Improving the Quality and Safety of Hospital Care

In FY18, a key broad theme in the Division of Hospital Medicine’s portfolio of quality improvement efforts was safety. Specifically, the Division of Hospital Medicine continues to work on ways to safely do less. One key example of impactful work led by one of our fellows, Dr. Sonya Tang-Girdwood, and her Hospital Medicine faculty mentors, key partners in pharmacy and infectious diseases, and the pediatric residency. Dr. Tang-Girdwood’s team focused on the timely and safe transition of hospitalized patients from intravenous antibiotics to oral antibiotics with the intent of decreasing costs via lower medication expenses and possibly decreased the length of stay (LOS) and decreasing potential harm from unnecessary intravenous (IV) access and antibiotic resistance. Several national scientific meetings featured the team's results; highlights include an annual savings of $30,000 in medication costs, a 70% decrease in antibiotic cost per patient encounter, and a doubling of the proportion of patients who have a timely transition from IV to oral antibiotics.

In addition, division providers at the Liberty campus, led by Drs. Anna Ipsaro, MD, MBE; Shivani Patel, DO, MS; and Philip Hagedorn, MD, FAAP, tackled a very challenging patient safety issue of how to better manage diagnostic uncertainty. Dr. Ipsaro and team partnered with the Divisions of Emergency Medicine and Patient Services colleagues, as well as parents of patients, to improve the open sharing of diagnostic concerns. The team established a shared language about uncertainty which they then embedded as an “uncertain diagnosis flag” within our existing, industry leading system of situational awareness. Now, when any clinician has diagnostic uncertainty, that concern is reliably and systematically shared with the other members of the patient’s care team. Subsequently, the team was able to identify several cases when there was rapid recognition of patient’s evolving diagnosis that clinicians believed was enabled by the “uncertain diagnosis” flag. Researchers presented this pilot work at the national Pediatric Hospital Medicine meeting and will be spread in FY19 to other services at the Liberty campus and to the Division of Hospital Medicine patients at the Burnet campus.

Enhancing the Use of Biomedical Informatics to Improve Patient Care

Dr. Philip Hagedorn, MD, has led the Division of Hospital Medicine’s at the intersection of clinical medicine, operations, and research through innovative efforts in clinical informatics. The group is currently leveraging data services offered by information services to drive quality improvement, care standardization and research. Karen Jerardi, MD, MEd, has piloted a live bronchiolitis care standardization dashboard, detailing with near real-time data when, where and how the division’s treatment of bronchiolitis deviates from standard of care by accessing and aggregating medication administration data with diagnosis and other metadata associated with a patient’s admission. Patrick Brady, MD, MSc, has tested using this data pipeline for improved visualization of longitudinal patterns in patients with complex medical histories to compare parental perception of “normal” vital signs for these children with objective data during admissions. Additionally, Dr. Hagedorn developed a two-week elective to identify and empower pediatric residents with an interest in learning more about the field of clinical informatics. The experience provides young physicians insight into the work that goes on behind the scenes to keep Cincinnati Children's Hospital Medical Center’s clinical information systems running. The residents spend time with information service analysts and attend governance events for the electronic health record. They also receive insight into the types of research being conducted both in clinical informatics and bioinformatics here at Cincinnati Children's. Past graduates of the rotation have pursued longitudinal work in clinical informatics at Cincinnati Children's including Dr. Jesse Hansen, MD, a clinical fellow in the Heart Institute, who is now pursuing a certificate in clinical informatics and Dr. Chris Kovaleski who recently won a RISE award for work launched during his clinical informatics rotation.

Leading the Way in Medical Student Education

Multiple faculty members of the Division of Hospital Medicine hold leadership roles within the University of Cincinnati College of Medicine (UCCOM) and are revolutionizing the way we recruit, educate, and mentor our growing classes of medical students. The incoming Class of 2022 includes 179 students and the most women (57%) in the school’s 199-year history. Dr. Mia Mallory, MD, MEd, is UCCOM’s associate dean of Diversity and Inclusion.

