Pediatric Research in Inpatient Settings (PRIS) Network
The mission of PRIS is to improve the health of and healthcare delivery to hospitalized children and their families. This will be done by conducting large, multi-institutional studies in areas of inpatient pediatric care that are relevant to clinicians and the decisions they face when caring for children and their families in everyday clinical practice.
PRIS is a pediatric hospitalist research network. Hospitalists are physicians whose clinical practice is the care of hospitalized patients. Hospitalists are hospital-based physicians who want to ensure the system is delivering the highest quality of care for patients. The PRIS Network has a vision to be the premier research network and continually define what best practice is and how it should be implemented.
|PRIS Investigator Spotlight|
Assistant Professor of Pediatrics
University of Rochester Medical Center
Blood Culture Time to Positivity in Febrile but Non-Toxic Infants
|Study Summary: This was a retrospective observational study of positive blood culture data and chart review of blood cultures drawn from febrile but otherwise healthy infants admitted to the general care floors for suspected serious bacterial infection (a.k.a. the 'rule out sepsis'). The primary aim of the study was to determine the time at which a positive blood culture actually turns positive; hence, an infant admitted for a "rule out" with a negative blood culture at that time would be able to be discharged home. We've finished data collection, are in the process of running the statistics and are about to start drafting the manuscript. We also gave a platform presentation of the data at the PHM conference this past July in New Orleans. The results will include 391 cultures from 17 hospital systems around the country.
"I'm incredibly grateful that so many PRIS site leads saw this clinical question as one worth asking. We didn't have a single dollar to spend on this study, and yet 17 site principal investigators were able to obtain IRB approval and collect data in less than 6 months. In fact, the initial listserv email was sent out on February 25th, 2013 and we were finished data collection in time for a presentation at the PHM meeting last July. Additionally, a handful of other sites spent time on the project but unfortunately ran into IRB or time commitment issues. I'm hopeful that we've set an example within PRIS that a group of passionate investigators, despite being relatively inexperienced as a whole doesn't necessarily need a lot of funding to answer a clinical question. If anyone from this group ever needs help with a project, I'm there."
Pediatric IntraVenous Versus Oral antibiotic Therapy (PIVVOT) study
The aims of this project are 1) to compare the effectiveness of oral antibiotics vs. intravenous antibiotics delivered via a PICC and, 2) to compare patient and caregiver reported quality of life and adherence to therapy for oral antibiotics vs. IV antibiotics delivered via a PICC in children who require prolonged home antibiotic therapy after hospitalization for a serious bacterial infection.
During this quarter, we have recruited a total of 38 PHIS hospitals to participate in the project and have been focused on obtaining IRB approval at each site. Our next steps include conducting several training webinars on our REDCap database in early October and the commencement of chart reviews in mid-October.
Global Assessment of Pediatric Patient Safety (GAPPS): a national validation study of a comprehensive tool to identify adverse events in hospitalized children
The objective of this project is to test the validity and reliability of the Global Assessment of Pediatric Patient Safety (GAPPS) tool in identifying adverse events in the inpatient setting. In the current phase of this project we are testing a trigger tool modified based on a pilot study and expert panel results to validate its use across different hospital settings. Multiple academic and community sites from regions across the country are participating in the project, reviewing hospitalizations from their own medical records using the GAPPS methodology to gather data on the efficacy of the trigger tool. The results will be used to refine the final tool and improve the implementation of GAPPS in the future.
This project has two specific aims:
- To test a pediatric-specific global trigger tool, GAPPS, used to detect adverse events in all areas of care; and
- To test the GAPPS tool in a national setting allowing for comparison and utilization across a variety of hospitals with differing characteristics to allow improved national application across a large number of care centers
After being trained by trigger tool experts, the GAPPS teams began chart review this summer!
Infrastructure Funding + Prioritization Project
The Prioritization Project uses detailed administrative data from the PHIS database to identify pediatric hospital conditions that are prevalent, cumulatively expensive, and highly variable in terms of resource utilization.
