- Pediatric Critical Care Medicine
Chief Medical Information Officer, Stanford Children's Health (2016 - Present)
Program Director, Clinical Informatics Fellowship (2019 - Present)
Associate Program Director, Clinical Informatics Fellowship, Stanford University Medical Center (2014 - 2019)
Associate Chief Medical Information Officer, Stanford Children's Health (2015 - 2016)
Director of Clinical Informatics, Stanford Children's Hospital (2014 - 2016)
Physician Lead, Epic EMR Inpatient Implementation, Lucile Packard Children's Hospital (2012 - 2014)
Medical Director of Clinical Informatics, Lucile Packard Children's Hospital (2012 - 2014)
Associate Medical Director of Clinical Decision Support, Lucile Packard Children's Hospital (2010 - 2012)
Medical Education: Stanford University School of Medicine (2004) CA
Fellowship: Stanford University Pediatric Critical Care Fellowship (2010) CA
Residency: Stanford University Pediatric Residency (2007) CA
Board Certification: American Board of Preventive Medicine, Clinical Informatics (2014)
Board Certification: American Board of Pediatrics, Pediatrics (2007)
MEd, University of Cincinnati, Medical Education (2013)
Board Certification, American Board of Preventive Medicine, Clinical Informatics (2013)
Board Certification: American Board of Pediatrics, Pediatric Critical Care Medicine (2010)
Current Research and Scholarly Interests
In my administrative role, I oversee the development and maintenance of clinical decision support tools within the electronic medical record. These clinical decision support tools are designed to enhance patient safety, efficiency, and quality of care. My research focuses on rigorously evaluating--1) how these tools affect clinician knowledge, attitudes, and behaviors; and 2) how these tools affect clinical outcomes and efficiency of health care delivery.
Graduate and Fellowship Programs
Biomedical Informatics (Phd Program)
Pediatric Critical Care Medicine (Fellowship Program)
- Implications of the 21st Century Cures Act in Pediatrics. Pediatrics 2020
Early experiences of accredited clinical informatics fellowships.
Journal of the American Medical Informatics Association
2016; 23 (4): 829-834
Since the launch of the clinical informatics subspecialty for physicians in 2013, over 1100 physicians have used the practice and education pathways to become board-certified in clinical informatics. Starting in 2018, only physicians who have completed a 2-year clinical informatics fellowship program accredited by the Accreditation Council on Graduate Medical Education will be eligible to take the board exam. The purpose of this viewpoint piece is to describe the collective experience of the first four programs accredited by the Accreditation Council on Graduate Medical Education and to share lessons learned in developing new fellowship programs in this novel medical subspecialty.
View details for DOI 10.1093/jamia/ocv209
View details for PubMedID 27206458
Use of a Checklist and Clinical Decision Support Tool Reduces Laboratory Use and Improves Cost.
2016; 137 (1): 1-8
We hypothesized that a daily rounding checklist and a computerized order entry (CPOE) rule that limited the scheduling of complete blood cell counts and chemistry and coagulation panels to a 24-hour interval would reduce laboratory utilization and associated costs.We performed a retrospective analysis of these initiatives in a pediatric cardiovascular ICU (CVICU) that included all patients with congenital or acquired heart disease admitted to the cardiovascular ICU from September 1, 2008, until April 1, 2011. Our primary outcomes were the number of laboratory orders and cost of laboratory orders. Our secondary outcomes were mortality and CVICU and hospital length of stay.We found a reduction in laboratory utilization frequency in the checklist intervention period and additional reduction in the CPOE intervention period [complete blood count: 31% and 44% (P < .0001); comprehensive chemistry panel: 48% and 72% (P < .0001); coagulation panel: 26% and 55% (P < .0001); point of care blood gas: 43% and 44% (P < .0001)] compared with the preintervention period. Projected yearly cost reduction was $717, 538.8. There was no change in adjusted mortality rate (odds ratio 1.1, 95% confidence interval 0.7-1.9, P = .65). CVICU and total length of stay (days) was similar in the pre- and postintervention periods.Use of a daily checklist and CPOE rule reduced laboratory resource utilization and cost without adversely affecting adjusted mortality or length of stay. CPOE has the potential to hardwire resource management interventions to augment and sustain the daily checklist.
View details for DOI 10.1542/peds.2014-3019
View details for PubMedID 26681782
Optimizing care of adults with congenital heart disease in a pediatric cardiovascular ICU using electronic clinical decision support*.
