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Objectives: The objective of this paper was to compare the effectiveness of different materials for mouthguards in preventing oral and maxillofacial injuries during sports activities. The present study compares the stress-reduction and energy absorption capabilities of two other fused filament materials - poly(lactic-acid plus) (PLA+) and polycarbonate (PC), with Ethylene-vinyl acetate (EVA), which is the most commonly used material for mouthguard fabrication., Materials and Methods: Two human skulls were modelled, and a boxing glove simulated punches along the x, y, and z-axes with 5 mm displacement with 1 kN force. Firstly, the maximum principal stress curve in the skull was compared for forces along the three perpendicular directions. Furthermore, the present study examines materials energy absorption properties, including their specific energy absorption characteristics and initial peak von Mises stresses. Additionally, a topology optimization approach is used to create an alternative design for a mouthguard to improve specific energy absorption., Results: The model without a mouthguard showed the highest stress concentration of 32.298 MPa in the teeth, followed by the EVA material, which resulted in a maximum principal stress of 28.525 MPa. Fused filament 3D materials, such as PLA + and PC, on the other hand, showed better mechanical effectiveness in both lower jaw dislocation and lower maximum principal stress by 30.82% and 51.25% in the mandibular and maxillary teeth. Though EVA comparatively shows better specific energy absorption capability at 2.24 kJ/kg post-optimization than PLA + and PC, the peak principal stress experienced in the mandibular region was comparatively higher. The topology optimization, however, improved the energy-absorbing capabilities of PLA + by 4.5 times, reaching 1.37 kJ/kg and PC from 0.165 kJ/kg to 0.38 kJ/kg., Conclusions: This study demonstrates that PLA + and PC have better stress reduction capabilities than EVA and could be promising materials for the fabrication of mouthguards in sports activities. This study highlights the importance of topology optimization in dental materials science and engineering to develop safer and more effective mouthguard designs., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background:  Clinical Decision Support (CDS) tools have a mixed record of effectiveness, often due to inadequate alignment with clinical workflows and poor usability. While there is a consensus that usability testing methods address these issues, in practice, usability testing is generally only used for selected projects (such as funded research studies). There is a critical need for CDS operations to apply usability testing to all CDS implementations., Objectives:  In this State of the Art/Best Practice paper, we share challenges with scaling usability in health care operations and alternative methods and CDS governance structures to enable usability testing as a routine practice., Methods:  We coalesce our experience and results of applying guerilla in situ usability testing to over 20 projects in a 1-year period with the proposed solution., Results:  We demonstrate the feasibility of adopting " guerilla in situ usability testing" in operations and their effectiveness in incorporating user feedback and improving design., Conclusion:  Although some methodological rigor was relaxed to accommodate operational speed, the benefits outweighed the limitations. Broader adoption of usability testing may transform CDS implementation and improve health outcomes., Competing Interests: E.O. and N.M. are the cofounders and have equity in Phrase Health, a CDS analytics company. They are the Investigators on an R42 grant with Phrase Health from the National Library of Medicine (NLM) and the National Center for Advancing Translational Science (NCATS). Both of them receive salary support from the NLM and NCATS but no direct revenue from Phrase Health. Other authors have nothing to disclose., (Thieme. All rights reserved.)

Pediatric hospitalists frequently interact with clinical decision support (CDS) tools in patient care and use these tools for quality improvement or research. In this method/ology paper, we provide an introduction and practical approach to developing and evaluating CDS tools within the electronic health record. First, we define CDS and describe the types of CDS interventions that exist. We then outline a stepwise approach to CDS development, which begins with defining the problem and understanding the system. We present a framework for metric development and then describe tools that can be used for CDS design (eg, 5 Rights of CDS, "10 commandments," usability heuristics, human-centered design) and testing (eg, validation, simulation, usability testing). We review approaches to evaluating CDS tools, which range from randomized studies to traditional quality improvement methods. Lastly, we discuss practical considerations for implementing CDS, including the assessment of a project team's skills and an organization's information technology resources., (Copyright © 2024 by the American Academy of Pediatrics.)

