• The Association of Integrated Management of Childhood Illness' Asthma Management Protocol and Asthma Control in Omani Children 2-5 years Old

      Al Amri, Warda; Ogbolu, Yolanda; Johantgen, Mary E. (2018)
      Background: Oman had the highest asthma prevalence and severity in children among Eastern Mediterranean countries. Despite national implementation of Integrated Management of Childhood Illness (IMCI) asthma protocol, reports show no improvement in asthma-related hospital admissions among children aged 1-4 years. IMCI asthma treatment protocol implementation and factors affecting asthma control are understudied. Purpose: Describe characteristics of IMCI asthma management protocol implementation (medication, counselling, and specialist referral); explore multilevel factors associated with asthma control in children attending IMCI clinics; and analyze trends in acute care visits (emergency department [ED] and hospital admissions) by asthmatic children and their characteristics during one year follow-up. Methods: Retrospective cohort study of Omani children aged 2-5 years in Muscat was conducted using electronic health data (2012-2015). Asthma control was measured by number of exacerbations requiring visits to the health center, emergency care or hospitalization within one year of asthma index diagnosis. Generalized linear mixed-effects modelling was used to account for the clustering of children within health centers. Results: Mean age was 2.8 years, predominantly male (63.2%) and originally from Muscat (96.2%). On index diagnosis day, 61.2% were given reliever medications, and on discharge 47.1% were prescribed controller medications. Most (74%) children had well-controlled asthma that was highly associated with being treated in a health center with higher proportion of IMCI training (Adj. OR= 3.0; 95% CI =1.34, 6.73; p <0.01), and receiving short acting β2-agonists for acute management at index diagnosis (Adj. OR=2.4; 95% CI=1.38-4.09). There was limited data for specialist referrals and counselling. Majority of children with ED visits were infrequent attenders (94.1%), however, a small percentage had high acute care utilization (e.g. 21 visits/year). Conclusion: IMCI is designed to improve health outcomes of young children. A high proportion of children treated in IMCI clinics achieved well-controlled asthma. Training of physicians improved asthma outcomes, but specific components in the IMCI asthma management protocol need more reinforcement and further exploration. Utilizing prevention quality indicators to screen for implementation of IMCI components is recommend. Longitudinal investigation of multilevel factors (patient, family, practice, and health care system) associated with childhood asthma control in Oman is needed.
    • Implementation of a Pediatric-Based Algorithm to Improve Care of Symptomatic Hypoglycemia

      Arjoon, Amanda V.; Fitzgerald, Jennifer (2021-05)
      Problem & Purpose: Hypoglycemia in childhood is a low frequency, high-risk event that can lead to coma, seizures, and even death. Symptomatic hypoglycemia occurs when plasma glucose levels are low enough to cause signs and symptoms of impaired neurological function, increasing risk of neurogenic sequalae. In the pediatric emergency department at an urban academic medical center in the Mid-Atlantic region, delays in treatment occur due to pediatric-specific barriers including time intensive, weight-based calculations for drug doses and availability of multiple dextrose concentrations. Although there is no national benchmark for comparison, the average time from identification of symptomatic hypoglycemia to treatment on this unit is 35 minutes. The purpose of this quality improvement project was to implement an algorithm for treatment of symptomatic hypoglycemia for pediatric patients between one and five years of age in the proposed setting. Methods: An algorithm was created based on recommendations from the Pediatric Endocrine Society, the American Academy of Pediatrics, and other accredited organizations. Thirty-two small educational sessions with 59 nurses and three physician assistants were conducted over two months to provide education on algorithm use. Anonymous pre- and post-surveys were administered during the educational sessions to assess for improvements in knowledge of evidence-based care for symptomatic pediatric hypoglycemia patients. The primary outcome was to reduce time from symptomatic hypoglycemia identification to enteral or parental treatment. Results: The sample size (N=4) was smaller than expected due to a significantly reduced census on this unit during the COVID-19 pandemic. Three males and one female met inclusion criteria, with a mean age of 2.75 years. The mean time to treatment was reduced to 6.5 minutes. The most observed symptom was nausea, which appeared in all four cases. Nearly 93% of staff demonstrated improved knowledge in caring for pediatric symptomatic hypoglycemic patients through improved survey scores after the educational sessions. Conclusion: Findings suggest that use of a standardized algorithm contributes to reducing the time from identification of symptomatic hypoglycemia to time of treatment. All patients meeting inclusion criteria received interventions consistent with the algorithm. Future directions include expanding implementation of an algorithm to incorporate pediatric patients of all ages.
    • Improving Feeding Practices for Infants Transitioning to Oral Feeds