Pediatric critical care medicine
2014; 15 (5): 428-434
The optimal location for postoperative cardiac care of adults with congenital heart disease is controversial. Some congenital heart surgeons operate on these adults in children's hospitals with postoperative care provided by pediatric critical care teams who may be unfamiliar with adult national performance measures. This study tested the hypothesis that Clinical Decision Support tools integrated into the clinical workflow would facilitate improved compliance with The Joint Commission Surgical Care Improvement Project performance measures in adults recovering from cardiac surgery in a children's hospital.Retrospective chart review comparing compliance pre- and post-Clinical Decision Support intervention for Surgical Care Improvement Project measures addressed in the critical care unit: appropriate cessation of prophylactic antibiotics; controlled blood glucose; urinary catheter removal; and reinitiation of preoperative β-blocker when indicated.Cardiovascular ICU in a quaternary care freestanding children's hospital.The cohort included 114 adults 18-70 years old recovering from cardiac surgery in our pediatric cardiovascular ICU.Clinical Decision Support tools including data-triggered alerts, smart documentation forms, and order sets with conditional logic were integrated into the workflow.Compliance with antibiotic discontinuation was 100% pre- and postintervention. Compliance rates improved for glucose control (p = 0.007) and urinary catheter removal (p = 0.05). Documentation of β-blocker therapy (nonexistent preintervention) was 100% postintervention. Composite compliance for all measures increased from 53% to 84% (p = 0.002). There were no complications related to institution of the Surgical Care Improvement Project measures. There was no in-hospital mortality.Compliance with the national adult postoperative performance measures can be excellent in a children's hospital with the help of Clinical Decision Support tools. This represents an important step toward providing high-quality care to a growing population of adults with congenital heart disease who may receive care in a pediatric center.
View details for DOI 10.1097/PCC.0000000000000124
View details for PubMedID 24732291
Use of Electronic Medical Record-Enhanced Checklist and Electronic Dashboard to Decrease CLABSIs.
2014; 133 (3): e738-46
We hypothesized that a checklist enhanced by the electronic medical record and a unit-wide dashboard would improve compliance with an evidence-based, pediatric-specific catheter care bundle and decrease central line-associated bloodstream infections (CLABSI).We performed a cohort study with historical controls that included all patients with a central venous catheter in a 24-bed PICU in an academic children's hospital. Postintervention CLABSI rates, compliance with bundle elements, and staff perceptions of communication were evaluated and compared with preintervention data.CLABSI rates decreased from 2.6 CLABSIs per 1000 line-days before intervention to 0.7 CLABSIs per 1000 line-days after intervention. Analysis of specific bundle elements demonstrated increased daily documentation of line necessity from 30% to 73% (P < .001), increased compliance with dressing changes from 87% to 90% (P = .003), increased compliance with cap changes from 87% to 93% (P < .001), increased compliance with port needle changes from 69% to 95% (P < .001), but decreased compliance with insertion bundle documentation from 67% to 62% (P = .001). Changes in the care plan were made during review of the electronic medical record checklist on 39% of patient rounds episodes.Use of an electronic medical record-enhanced CLABSI prevention checklist coupled with a unit-wide real-time display of adherence was associated with increased compliance with evidence-based catheter care and sustained decrease in CLABSI rates. These data underscore the potential for computerized interventions to promote compliance with proven best practices and prevent patient harm.
View details for DOI 10.1542/peds.2013-2249
View details for PubMedID 24567021
- Refocusing medical education in the EMR era. JAMA-the journal of the American Medical Association 2013; 310 (21): 2249-2250
Medical education in the electronic medical record (EMR) era: benefits, challenges, and future directions.
2013; 88 (6): 748-752
In the last decade, electronic medical record (EMR) use in academic medical centers has increased. Although many have lauded the clinical and operational benefits of EMRs, few have considered the effect these systems have on medical education. The authors review what has been documented about the effect of EMR use on medical learners through the lens of the Accreditation Council for Graduate Medical Education's six core competencies for medical education. They examine acknowledged benefits and educational risks to use of EMRs, consider factors that promote their successful use when implemented in academic environments, and identify areas of future research and optimization of EMRs' role in medical education.
View details for DOI 10.1097/ACM.0b013e3182905ceb
View details for PubMedID 23619078
A clinical case of electronic health record drug alert fatigue: consequences for patient outcome.
2013; 131 (6): e1970-3
Despite advances in electronic medication order entry systems, it has been well established that clinicians override many drug allergy alerts generated by the electronic health record. The direct clinical consequences of overalerting clinicians in a pediatric setting have not been well demonstrated in the literature. We observed a patient in the PICU who experienced complications as a result of an extended series of non-evidence-based alerts in the electronic health record. Subsequently, evidence-based allergy alerting changes were made to the hospital's system. Incorporating clinical evidence in electronic drug allergy alerting systems remains challenging, especially in pediatric settings.
