12-13, 2005
MARIANNE GAUSCHE HILL: All right. Well, I'm here today to talk to you about our project, which is implementation, evaluation of care of children and emergency department guidelines for preparedness. And it's a project that was developed after the joint policy was passed by both the boards at the American Academy of Pediatrics and the American College of Emergency Physicians.
Essentially, those guidelines were one of the first joint policies passed by those two organizations together. And it took several years and 18 drafts, but we made it. And the whole idea was to provide some guidance for emergency departments, what they need in the ED in order to care for kids. And this includes equipment, supplies, staffing. QI issues, policies and procedures.
So we recognized the need afterwards to evaluate the guidelines, effectiveness and improving care for children, but that's not a simple task. And one of the issues are: Will hospitals implement the guidelines? Will an implementation kit that we were thinking of developing assist hospitals in guidelines and implementation, and does guidelines implementation have an effect on the quality of pediatric care? Those are actually ‑‑ they seem like simple questions, but logistically it's very difficult to answer that question.
Luckily, the American Academy of Pediatrics received a four‑year cooperative agreement, of which one aspect of that agreement was to evaluate the guidelines. And our project coordinator at the AAP is Sue Teles; and I'm the project principal investigator, and I'm working hand in hand with my co‑investigator, Roger Lewis, at Harvard UCLA Medical Center .
The implementation kit I referred to was an idea we had to help emergency departments implement the guidelines. It would, in a sense it would be one‑stop shopping. On the kit are a CD, would have a copy of the guidelines, a checklist so it could go through and say yes, we did this and this, consistent with the guidelines. And we spent a great deal of time in a multi‑disciplinary fashion getting policies from all over the country and honing them down to sample policies, or sample policies for the 12 different policies and procedures that were recommended in the guidelines.
So a hospital could essentially use the kit, go to the policy section, pull it up as a Word document, take it and make it their own. And they wouldn't have to reinvent the wheel, which is a really good thing. And then other clinical guidelines and other policies related to children that had been passed and available through both those professional organizations.
So what are the goals of this evaluation project? And I know I have to move quickly. I get 15 minutes or something. We wanted to identify factors that impact the committee's intent to implement the guidelines; and we wanted to identify those components in the implementation kit that would improve the implementation rate of these preparedness guidelines.
In addition, we wanted to characterize current preparedness and a nationwide sample of institutions and I'll tell you about that in a second. We wanted to also estimate the effect of the provision of this kit and not only the kit but a preparedness DVD, kind of a pep talk DVD to hospitals on institutional preparedness in compliance with the guidelines. And then eventually look at quality of pediatric emergency care.
In addition, we wanted to estimate the effect of the provision of this kit. And on staff's satisfaction and self‑advocacy and possibly changing configuration of their emergency department and other end points related to their institutional culture.
And then eventually this information would be utilized to improve the kit and then distribute to all emergency departments in the country with the hope that that kit would then serve as the impetus for them to become fully prepared to care for children.
Our project infrastructure is quite simple. We have a steering committee, quality subcommittee and the quality subcommittee developed the quality of care assessment and a self‑advocacy subcommittee, which developed the survey of the staff for the emergency department.
The chair of our quality subcommittee is none other than Robert Weibe and the chair of the self‑advocacy committee is Steve Kruege. Some good people working on the project. I'll skip through this very quickly but you can see again we have a multi‑disciplinary steering committee with representatives from a number of organizations, and you can see them listed here. And I'll just quickly run through them. We wanted to include physicians, nursing, joint commission, also the National Committee on Quality Assurance, rural health, et cetera.
Our methodology, we wanted to first survey all the U.S. emergency departments on adherence to published guidelines and then from there we were going to calculate preparedness scores from these data. From that data we would then select 20 hospitals and ten would be matched for the interventional project. The study hospitals, after baseline, baseline site review would receive the implementation kit and the preparedness DVD and the control hospitals would receive no intervention. And then all the hospitals will be studied longitudinally for one to two years, to look for their change in pediatric preparedness.
On site we plan and we've already started our on site surveys, to look at equipment supplies, review of the QIPI activities and a quality review of 40 patient charts using our five quality templates. I don't have the time to really go into the templates, but that was quite a process.
And then those paired hospitals are going to be compared to look at the change in preparedness over time.
What have we done so far in the three years? It's been a challenge, but we've been able to get IRB approvals from both Harvard UCLA and AAP for phase one and phase two of the project. In addition, we've also now enrolled all 20 hospitals and gotten IRB approval from almost all of the 20 hospitals. I think we just have like two more to go. So we're almost there. But we've already started doing the on‑site surveys. Steering committee has met three times. We've had multiple conference calls and the baseline survey has been created and distributed to every emergency department in the country. Those returns, they were returned to us, analyzed and we're beginning the report phase.
In addition, we are doing a cost analysis to look at the cost of implementation of the guidelines. And, again, the chair of the quality subcommittee is Dr. Wiebe and these are the five conditions on which we're looking at quality measures. You can see blunt head trauma, febrile seizure, diarrhea and dehydration long bone fracture and asthma. And then Deborah Henderson and Nancy McGrath, two research nurses, completed an interrelated reliability on 20 charts per condition, well over 100 charts using the quality templates and Steve Kruege has successfully completed not only a pilot study of our self‑satisfaction survey but we've been through at least 11 drafts, I believe, and we are now at the stage that we're beginning to distribute those to the hospitals once they're surveyed.