In this role, Dr. Mallory leads efforts within UCCOM to recruit, educate, and support minority students, residents and faculty members. These efforts are critical as society becomes more diverse, making cultural competency in medicine and the presence of historically underrepresented groups in the profession imperative. Dr. Matthew Kelleher, MD, MEd, is the co-director of the Clinical Skills Course for the 1st and 2nd year medical students at UCCOM. In this course, medical students acquire the skills to obtain a history, perform a physical examination, communicate with patients, and assimilate information to begin making diagnostic and management decisions. After assuming this new role in 2017, Dr. Kelleher has implemented many new and innovative changes and is constantly striving to improve the educational value of the course. After only a year of teaching this course, he was awarded the Silver Teaching Apple from the 1st and 2nd students in recognition of his teaching efforts. Dr. Amy Guiot, MD, MEd, serves as director of Intersessions and Electives for the 3rd and 4th year students at UCCOM. She oversees the three, week-long intersessions that 3rd year students participate in to prepare them for clerkships and future careers, as well as promote health and wellness during their busy clinical times. Dr. Guiot is also the associate pediatric clerkship director, director of the pediatric acting internship, and director of the Medical Student Scholars Program where she oversees 10 programs in which motivated students can participate in scholarly projects and research. In 2018, Drs. Leslie Farrell, MD, and Shivani Patel, became members of the new Department of Pediatrics Medical Student Education Committee. They facilitate small group learning for the medical students on their pediatrics clerkship, assist the clerkship leadership with educational programming and student assessment, and contribute to developing innovative educational strategies for medical student clinical rotations.

Determining Best Transition Practices from Hospital to Home

Across the United States, roughly one in every 11 children discharged from the hospital will face readmission in the next 30 days. Consequently, there is increased focus nationally on how to develop and test interventions to reduce readmissions and improve the transition from hospital to home. Drs. Kathy Auger, MD, MSc; Jeff Simmons, MD, MSc; and Samir Shah, MD, MSCE, led a series of studies funded by the Patient Centered Outcomes Research Institute (PCORI) which culminated in two randomized controlled trials completed this past year. In the first, half of the children under the care of the Divisions of Hospital Medicine, Neurology, and Neurosurgery were randomized to a home nursing visit several days after hospital discharge. The other half of children received usual care. The study team found that the nursing home visit did not decrease unplanned healthcare reuse and may have increased reuse; in current research, the team is interviewing families, nurses, and doctors to determine why this outcome occurred. In a second randomized controlled trial with a similar group of children the team found that a nurse phone call shortly after discharge also failed to reduce unplanned healthcare reuse. Together, the findings illustrate how critical it is to perform randomized controlled trials, as promising ideas often fail to deliver the impact one might expect. Drs. Auger, Simmons, and Shah continue to work with their talented and multidisciplinary team to further understand and improve the transition from hospital to home. The named authors on the two main studies also include: Dr. Heather Tubbs-Cooley, Dr. Heidi Sucharew, PhD, Dr. Angela Statile, MD, MEd, Dr. Rita Pickler, Ms. Hadley Sauers Ford, Ms. Jennifer Gold, Dr. Jane Khoury, PhD, Dr. Andrew Beck, Ms. Susan Wade-Murphy, Mr. Pierce Kuhnell, Ms. Kat Bell, and Ms. Colleen Mangeot.

Other Significant Accomplishments

Excellence of Division Fellows and Faculty 

Fellows:

The fellowship in Pediatric Hospital Medicine continues to grow as the field has transitioned to board subspecialty status. There has been a significant increase in qualified applicants and an increased demand for fellowship trained faculty nationally. This progress provides the opportunity to expand our training program to meet the needs of the field during fellowship training and beyond. To ensure continued success, we have added two associate fellowship directors. Dr. Laura Brower, MD, will focus on the clinical and quality improvement training components of the fellowship curriculum, and Dr. Joanna Thomson, MD, MPH, will focus on further development of the research curriculum including dedicated fellowship research conferences and formalized didactic sessions. The strong training provided to our fellows serves as a model for fellowship programs nationally. The success of our fellows over the past year includes significant contributions to the care of hospitalized children.