View details for DOI 10.1542/peds.2012-3252
View details for PubMedID 23713099
Embedding time-limited laboratory orders within computerized provider order entry reduces laboratory utilization*.
Pediatric critical care medicine
2013; 14 (4): 413-419
: To test the hypothesis that limits on repeating laboratory studies within computerized provider order entry decrease laboratory utilization.: Cohort study with historical controls.: A 20-bed PICU in a freestanding, quaternary care, academic children's hospital.: This study included all patients admitted to the pediatric ICU between January 1, 2008, and December 31, 2009. A total of 818 discharges were evaluated prior to the intervention (January 1, 2008, through December 31, 2008) and 1,021 patient discharges were evaluated postintervention (January 1, 2009, through December 31, 2009).: A computerized provider order entry rule limited the ability to schedule repeating complete blood cell counts, chemistry, and coagulation studies to a 24-hour interval in the future. The time limit was designed to ensure daily evaluation of the utility of each test.: Initial analysis with t tests showed significant decreases in tests per patient day in the postintervention period (complete blood cell counts: 1.5 ± 0.1 to 1.0 ± 0.1; chemistry: 10.6 ± 0.9 to 6.9 ± 0.6; coagulation: 3.3 ± 0.4 to 1.7 ± 0.2; p < 0.01, all variables vs. preintervention period). Even after incorporating a trend toward decreasing laboratory utilization in the preintervention period into our regression analysis, the intervention decreased complete blood cell counts (p = 0.007), chemistry (p = 0.049), and coagulation (p = 0.001) tests per patient day.: Limits on laboratory orders within the context of computerized provider order entry decreased laboratory utilization without adverse affects on mortality or length of stay. Broader application of this strategy might decrease costs, the incidence of iatrogenic anemia, and catheter-associated bloodstream infections.
View details for DOI 10.1097/PCC.0b013e318272010c
View details for PubMedID 23439456
Computerized Physician Order Entry With Decision Support Decreases Blood Transfusions in Children
2011; 127 (5): E1112-E1119
Timely provision of evidence-based recommendations through computerized physician order entry with clinical decision support may improve use of red blood cell transfusions (RBCTs).We performed a cohort study with historical controls including inpatients admitted between February 1, 2008, and January 31, 2010. A clinical decision-support alert for RBCTs was constructed by using current evidence. RBCT orders resulted in assessment of the patient's medical record with prescriber notification if parameters were not within recommended ranges. Primary end points included the average pretransfusion hemoglobin level and the rate of RBCTs per patient-day.In total, 3293 control discharges and 3492 study discharges were evaluated. The mean (SD) control pretransfusion hemoglobin level in the PICU was 9.83 (2.63) g/dL (95% confidence interval [CI]: 9.65-10.01) compared with the study value of 8.75 (2.05) g/dL (95% CI: 8.59-8.90) (P < .0001). The wards' control value was 7.56 (0.93) g/dL (95% CI: 7.47-7.65), the study value was 7.14 (1.01) g/dL (95% CI: 6.99-7.28) (P < .0001). The control PICU rate of RBCTs per patient-day was 0.20 (0.11) (95% CI: 0.13-0.27), the study rate was 0.14 (0.04) (95% CI: 0.11-0.17) (P = .12). The PICU's control rate was 0.033 (0.01) (95% CI: 0.02-0.04), and the study rate was 0.017 (0.007) (95% CI: 0.01-0.02) (P < .0001). There was no difference in mortality rates across all cohorts.Implementation of clinical decision-support alerts was associated with a decrease in RBCTs, which suggests improved adoption of evidence-based recommendations. This strategy might be widely applied to promote timely adoption of scientific evidence.
View details for DOI 10.1542/peds.2010-3252
View details for Web of Science ID 000290097800002
View details for PubMedID 21502229
Pediatric subspecialty telemedicine use from the patient and provider perspective.