In addition, Chuck Schmitz, he's an MD researcher, he's doing a research fellowship with us, was able to get 11 payors. We have one spare payor in case a hospital drops out. And, you know, getting those payors was quite a task and getting them through the review process.
Our on‑site surveys have begun. Our first phase is now. Our first hospital was surveyed. It's Kadlic Medical Center , and four hospital surveys will be completed by the end of April. In fact Nancy McGrath is out now in somewhere in Maryland surveying one of our hospitals today.
Our future tasks which will be done quite soon is to produce our preparedness DVD. We've written the script, and we've been very fortunate to have Noah Wylie, who is Dr. John Carter on ER, be our spokesperson; and he's agreed to do that so we're waiting to go ahead and shoot that, which should be done sometime either the end of this month or early next month.
Our other future task is to publish the results of the baseline survey; and I'll tell you a little bit more about that in a second. And we're going to send the implementation kits also to a random selection of 300 hospitals for review of the kit and feedback. Kind of a focus group.
Once that's done, we can modify the kit with the hope of sending it to all hospitals. Sometime in 2007, most likely. And hopefully we'll have our final publication by then as well. So let's go over what our survey was and I'll quickly, I've got to run through this quickly because I know I'm almost out of time. 33‑question survey developed by the steering committee. The only implementation of it it was eight pages long. It was hard for us to hone down what we wanted. You can see some of the information that we obtained.
We sent out 5144 surveys we had two postcard reminders and got a 30% response rate. We had 35 hospitals excluded because they actually did not see any pediatric patients at all. We had 1489 usable surveys. We then had to resurvey some of the hospitals for clarification, which we did. And these are the persons completing the survey. We wanted the medical director or the nursing director. So we were pretty close. One of the limitations of surveys you have so many different types of people responding you don't know how valid your results are. So almost all of them were filled out by the ED medical director or nursing director or combination of both.
As you can see, this is the location of our hospitals. 49% are in rural areas. I just want to point out. And in comparison with other surveys, we're actually biased towards an urban, a more urban sampling, and indeed we still had 49% reported in rural areas. In addition, the median volume is about 21,000 patients. The median pediatric volume is only 3700 patients. If you look at three‑quarters of the children, three‑quarters of the hospitals see less than 7,000 children a year. And if you look at non‑children's hospital the median volume is 4,000 and children's hospital is 28,000 plus.
What was interesting, and I can't give you all the data here, because in the interests of time, but 92% of children seen in emergency setting are seen in non-children's hospitals. And 7% are seen in children's hospitals. So most of the children are being seen in community EDs.
If we look at quality improvement, 52% of those hospitals have a plan. Of the hospitals that have a plan, most are integrated into the main ED plan, and very few have separate pediatric plans.
In terms of policies and procedures, we saw that for some of the policies, almost all of the hospitals had some child maltreatment policy. And as you can see, communication with the primary care provider and restraint were the ones most wanting, as well as D and R.
Do these hospitals have equipment? The hospitals lack the following equipment: 50% of the hospitals lacked laryngeal mask airways, and really, overall, the equipment that was missing are all the smaller‑sized equipment. In addition, 17% of the hospitals did not have pediatric McGill forceps, which in my mind is life saving to care for foreign body obstruction in children.
Medications: We found that almost all the hospitals had all the medications listed. In addition, we looked to see how many hospitals had prostaglandin E‑1, even though that was not included in the guidelines; and about 48% of the hospitals reported they had prostaglandin E‑1.
We then weighted the survey based on a committee that got together and said, you know, one item shouldn't be weighted. For example, three end endotracheal tube as good as having a quality improvement plan for children? So we had to do some weighting. And when we went through that, the weighted score was between 0 and 100. So the median preparedness of emergency departments, we determined was 55 out of 100. And the range was 2 to 100.
If you look at this, the preparedness was definitely varied by institution type, volume of availability of physician nurse and awareness of the guidelines. So as you become more of a comprehensive hospital, you're more prepared, which we were thankful it turned out this way because that makes sense.
51% of children are seen in remote or rural areas and see less than 2200 patients a day, excuse me, per year, which averages to about less than six pediatric patients seen in a day. And again 93% of children are seen in the main ED with 4% in a separate area of the main ED and 6% overall in children's hospitals.
All right. So in terms of the rural areas, 50% of our hospitals were reported in rural areas. So overall 26% of children are seen in rural or remote areas. Again, hospitals that tended to be more prepared are urban, higher volume, provide separate care for pediatrics and have a physician and nursing coordinator for pediatric emergency medicine.
That gives you just a quick idea of what our baseline survey is and what our intent is. Again, we've already started our on site surveys and then we'll provide our intervention, and in another year or so I'll have a lot more data to tell you about and relationship to how prepared everybody is and whether or not the kit has an effect. Thank you very much.
(Applause)