Michael Tchou, MD, MSc, gave the Academic Pediatric Association Presidential Plenary Presentation at the 2018 meeting of the Pediatric Academic Societies, where he shared his team’s work in improving value of care through the reduction of unnecessary electrolyte testing. Through interventions focused on improved provider awareness, electrolyte testing was reduced by 35% and the usage of highest cost panels decreased by 60%. Dr. Tchou also received a Novice Research Award from the Gerber Foundation to further study how repeat electrolyte testing changes patient care and determine how we can predict tests that provide little value to patient care outcomes.

Dr. Sanya Desai, MD, presented her work at the Plenary Session of the 2018 Pediatric Hospital Medicine Meeting. In her study of young infants with bacteremic UTI, those who received < 7 days of IV antibiotic therapy did not have significantly more 30-day recurrent UTIs or increased 30-day reutilization as compared to infants receiving longer courses of IV antibiotic therapy. This work suggesting that short course IV therapy with early conversion to oral antibiotics considered in this population is likely to decrease IV antibiotic and shorten hospital length of stay for these patients.

Dr. Ashley Jenkins, MD, received the CCTST Partnership Development Grant in partnership with the Center for Spina Bifida at Cincinnati Children’s. They will work together with the Spina Bifida Coalition of Cincinnati to focus on the stressful and often challenging time of transition from pediatric to adult care for patients with spina bifida. They will use community-based participatory research methods to identify barriers and facilitators of a successful transition.

Faculty:

The prestigious Society for Pediatric Research (SPR) elected new members Drs. Jennifer O’Toole, MD, MEd, and Eric Kirkendall, MD, MBI, FAAP. The SPR mission is to create a network of multidisciplinary researchers to improve child health. Criteria for membership includes demonstration of exceptional scholarship and leadership in pediatrics. They join current SPR members, Drs. Lilliam Ambroggio, Katherine Auger, Patrick Brady, Amanda Schondelmeyer and Samir S. Shah. Dr. Shah served as a member of the SPR Leadership Council.

Dr. Katherine Auger received the Pediatric Hospital Medicine Excellence in Research Award, jointly from the Academic Pediatric Association, the American Academy of Pediatrics, and the Society for Hospital Medicine for research providing insights into understanding reasons for hospital readmissions and testing interventions to prevent them. Dr. Auger was also named associate chair of Outcomes. In this role, she leads efforts to improve measurement of quality across the Department of Pediatrics. She is an associate member of the Pediatric Research in Inpatient Settings (PRIS, pronounced ‘prize’) Executive Leadership Council. PRIS is a >120 hospital-based research network with >120 hospital members across North America.

Dr. Patrick Brady received the prestigious national Pediatric Hospital Medicine Excellence in Patient Safety and Quality Award, jointly from the Academic Pediatric Association, the American Academy of Pediatrics, and the Society for Hospital Medicine in recognition of his groundbreaking work to reduce unrecognized clinical deterioration and serious safety events among hospitalized children. Dr. Brady received a promotion to associate editor of Hospital Pediatrics, an American Academy of Pediatrics journal and the first and largest devoted to pediatric hospital medicine. He serves on the Center for Disease Control and Prevention’s (CDC’s) first pediatric sepsis meeting. He represents the American Academy of Pediatrics Section of Hospital Medicine on this group which aims to develop objective pediatric sepsis surveillance definitions. Dr. Brady also joined the Research Oversight Group for the Solutions for Patient network. He is one of four leaders directing research in the >130 hospital Centers for Medicare & Medicaid Services (CMS) funded collaborative which aims to eliminate serious harm for hospitalized children.

The Society for Hospital Medicine selected Dr. Yemisi Jones, MD, as a fellow for her exceptional leadership in the field, and her dedication to providing outstanding care and improving hospital systems. The Society for Hospital Medicine is a >15,000 member national organization dedicated to promoting high quality and high value healthcare for every hospitalized patient and to improving hospitals and the healthcare community through innovation, collaboration, and patient-centered care.