BACKGROUND: To characterize telemedicine use among pediatric subspecialties with respect to clinical uses of telemedicine, provider experience, and patient perceptions during the COVID-19 pandemic.METHODS: We performed a mixed-methods study of telemedicine visits across pediatric endocrinology, nephrology, orthopedic surgery, and rheumatology at a large children's hospital. We used deductive analysis to review observational data from 40 video visits. Providers and patients/caregivers were surveyed around areas of satisfaction and communication.RESULTS: We found adaptations of telemedicine including shared-screen use and provider-guided parent procedures among others. All providers felt that it was safest for their patients to conduct visits by video, and 72.7% reported completing some component of a clinical exam. Patients rated the areas of being respected by the clinical staff/provider and showing care and concern highly, and the mean overall satisfaction was 86.7±19.3%.CONCLUSIONS: Telemedicine has been used to deliver care to pediatric patients during the pandemic, and we found that patients were satisfied with the telemedicine visits during this stressful time and that providers were able to innovate during visits. Telemedicine is a tool that can be successfully adapted to patient and provider needs, but further studies are needed to fully explore its integration in pediatric subspecialty care.IMPACT: This study describes telemedicine use at the height of the COVID-19 pandemic from both a provider and patient perspective, in four different pediatric subspecialties. Prior to COVID-19, pediatric telehealth landscape analysis suggested that many pediatric specialty practices had pilot telehealth programs, but there are few published studies evaluating telemedicine performance through the simultaneous patient and provider experience as part of standard care. We describe novel uses and adaptations of telemedicine during a time of rapid deployment in pediatric specialty care.
View details for DOI 10.1038/s41390-021-01443-4
View details for PubMedID 33753896
The Value of OpenNotes for Pediatric Patients, Their Families and Impact on the Patient-Physician Relationship.
Applied clinical informatics
2021; 12 (1): 76–81
BACKGROUND: OpenNotes, the sharing of medical notes via a patient portal, has been extensively studied in adults but not in pediatric populations. This has been a contributing factor in the slower adoption of OpenNotes by children's hospitals. The 21st Century Cures Act Final Rule has mandated the sharing of clinical notes electronically to all patients and as health systems prepare to comply, some concerns remain particularly with OpenNotes for pediatric populations.OBJECTIVES: After a gradual implementation of OpenNotes at an academic pediatric center, we sought to better understand how pediatric patients and families perceived OpenNotes. This article presents the detailed steps of this informatics-led rollout and patient survey results with a focus on pediatric-specific concerns.METHODS: We adapted a previous OpenNotes survey used for adult populations to a pediatric outpatient setting (with parents of children <12 years old). The survey was sent to patients and families via a notification email sent as a standard practice after a clinic visit, in English or Spanish.RESULTS: Approximately 7% of patients/families with access to OpenNotes read the note during the study period, and 159 (20%) of those patients responded to the survey. Of the survey respondents, 141 (89%) of patients and families understood their notes; 126 (80%) found the notes always or usually accurate; 24 (15%) contacted their clinicians after reading a note; and 153 (97%) patients/families felt the same or better about their doctor after reading the note.CONCLUSION: Although limited by relatively low survey response rate, OpenNotes was well-received by parents of pediatric patients without untoward consequences. The main concerns pediatricians raise about OpenNotes proved to not be issues in the pediatric population. Our results demonstrate clear benefits to adoption of OpenNotes. This provides reassurance that the transition to sharing notes with pediatric patients can be successful and value additive.
View details for DOI 10.1055/s-0040-1721781
View details for PubMedID 33567464
A Clinical Informatics Program Directors' Proposal to the American Board of Preventive Medicine.
Applied clinical informatics
2020; 11 (3): 483–86
In 2013, the American Board of Preventive Medicine (ABPM) and the American Board of Pathology (ABPath) offered the first board certification examination in Clinical Informatics to eligible physicians in the United States. In 2022, the Practice Pathway will expire and in 2023 only candidates eligible through the Fellowship Pathway will be eligible for the board certification. To date, Clinical Informatics as a specialty has not had a regular match process and used a controlled offer-acceptance process that does not meet candidates' or programs' needs. Fellows may not be offered a position with their top choice program initially, and they may accept offers from other programs to avoid risk by ensuring that they have a fellowship position. Programs have to consider losing an applicant in the first round in the ranking of applicants. The process is open to manipulation including early agreements between program directors and candidates. In this open letter to the ABPM, program directors make the case for a third-party match and are calling on the ABPM to leverage its status as the Clinical Informatics certifying body and its existing infrastructure to implement a Clinical Informatics match.
View details for DOI 10.1055/s-0040-1714348
View details for PubMedID 32668481
Rapid Deployment of Inpatient Telemedicine In Response to COVID-19 Across Three Health Systems.
