PEDIATRICS recent issues

Improving the Safety of Teratogen Prescribing Practices in a Pediatric Rheumatology Clinic

OBJECTIVES:

Although teratogenic medications are commonly used to treat rheumatic disease, no standard model currently exists for educating adolescent patients about teratogenic risk or performing routine pregnancy screening. We performed a quality improvement project to increase education and pregnancy screening in girls and women of childbearing age prescribed teratogenic medications in our pediatric rheumatology clinic.

METHODS:

Eligible participants included female patients age 10 and older prescribed teratogenic medications in a single-center tertiary care pediatric rheumatology clinic. Seven plan-do-study-act cycles were completed to test the following interventions: visible project reminders, physician and nurse education, progress updates, previsit planning, and development of an electronic health record education template. Chart reviews were performed, and control charts were created for each aim to analyze improvement over time.

RESULTS:

At baseline, 57 of 231 (24.7%) clinic encounters of female patients age 10 years and older taking teratogenic medications had education documented within the last 12 months, and 47 of 231 (20.3%) had pregnancy screening performed at the visit. Implementation of our interventions resulted in improvement in documentation of annual teratogen education (904 of 1135; 79.6%) and routine pregnancy screening (940 of 1135; 82.8%), both of which were statistically significant (P < .0001). Control charts revealed special cause with sustained improvement over >1 year.

CONCLUSIONS:

The interventions made through this quality improvement project increased the frequency of both teratogen education and urine pregnancy screening in patients taking teratogenic medications. Development of a standardized education template in the electronic health record played a key role in sustaining these improvements over time.

Lay Field-worker-Led School Health Program for Primary Schools in Low- and Middle-Income Countries

BACKGROUND AND OBJECTIVES:

School health programs are frequently attempted in low- and/or middle-income countries; however, programmatic scope and reach is limited by human resource constraints. We sought to determine if trained community members could implement a school health program that improved outcomes in rural primary schools in India.

METHODS:

This was a mixed-methods, stepped-wedge, cluster-controlled study of schools pragmatically assigned to receive a multicomponent, comprehensive school health program delivered by lay field-workers.

RESULTS:

All students in 22 primary schools (9 government schools and 13 low-cost private schools) participated in this study. A total of 3033 student-years were included in the analysis (2100 student-years in the intervention period and 933 student-years in the control period). Qualitative feedback was collected from 38 teachers, 49 parents, and 4 field-workers. In low-cost private schools, the diarrhea incidence was lower in students receiving the intervention (incidence rate ratio 0.58; 95% confidence interval [CI] 0.47 to 0.71; P < .001). There was no difference in diarrhea incidence for students in government schools (incidence rate ratio 0.87; 95% CI 0.68 to 1.12; P = .29). Health-knowledge acquisition was higher in intervention schools (mean difference 12.6%; 95% CI 8.8 to 16.4; P < .001) and similar in both school types. Intervention coverage rates were high (mean 93.9%; SD 2.0%), and performance assessment scores indicated fidelity (mean 3.45; SD 0.69). Stakeholders revealed favorable perceptions of the field-workers and high levels of perceived impact.

CONCLUSIONS:

Lay field-worker–led school health programs offer a promising alternative for improving school health delivery in resource-constrained settings.

Telephone-Based Developmental Screening and Care Coordination Through 2-1-1: A Randomized Trial

BACKGROUND AND OBJECTIVES:

Despite professional guidelines to conduct universal early childhood developmental screening, primary care providers often struggle with early identification of developmental delays, referrals to interventions, and connecting families to services. In this study, we tested the efficacy of telephone-based developmental screening and care coordination through 2-1-1 Los Angeles County, which is part of a national network of call centers, compared with usual care alone.

METHODS:

Children ages 12 to 42 months old who receive well-child care at a community health center serving predominantly Hispanic families were recruited and randomly assigned to intervention and control groups. Families in the intervention group were connected with 2-1-1, in which a trained care coordinator conducted developmental screening over the phone using the Parental Evaluation of Development Status Online system and made referrals to intervention services on the basis of developmental risk. The 2-1-1 care coordinator then followed-up with families to assist with connections to evaluations and services. After 6 months, primary outcomes included the following: (1) percentage of children referred for developmental evaluation and intervention services and (2) percentage of children actually receiving services.