During the 3rd quarter of 2013, the project team continued to 'drill-down' to find explanations for variation in selected high priority conditions, with most work focusing on the appendectomy and pneumonia.
The appendectomy drill-down team, led by Shawn Rangel and Samir Shah, is currently in the process of preparing a manuscript based on the data analysis that has been completed. The team has focused on a cohort of 37,469 children treated with low-severity appendicitis (non-perforated) at 39 PHIS hospitals with a goal to characterize the magnitude of cost variation across hospitals and to identify aspects of management that are associated with the greatest relative cost in the treatment of this disease. The manuscripts will report on key findings from the analysis, which include a greater than two-fold difference among hospitals in overall median treatment-related cost, as well as significantly different treatment-related cost within the cohort for each of the individual management areas examined. Operating room costs were found to be the greatest driver of cost variation overall and among most hospitals, while facility costs were a close second for both overall cost and inter-hospital variation. The team hopes to have the manuscript ready for submission in October. In the next phase, the team will explore the relationship between practice patterns, resource use and outcomes, and will drill-down deeper into the nature of cost variation within the individual management areas (e.g. operative costs).
Karen Wilson is leading the fourth and final drill-down for pneumonia which was chosen in August. Dr. Wilson has spent significant time developing the study framework and organizing the study team. The team is currently working on defining the study cohort and looking at preliminary data.
The DKA (Diabetic Ketoacidosis) project team, led by Joel Tieder, had its manuscript, "Variation in Resource Use and Readmission for Diabetic Ketoacidosis in Children's Hospitals" published in Pediatrics in July 2013. The paper reports the project's finding that readmission for DKA within a year of hospitalization is common, accounting for one-fifth of all DKA admissions and that resource use, hospital length of stay, and readmission rates vary widely across major U.S. children's hospitals, even after adjusting for differences in patients. The study paper concludes that further research is needed to understand these differences and to identify the most cost effective strategies for managing diabetes.
Work has continued to progress on the tonsillectomy drill-down, which is led by Sanjay Mahant. The two major questions to be explored in this drill-down are: 1) the relationship between perioperative care processes and revisits in the first 30 days, and 2) the relationship between perioperative costs and revisits in the first 30 days.
PHIS+: Augmenting the Pediatric Health Information System (PHIS) with Clinical Data
Grant funding period: September 30, 2010 - September 29, 2014
This project is linking clinical data from six hospitals to a common administrative database to conduct comparative effectiveness research (CER) studies.
Over the last few months we have continued to make significant progress with laboratory and radiology data. Lab data for the initial period (2007-2011) has been processed and validated for all six hospitals. Children's Hospital Association (CHA) is in the process of analyzing the data for the CER studies. Hospitals have also submitted lab data for 2012.
Validation of radiology data is now complete at all six hospitals. Work has continued on the natural language processing (NLP) for the PHIS+ Pneumonia study. The CER team is in the process of annotating a sample of thoracic radiology reports from each site. The NLP tool will learn from the expert annotations and then automatically extract this information from clinical notes. NLP will be applied to reports meeting study criteria for appendicitis and osteomyelitis as well. Radiology reports have been extracted for the osteomyelitis and GERD studies and are currently being reviewed by the teams. CHA is compiling additional reports for the appendicitis and pneumonia studies.
All six hospitals have submitted microbiology data. CHA staff has provided validation files and hospitals are in the process of reviewing. Five of the six hospitals have successfully validated non-culture micro data.
The CER project teams continue to work on portions of their projects that can be started before the clinical data are available. Project timelines have been adjusted based on delays with the data validation process. We received AHRQ approval to work into a no cost extension year.
New publications and presentations for PHIS+ include a presentation on PHIS+ terminology mapping for the SMOMED CT Implementation Showcase 2013, and abstracts related to Standardized Terminologies and the Federated Utah Research and Translational Health e-Repository (FURTHeR). The citations are listed below:
- Using SNOMED CT in Building a Database for Comparative Effectiveness Research, Ramkiran Gouripeddi, MS, MBBS, Ryan Butcher, MS; Phillip B. Warner, MS, Peter Mo, MS, SNOMED CT Implementation Showcase 2013.