Journal of the American Medical Informatics Association : JAMIA
To reduce pathogen exposure, conserve personal protective equipment, and facilitate health care personnel work participation in the setting of the COVID-19 pandemic, three affiliated institutions rapidly and independently deployed inpatient telemedicine programs during March 2020. We describe key features and early learnings of these programs in the hospital setting.Relevant clinical and operational leadership from an academic medical center, pediatric teaching hospital, and safety net county health system met to share learnings shortly after deploying inpatient telemedicine. A summative analysis of their learnings was re-circulated for approval.All three institutions faced pressure to urgently standup new telemedicine systems while still maintaining secure information exchange. Differences across patient demographics and technological capabilities led to variation in solution design, though key technical considerations were similar. Rapid deployment in each system relied on readily available consumer-grade technology, given the existing familiarity to patients and clinicians and minimal infrastructure investment. Preliminary data from the academic medical center over one month suggested positive adoption with 631 inpatient video calls lasting an average (standard deviation) of 16.5 minutes (19.6) based on inclusion criteria.The threat of an imminent surge of COVID-19 patients drove three institutions to rapidly develop inpatient telemedicine solutions. Concurrently, federal and state regulators temporarily relaxed restrictions that would have previously limited these efforts. Strategic direction from executive leadership, leveraging off-the-shelf hardware, vendor engagement, and clinical workflow integration facilitated rapid deployment.The rapid deployment of inpatient telemedicine is feasible across diverse settings as a response to the COVID-19 pandemic.
View details for DOI 10.1093/jamia/ocaa077
View details for PubMedID 32495830
Electronic health record (EHR) training program identifies a new tool to quantify the EHR time burden and improves providers' perceived control over their workload in the EHR.
2019; 2 (2): 222–30
To understand if providers who had additional electronic health record (EHR) training improved their satisfaction, decreased personal EHR-use time, and decreased turnaround time on tasks.This pre-post study with no controls evaluated the impact of a supplemental EHR training program on a group of academic and community practice clinicians that previously had go-live group EHR training and 20 months experience using this EHR on self-reported data, calculated EHR time, and vendor-reported metrics.Providers self-reported significant improvements in their knowledge of efficiency tools in the EHR after training and doubled (significant) their preference list entries (mean pre = 38.1 [65.88], post = 63.5 [90.47], P < .01). Of the 7 EHR satisfaction variables, only 1 self-reported variable significantly improved after training: Control over my workload in the EHR (mean pre = 2.7 [0.96], post = 3.0 [1.04], P < .01). There was no significant decrease in their calculated EHR usage outside of clinic (mean pre = 0.39 [0.77] to post = 0.37 [0.48], P = .73). No significant difference was seen in turnaround time for patient calls (mean pre = 2.3 [2.06] days, post = 1.9 [1.76] days, P = .08) and results (mean before = 4.0 [2.79] days, after = 3.2 [2.33] days, P = .03).Multiple sources of data provide a holistic view of the provider experience in the EHR. This study suggests that individualized EHR training can improve the knowledge of EHR tools and satisfaction with their perceived control of EHR workload, however this did not translate into less Clinician Logged-In Outside Clinic (CLOC) time, a calculated metric, nor quicker turnaround on in box tasks. CLOC time emerged as a potential less-costly surrogate metric for provider satisfaction in EHR work than surveying clinicians. Further study is required to understand the cost-benefit of various interventions to decrease CLOC time.This supplemental EHR training session, 20 months post go-live, where most participants elected to receive 2 or fewer sessions did significantly improve provider satisfaction with perceived control over their workload in the EHR, but it was not effective in decreasing EHR-use time outside of clinic. CLOC time, a calculated metric, could be a practical trackable surrogate for provider satisfaction (inverse correlation) with after-hours time spent in the EHR. Further study into interventions that decrease CLOC time and improve turnaround time to respond to inbox tasks are suggested next steps.
View details for DOI 10.1093/jamiaopen/ooz003
View details for PubMedID 31984357
View details for PubMedCentralID PMC6952029
Your Patient Has a New Health App? Start With Its Data Source.
Journal of participatory medicine
2019; 11 (2): e14288
Recent regulatory and technological advances have enabled a new era of health apps that are controlled by patients and contain valuable health information. These health apps will be numerous and use novel interfaces that appeal to patients but will likely be unfamiliar to practitioners. We posit that understanding the origin of the health data is the most meaningful and versatile way for physicians to understand and effectively use these apps in patient care. This will allow providers to better support patients and encourage patient engagement in their own care.
View details for DOI 10.2196/14288
View details for PubMedID 33055064
View details for PubMedCentralID PMC7434101
OpenNotes: Toward a Participatory Pediatric Health System.
2018; 142 (4)
View details for PubMedID 30228169
Enhancing pediatric airway safety using the electronic medical record.