RESULTS:

One hundred and fifty-two children were randomly assigned to intervention (n = 77) and control (n = 75) groups. On the basis of intention-to-treat analyses, significantly more children assigned to the intervention group were referred (32% vs 9%; P = .001) and were receiving services (16% vs 1%; P = .002) within 6 months compared with children assigned to usual care alone.

CONCLUSIONS:

Telephone-based developmental screening and care coordination through 2-1-1 appears to be an effective approach for increasing the numbers of young children referred to, and receiving, intervention services for developmental delays.

Improving Standardization of Paging Communication Using Quality Improvement Methodology

BACKGROUND AND OBJECTIVES:

Paging is a primary mode of communication in hospitals, but message quality varies. With this project, we aimed to standardize paging, thus improving end user (EU) satisfaction, patient safety, and efficiency. Objectives were to increase the percent of pages containing 6 critical elements (CEs) (ie, the sender’s first and last name, a 7-digit callback number, patient name, room number, and urgency indicator [information only, call, or come] to 90%); improve EU satisfaction to 80% rating paging communication as good or excellent; and decrease the frequency of safety events related to paging.

METHODS:

This multidisciplinary, system-wide quality improvement study was conducted at our stand-alone academic children’s hospital. CEs were determined by EU consensus. Outcome measures were inclusion of all 6 CEs, provider satisfaction, and frequency of safety events. Process measures were inclusion of individual CEs and appropriateness and timeliness of response to pages. Balancing measures included number of work-arounds (WAs). Interventions included education, engineering a platform with required fields, and optimization enhancements. Statistical process control charts (p-charts; XmR) were used to track the impact of interventions.

RESULTS:

Special-cause improvement was noted in use of all 6 CEs (4.4%–79.7%) and individual CEs. EU satisfaction improved from 50% to 85% rating paging communication as good or excellent. Safety events related to paging remain infrequent. Specific WA use decreased by 60%.

CONCLUSIONS:

System-wide use of required fields produced significant improvement in inclusion of all 6 CEs and EU satisfaction. WAs were curbed by improving the ease of CE incorporation. Required fields should be considered at institutions seeking improved paging communication.

Parental Disengagement in Childhood and Adolescent Male Gun Carrying

OBJECTIVES:

To examine the association between parental disengagement in childhood and adolescent gun carrying and determine whether this association is accounted for by externalizing problems and affiliation with delinquent peers during early adolescence.

METHODS:

The sample included 503 boys (55.7% African American, 40.6% white, 3.7% other) recruited from first-grade classrooms in Pittsburgh public schools. Multi-informant assessments were conducted regularly (semiannually then annually) from approximately ages 7.5 to 20 years. Latent factors were constructed by using parent-reported parental disengagement (ie, poor parental involvement, poor parent-son communication, poor parent-son relationship quality) collected from ages 7.5 to 10 years, youth-reported peer delinquency from ages 10.5 to 13 years, and teacher-reported externalizing problems from ages 10.5 to 13 years. The outcome was youth-reported gun carrying from ages 14 to 20 years.

RESULTS:

Twenty percent of individuals sampled reported carrying a gun during adolescence. Childhood parental disengagement was significantly associated with adolescent gun carrying (β = .22; 95% confidence interval: 0.08 to 0.36). Furthermore, the association between parental disengagement and gun carrying was partially mediated through peer delinquency and externalizing problems during early adolescence. The 2 indirect paths accounted for ~29% of the total effect of parental disengagement.

CONCLUSIONS:

Boys exposed to poorer parental engagement during childhood are more likely to affiliate with delinquent peers and exhibit externalizing problems during early adolescence, which (in turn) increases their risk of carrying a firearm in later adolescence. This suggests that gun violence prevention efforts with children should work to enhance aspects of parental engagement.

Pages