Use of Standardized Terminologies in Federating Clinical Data from Six Pediatric Hospitals for Comparative Effectiveness Research: Lessons Learned from the PHIS+ Consortium, Ramkiran Gouripeddi, MBBS, MS, Ryan Butcher, MS, MBA, Phillip B. Warner, MS, Peter Mo, MS, Lauren D. Tanzer, MS, PMP, Rajendu Srivastava, MD, FRCP(C), MPH, Ron Keren, MD, MPH; Electronic Data Methods (EDM) Forum Annual Symposium 2013
FURTHeR: An Infrastructure for Clinical, Translational and Comparative Effectiveness Research, Ramkiran Gouripeddi, MBBS, MS, N. Dustin Schultz, MS, Richard L. Bradshaw, MS, Peter Mo, BS, Randy K. Madsen, BS, Phillip B. Warner, MS, Bernie LaSalle, BS, Julio C. Facelli, PhD. Systems Demonstration, Fall AMIA Annual Symposium 2013
I-PASS: IIPE-PRIS Accelerating Safer Signouts
This study is examining the effectiveness of a "resident handoff bundle" in accelerating adoption of safer communication practices in pediatric hospitals, and was developed within the PRIS network and endorsed by the Initiative for Innovation in Pediatric Education (IIPE).
This study progressed as planned across all study sites until its official end on August 31, 2013. In the past quarter, the Data Coordinating Center (DCC) at Brigham and Women's Hospital (Boston, MA) and the Coordinating Center (CC) at Boston Children's Hospital (Boston, MA) worked very closely to support the transmission of remaining data from Wave 3 sites to the DCC.
Additionally, the two centers coordinated the analysis of medical error data by physician raters, as well as time-motion and survey data by statisticians at the DCC.
Overseen by the Coordinating Council and Education Executive Committee, teams continued dissemination efforts this quarter. The I-PASS Study Group presented one workshop and one Grand Rounds presentation. Work groups met and prepared several manuscripts and resources for publication. Two suites of curricular materials were published as peer-reviewed resources through MedEdPORTAL this quarter: I-PASS Handoff Curriculum: Computer Module and I-PASS Handoff Curriculum: Faculty Development Resources. The I-PASS Study Group also continued to disseminate curricular resources through its study website, www.ipasshandoffstudy.com. To date, the group has received 760 requests for educational materials from 48 states and 20 countries outside the U.S.
Bismilla Z, Rosenbluth G, West DC, Starmer AJ. "The I-PASS Handoff Process: Teaching and Evaluating Standardized Approaches to Transitions of Care" Workshop to be presented at Royal College's International Conference on Resident Education, Sept. 27-28, 2013; Calgary, Canada.
Spector ND, Sectish TC. The I-PASS Study: Standardizing the Handoff Process for Better Handoffs and Safer Care. Grand Rounds. Jersey Shore Medical Center, Neptune Township, NJ. August 6, 2013.
Calaman S, Spector ND, Starmer AJ, O'Toole JK, Allen AD, Tse L, Bale JF, Coffey M, Cole FS, Destino L, Everhart J, Hepps J, Kahana M, McGregor RS, Patel SJ, Rosenbluth G, Srivastava R, Stevenson A, West DC, Sectish TC, Landrigan CP, Yu CE, Lopreiato JO. I-PASS Handoff Curriculum: Online Module. MedEdPORTAL; 2013. In press.
O'Toole JK, Allen AD, Rosenbluth G, Sectish TC, Starmer AJ, West DC, Hepps J, Lopreiato JO, Calaman S, Yu CE, Spector ND, and the I-PASS Educational Executive Committee. I-PASS Handoff Curriculum: Faculty Development Resources. MedEdPORTAL; 2013. In press.
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