Difficult intubations are not uncommon in tertiary care children's hospitals, and effective documentation of the difficult airway is a fundamental element of safe airway management. The primary goal of our quality improvement initiative was to improve access to airway information via an alert and documentation system within the electronic medical record (EMR).We created a difficult airway alert within the EMR, linking common airway evaluation templates used by specialists involved in airway management. We assessed the time required for different specialists to answer an airway information questionnaire using the electronic charts of patients before and after the EMR modification. Satisfaction with the EMR modification was also surveyed.Questionnaires were administered to 12 participants before the Epic (Epic Systems Corp., Verona, WI) changes were implemented and to 19 participants after they were implemented. Each participant was asked to answer the airway data questionnaire for two patients, for a total of 24 questionnaires before the EMR changes and 38 questionnaires after the changes. Respondents averaged 7.24 minutes to complete the entire airway data questionnaire before the EMR changes and 3.16 minutes following modification (P < 0.0001). Correct airway information was more consistently collected with the modified EMR (98.6% vs 51.4%, P < 0.00001). Satisfaction surveys revealed that participants found the accessibility of airway data to be significantly improved following the EMR changes.An EMR airway alert that provides rapid access to relevant airway information critical tool during urgent and emergent events. Based on our preliminary data, further use of this instrument is expected to continue to improve patient safety and practitioner satisfaction.4. Laryngoscope, 2018.
View details for PubMedID 30195274
Integration of Single-Center Data-Driven Vital Sign Parameters into a Modified Pediatric Early Warning System.
Pediatric critical care medicine
2017; 18 (5): 469-476
Pediatric early warning systems using expert-derived vital sign parameters demonstrate limited sensitivity and specificity in identifying deterioration. We hypothesized that modified tools using data-driven vital sign parameters would improve the performance of a validated tool.Retrospective case control.Quaternary-care children's hospital.Hospitalized, noncritically ill patients less than 18 years old. Cases were defined as patients who experienced an emergent transfer to an ICU or out-of-ICU cardiac arrest. Controls were patients who never required intensive care. Cases and controls were split into training and testing groups.The Bedside Pediatric Early Warning System was modified by integrating data-driven heart rate and respiratory rate parameters (modified Bedside Pediatric Early Warning System 1 and 2). Modified Bedside Pediatric Early Warning System 1 used the 10th and 90th percentiles as normal parameters, whereas modified Bedside Pediatric Early Warning System 2 used fifth and 95th percentiles.The training set consisted of 358 case events and 1,830 controls; the testing set had 331 case events and 1,215 controls. In the sensitivity analysis, 207 of the 331 testing set cases (62.5%) were predicted by the original tool versus 206 (62.2%; p = 0.54) with modified Bedside Pediatric Early Warning System 1 and 191 (57.7%; p < 0.001) with modified Bedside Pediatric Early Warning System 2. For specificity, 1,005 of the 1,215 testing set control patients (82.7%) were identified by original Bedside Pediatric Early Warning System versus 1,013 (83.1%; p = 0.54) with modified Bedside Pediatric Early Warning System 1 and 1,055 (86.8%; p < 0.001) with modified Bedside Pediatric Early Warning System 2. There was no net gain in sensitivity and specificity using either of the modified Bedside Pediatric Early Warning System tools.Integration of data-driven vital sign parameters into a validated pediatric early warning system did not significantly impact sensitivity or specificity, and all the tools showed lower than desired sensitivity and specificity at a single cutoff point. Future work is needed to develop an objective tool that can more accurately predict pediatric decompensation.
View details for DOI 10.1097/PCC.0000000000001150
View details for PubMedID 28338520
Improving Communication with Primary Care Physicians at the Time of Hospital Discharge.
Joint Commission journal on quality and patient safety
2017; 43 (2): 80-88
Communication with primary care physicians (PCPs) at the time of a patient's hospital discharge is important to safely transition care to home. The goal of this quality improvement initiative was to increase discharge communication to PCPs at an academic children's hospital.A multidisciplinary team at Lucile Packard Children's Hospital Stanford used Lean A3 problem solving methodology to address the problem of inadequate discharge communication with PCPs. Emphasis was placed on frontline provider (resident physicians) involvement in the improvement process, creating standards, and error proofing. Root cause analysis identified several key drivers of the problem, and successive countermeasures were implemented beginning in August 2013 aimed at achieving the target of 80% attempted verbal communication within seven days before or after (usually 24-48 hours) on the pediatric medical services. Run charts were generated tracking the outcome of PCP communication.On the pediatric medical services, the goal of 80% communication was met and sustained during a seven-month period starting October 2013, a statistically significant improvement. In the eight months prior to October 2013, hospitalwide PCP communication prior to discharge averaged 59.1% (n = 5,397) and improved to 76.7% (n = 4,870) in the seven months after (p <0.001). Fifteen of 19 specialty services had a significant increase in discharge communication after October 2013.Lean improvement methodology (including structured problem solving using A3 thinking), intensive frontline provider involvement, and process-oriented electronic health record work flow redesign led to increased verbal PCP communication at around the time of a patient's discharge.