      Burch, Kendra S.; Connolly, Mary Ellen (2022-05)
      Problem: Approximately 30 feeding intolerance events including aspiration, bradycardia, and desaturation occurred within the large metropolitan pediatric center over one year. The adverse feeding events were related to quantity-based feeding, incorrect nipple selection, and the staff's lack of awareness of stress signs during oral feedings. Interviews with nursing staff reveal limited knowledge and hesitancy to educate parents about feeding techniques. Purpose: The quality improvement initiative aimed to promote cue-based feeding and appropriate nipple selection to prevent adverse feeding events and improve consistency in infant feeding practices in a step-down pediatric cardiac unit. Methods: A multidisciplinary team of stakeholders, including a lactation consultant, nurses, clinical nurse specialists, occupational therapists, speech-language pathologists, and nurse practitioners, was formed to improve feeding practices. An educational program including cue-based feeding, nipple selection, and feeding techniques was provided to the nursing staff. The nursing staff received education to document feeding cues, feeding techniques, time to feed, and feeding intolerance under the General Infant Feeding Assessment (GIFA) in the electronic medical record. Individualized feeding guides were developed by speech-language pathologists and occupational therapists for use at the bedside by the nursing staff and family. Signs were placed around the unit to increase awareness of the practice change. Results: Documentation compliance and use of feeding resources were low throughout implementation. Infants with inconsistent feeding assessments or nipple selection documentation were found to have signs of vital sign instability with oral feedings. Conclusions: The educational program and documentation of feeding assessments may improve feeding practices when used consistently.
    • Improving Provider Compliance with Glycemic Guidelines in Children with Type 1 Diabetes

      Burr, Mary S. (2016)
      The serum glycated hemoglobin or hemoglobin A1c (HbA1c) measurement is the most important long-term measurement of glycemic control and treatment effect when caring for the child with Type 1 diabetes mellitus (T1DM). The goal of treatment in diabetes is to maintain the patient’s blood glucose within a specific therapeutic range. A team of specialized providers is typically responsible for the care of these children, and continuity of the treatment among providers has been shown to improve glycemic control. Additionally, provision of guideline driven care has been shown to have positive outcomes in terms of therapeutic HbA1c measurement. In January 2015, The American Diabetes Association (ADA) released revised HbA1c guidelines for children with T1DM. Their recommendation was all children with T1DM should have an HbA1c level of < 7.5%. The goal of this quality improvement (QI) project was to promote and measure the level of provider compliance with current (2015) ADA glycemic guidelines using a standardized phrase for documentation in the electronic medical record (EMR). Methods: There were three phases to the implementation of the project. The initial phase was the completion of an EMR audit to assess the current HbA1c measurements of the pediatric patients in the clinic. The second phase was performance of a survey to assess provider knowledge of current ADA guidelines and the third phase was the creation and implementation of a “smart phrase” for EMR documentation, which confirmed that the HbA1c measurement and the recommendations of the ADA had been addressed with the patient and family. At the completion of the intervention phase, the project leader performed a manual retrospective chart review, which provided the nominal data needed to measure provider compliance in the use of the EMR smart phrase. Results: The project took place in a Diabetes and Endocrinology Center of a large urban academic medical center. The convenience sample of providers consisted of 9 pediatric diabetes care providers who currently practice at the center: three pediatric endocrinologists, three pediatric nurse practitioners and three certified diabetes educators. Data collection for the project was conducted over a six-week period, capturing 122 patient visits. Overall there was a 59% provider compliance rate with smart phrase usage; the group most compliant in smart phrase usage was the group of APRN providers, who used the phrase in 70% of patient visits. Conclusions: The standardized EMR phrase was helpful in identifying provider compliance with discussing current ADA guidelines when utilized. Consistent use of the smart phrase reflects guideline-driven care by diabetes providers and sends a clear message to families of patients with T1DM regarding the importance of glycemic control and improved patient outcomes.