Dr. Matthew Kelleher, MD, MEd, received Silver Apple Teaching Awards from both the first and second year medical student classes. These awards recognize excellence in education, small group and bedside learning experience facilitation, and extraordinary and sustained dedication and effort on behalf of medical student education. Dr. Kelleher is also a member of the Content Development Team for the American Board of Pediatrics (ABP) Hospital Medicine Sub-Board. Dr. Jennifer O’Toole is one of the inaugural leaders of the ABP Sub-Board in Hospital Medicine.

Dr. Benjamin Kinnear, MD, received the honor of identifying and presenting the top articles in the field at Pediatric Hospital Medicine, an annual international scientific meeting jointly sponsored by the American Academy of Pediatrics, the Academic Pediatric Association, and the Society of Hospital Medicine. An extraordinary educator, Dr. Kinnear also received the award for the 2017-2018 top Department of Internal Grand Rounds presentation. Dr. Kinnear also serves as an associate program director in both the Internal Medicine Residency Program and the Internal Medicine-Pediatrics Combined Residency Program.

Dr. Jennifer O’Toole received the Excellence in Teaching Award from the Society of Hospital Medicine. This award recognizes Dr. O’Toole’s dedication to teaching, leadership in the advancement of innovative educational techniques, outstanding contributions to medical education administration and exceptional mentorship of learners at all levels.

Dr. Sarah Riddle, MD, IBCLC, FAAP, received the Division of Hospital Medicine Clinical Care Award for her dedication to providing the highest level of and leading improvements in clinical care, noteworthy dedication to providing patient- and family-centered care, outstanding leadership of the inter-professional team and exemplary role modeling of professionalism to colleagues, learners, and patients.

Dr. Anita Shah, DO, MMS, MPH, was named a member of the Pediatric Policy and Advocacy Committee of the Academic Pediatric Association.

Dr. Samir S. Shah received the Cincinnati Children’s Senior Faculty Mentorship Award for his exceptional mentorship of residents, students, and faculty both locally and nationally and for serving as a role model to those who aspire to excel as mentors. He was also named chief metrics officer through the James M. Anderson Center for Health Systems Excellence to lead cross-departmental efforts to inform measure selection and promote organizational alignment to drive improvement at all levels of the care delivery system.

Dr. Angela Statile, MD, MEd, received the Cincinnati Children’s Junior Faculty Clinical Care Award for her leadership of clinical initiatives to improve the care of hospitalized children. Most notably, she led the implementation of strategies to improve efficient transitions of acute care patients from the hospital to their home by working with a multidisciplinary team to proactively address patient discharge needs. As a medical unit leader, she also worked with nursing leaders on a variety of quality initiatives, including implementation of high flow nasal cannula in infants outside the intensive care unit.

Dr. Ndidi Unaka, MD, MEd, received the Cincinnati Children’s Junior Faculty Education Award for her role in training and mentoring pediatric residents as associate program director of the Categorical Pediatric Residency Program and her focus on health literacy. Dr. Unaka led a quality improvement initiative to create readable, understandable and standardized instructions provided to families upon hospital discharge. Dr. Unaka also received the 2018 Leonard Town Humanism in Medicine Award from the University of Cincinnati College of Medicine.

Drs. Angela Statile and Ndidi Unaka were named editors for the Hospital Medicine section of The Journal Current Treatment Options in Pediatrics named Drs. Statile and Unaka as editors for the hospital medicine section. The journal serves educators, researchers, and clinicians, and others involved in the care of children. The newly created section will feature contemporary topics focused on issues pertinent to the care of hospitalized children and authored by leaders in the field.

Dr. Dane Warner, MD, MPH, received the Hope Award, which recognizes the Cincinnati Children's employee who demonstrates the highest orthopaedic patient experience.

Dr. Christine White, MD, MAT, received the University of Missouri Medical Alumni Organization’s Outstanding Young Physician Award given to distinguished alumni under the age of 45. Dr. White received recognition for her extensive work that has led to improved patient throughput and operational processes at Cincinnati Children’s and serves as a model for other institutions.