View details for DOI 10.1016/j.jcjq.2016.11.005
View details for PubMedID 28334566
- Designing An Individualized EHR Learning Plan For Providers APPLIED CLINICAL INFORMATICS 2017; 8 (3): 924–35
Safety Analysis of Proposed Data-Driven Physiologic Alarm Parameters for Hospitalized Children
JOURNAL OF HOSPITAL MEDICINE
2016; 11 (12): 817-823
Modification of alarm limits is one approach to mitigating alarm fatigue. We aimed to create and validate heart rate (HR) and respiratory rate (RR) percentiles for hospitalized children, and analyze the safety of replacing current vital sign reference ranges with proposed data-driven, age-stratified 5th and 95th percentile values.In this retrospective cross-sectional study, nurse-charted HR and RR data from a training set of 7202 hospitalized children were used to develop percentile tables. We compared 5th and 95th percentile values with currently accepted reference ranges in a validation set of 2287 patients. We analyzed 148 rapid response team (RRT) and cardiorespiratory arrest (CRA) events over a 12-month period, using HR and RR values in the 12 hours prior to the event, to determine the proportion of patients with out-of-range vitals based upon reference versus data-driven limits.There were 24,045 (55.6%) fewer out-of-range measurements using data-driven vital sign limits. Overall, 144/148 RRT and CRA patients had out-of-range HR or RR values preceding the event using current limits, and 138/148 were abnormal using data-driven limits. Chart review of RRT and CRA patients with abnormal HR and RR per current limits considered normal by data-driven limits revealed that clinical status change was identified by other vital sign abnormalities or clinical context.A large proportion of vital signs in hospitalized children are outside presently used norms. Safety evaluation of data-driven limits suggests they are as safe as those currently used. Implementation of these parameters in physiologic monitors may mitigate alarm fatigue. Journal of Hospital Medicine 2015;11:817-823. © 2015 Society of Hospital Medicine.
View details for DOI 10.1002/jhm.2635
View details for Web of Science ID 000389420100001
View details for PubMedID 27411896
A rational approach to legacy data validation when transitioning between electronic health record systems.
Journal of the American Medical Informatics Association
2016; 23 (5): 991-994
The objective of this project was to use statistical techniques to determine the completeness and accuracy of data migrated during electronic health record conversion.Data validation during migration consists of mapped record testing and validation of a sample of the data for completeness and accuracy. We statistically determined a randomized sample size for each data type based on the desired confidence level and error limits.The only error identified in the post go-live period was a failure to migrate some clinical notes, which was unrelated to the validation process. No errors in the migrated data were found during the 12- month post-implementation period.Compared to the typical industry approach, we have demonstrated that a statistical approach to sampling size for data validation can ensure consistent confidence levels while maximizing efficiency of the validation process during a major electronic health record conversion.
View details for DOI 10.1093/jamia/ocv173
View details for PubMedID 26977100
Implementation of Data Drive Heart Rate and Respiratory Rate parameters on a Pediatric Acute Care Unit.
Studies in health technology and informatics
2015; 216: 918-?
The majority of hospital physiologic monitor alarms are not clinically actionable and contribute to alarm fatigue. In 2014, The Joint Commission declared alarm safety as a National Patient Safety Goal and urged prompt action by hospitals to mitigate the issue . It has been demonstrated that vital signs in hospitalized children are quite different from currently accepted reference ranges . Implementation of data-driven, age stratified vital sign parameters (Table 1) for alarms in this patient population could reduce alarm frequency.
View details for PubMedID 26262220
Propylene glycol toxicity in children.
The journal of pediatric pharmacology and therapeutics : JPPT : the official journal of PPAG
2014; 19 (4): 277-282
Propylene glycol (PG) is a commonly used solvent for oral, intravenous, and topical pharmaceutical agents. Although PG is generally considered safe, when used in high doses or for prolonged periods, PG toxicity can occur. Reported adverse effects from PG include central nervous system (CNS) toxicity, hyperosmolarity, hemolysis, cardiac arrhythmia, seizures, agitation, and lactic acidosis. Patients at risk for toxicity include infants, those with renal or hepatic insuficiency, epilepsy, and burn patients receiving extensive dermal applications of PG containing products. Laboratory monitoring of PG levels, osmolarity, lactate, pyruvate, bicarbonate, creatinine, and anion gap can assist practitioners in making the diagnosis of PG toxicity. Numerous studies and case reports have been published on PG toxicity in adults. However, very few have been reported in pediatric patient populations. A review of the literature is presented.
View details for DOI 10.5863/1551-6776-19.4.277
View details for PubMedID 25762872
View details for PubMedCentralID PMC4341412
Severe lactic acidosis and multiorgan failure due to thiamine deficiency during total parenteral nutrition.
BMJ case reports
A 16-year-old perioperative paediatric patient presented with refractory lactic acidosis and multiorgan failure due to thiamine-deficient total parenteral nutrition during a recent national multivitamin shortage. Urgent empiric administration of intravenous thiamine resulted in prompt recovery from this life-threatening condition. Despite readily available treatment, a high index of suspicion is required to prevent cardiovascular collapse and mortality.
View details for DOI 10.1136/bcr-2014-205264
View details for PubMedID 24895398
- In reply. Academic medicine 2013; 88 (12): 1790-1791
Significant Toxicity in a Young Female After Low-Dose Tricyclic Antidepressant Ingestion
PEDIATRIC EMERGENCY CARE
2012; 28 (10): 1066-1069
Tricyclic antidepressant (TCA) ingestions are a relatively common pediatric ingestion, with significant potential for both cardiac and neurological toxicity. Previous studies on pediatric TCA ingestions have found the threshold of toxicity to be 5 mg/kg.We report a case of an 8-year-old girl who presented to the emergency department with depressed mental status and seizure-like movements. An extensive workup was pursued to evaluate the cause of her mental status, which only revealed a positive urine toxicology screen for TCA. Quantified serum levels of amitriptyline were 121 ng/mL (therapeutic range, 50-300 ng/mL) and nortriptyline were 79 ng/mL (therapeutic range 70-170 ng/mL), 18 hours after onset of symptoms. Subsequent history obtained after her mental status returned to normal revealed that she had ingested amitriptyline at a dose of 0.8 mg/kg.Tricyclic antidepressant ingestion has a high potential for toxicity in pediatric patients. This case suggests, contrary to previous literature, that toxicity may occur even with small doses.
View details for DOI 10.1097/PEC.0b013e31826cebfb
View details for Web of Science ID 000309656900025
View details for PubMedID 23034495
- Making pediatrics residency programs family friendly: Views along the professional educational continuum JOURNAL OF PEDIATRICS 2006; 149 (1): 1-2
Heart rate correlates of attachment status in young mothers and their infants
JOURNAL OF THE AMERICAN ACADEMY OF CHILD AND ADOLESCENT PSYCHIATRY
2005; 44 (5): 470-476
To explore heart rate (HR) correlates of attachment behavior in young mothers and their infants to generate specific hypotheses and to provide pilot data on which studies to test those hypotheses might be based.Using the strange situation procedure, patterns of attachment were assessed in 41 low-income adolescent mothers and their infants. During the procedure, the HRs of the infants and mothers were recorded. The HR changes were analyzed and infant attachment group differences were examined.Infants in all attachment groups demonstrated a similar HR response. There were, however, notably different behavioral reactions in the insecure groups: relatively increased behavioral distress in the insecure/resistant infants and relatively decreased behavioral distress in insecure-avoidant infants. Mothers of insecure-resistant infants demonstrated elevated HRs during reunions and the insecure/resistant dyads demonstrated lower consistency between HR changes in infant and mother than the secure dyads.The results suggest the discrepancy between attachment-related behavioral reactions and HR response in insecurely attached infants. Maternal and dyadic HR changes vary between the attachment groups.
View details for DOI 10.1097/01.chi.0000157325.10232.b1
View details for PubMedID 15843769
Effect of head orientation on gaze processing in fusiform gyrus and superior temporal sulcus
2003; 20 (1): 318-329
We used functional MRI with an event-related design to dissociate the brain activation in the fusiform gyrus (FG) and posterior superior temporal sulcus (STS) for multiple face and gaze orientations. The event-related design allowed for concurrent behavioral analysis, which revealed a significant effect of both head and gaze orientation on the speed of gaze processing, with the face and gaze forward condition showing the fastest reaction times. In conjunction with this behavioral finding, the FG responded with the greatest activation to face and gaze forward, perhaps reflecting the unambiguous social salience of congruent face and gaze directed toward the viewer. Random effects analysis showed greater activation in both the FG and posterior STS when the subjects viewed a direct face compared to an angled face, regardless of gaze direction. Additionally, the FG showed greater activation for forward gaze compared to angled gaze, but only when the face was forward. Together, these findings suggest that head orientation has a significant effect on gaze processing and these effects are manifest not only in the STS, but also the FG.
View details for DOI 10.1016/S1053-8119(03)00229-5
View details for Web of Science ID 000185746400028
View details for PubMedID 14527592