Implementing pediatric-focused clinical decision support (CDS) into hospital electronic health records can lead to improvements in patient care and accelerate quality improvement and research initiatives. However, its design, development, and implementation can be a time-consuming and costly endeavor that may not be feasible for all hospital settings. In this cross-sectional study, we surveyed Pediatric Research in Inpatient Settings (PRĪS) Network hospitals about the availability of CDS tools to gain an understanding of the functionality available across 8 common inpatient pediatric diagnoses. Among the conditions, asthma had the most extensive CDS availability, while mood disorders had the least. Overall, freestanding children's hospitals had the greatest breadth in CDS coverage across conditions and depth in CDS types within conditions. Future initiatives should examine the relationship between CDS availability and clinical outcomes as well as its relationship with hospitals' performance executing multicenter informatics projects, quality improvement collaboratives, and implementation science strategies., (© 2023 Society of Hospital Medicine.)

Objective: We sought to develop and evaluate an electronic health record (EHR) genetic testing tracking system to address the barriers and limitations of existing spreadsheet-based workarounds., Materials and Methods: We evaluated the spreadsheet-based system using mixed effects logistic regression to identify factors associated with delayed follow up. These factors informed the design of an EHR-integrated genetic testing tracking system. After deployment, we assessed the system in 2 ways. We analyzed EHR access logs and note data to assess patient outcomes and performed semistructured interviews with users to identify impact of the system on work., Results: We found that patient-reported race was a significant predictor of documented genetic testing follow up, indicating a possible inequity in care. We implemented a CDS system including a patient data capture form and management dashboard to facilitate important care tasks. The system significantly sped review of results and significantly increased documentation of follow-up recommendations. Interviews with key system users identified a range of sociotechnical factors (ie, tools, tasks, collaboration) that contribute to safer and more efficient care., Discussion: Our new tracking system ended decades of workarounds for identifying and communicating test results and improved clinical workflows. Interview participants related that the system decreased cognitive and time burden which allowed them to focus on direct patient interaction., Conclusion: By assembling a multidisciplinary team, we designed a novel patient tracking system that improves genetic testing follow up. Similar approaches may be effective in other clinical settings., (© The Author(s) 2023. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Late recognition of in-hospital deterioration is a source of preventable harm. Emergency transfers (ET), when hospitalized patients require intensive care unit (ICU) interventions within 1 h of ICU transfer, are a proximal measure of late recognition associated with increased mortality and length of stay (LOS)., Objective: To apply diagnostic process improvement frameworks to identify missed opportunities for improvement in diagnosis (MOID) in ETs and evaluate their association with outcomes., Design, Settings, and Participants: A single-center retrospective cohort study of ETs, January 2015 to June 2019. ET criteria include intubation, vasopressor initiation, or ≥ $\ge \phantom{\rule{}{0ex}}$ 60 mL/kg fluid resuscitation 1 h before to 1 h after ICU transfer. The primary exposure was the presence of MOID, determined using SaferDx. Cases were screened by an ICU and non-ICU physician. Final determinations were made by an interdisciplinary group. Diagnostic process improvement opportunities were identified., Main Outcome and Measures: Primary outcomes were in-hospital mortality and posttransfer LOS, analyzed by multivariable regression adjusting for age, service, deterioration category, and pretransfer LOS., Results: MOID was identified in 37 of 129 ETs (29%, 95% confidence interval [CI] 21%-37%). Cases with MOID differed in originating service, but not demographically. Recognizing the urgency of an identified condition was the most common diagnostic process opportunity. ET cases with MOID had higher odds of mortality (odds ratio 5.5; 95% CI 1.5-20.6; p = .01) and longer posttransfer LOS (rate ratio 1.7; 95% CI 1.1-2.6; p = .02)., Conclusion: MOID are common in ETs and are associated with increased mortality risk and posttransfer LOS. Diagnostic improvement strategies should be leveraged to support earlier recognition of clinical deterioration., (© 2023 Society of Hospital Medicine.)

Objective: State agencies have developed reporting systems of safety events that include events related to health information technology (HIT). These data come from hospital reporting systems where staff submit safety reports and nurses, in the role of safety managers, review, and code events. Safety managers may have varying degrees of experience with identifying events related to HIT. Our objective was to review events potentially involving HIT and compare those with what was reported to the state., Methods: We performed a structured review of 1 year of safety events from an academic pediatric healthcare system. We reviewed the free-text description of each event and applied a classification scheme derived from the AHRQ Health IT Hazard Manager and compared the results with events reported to the state as involving HIT., Results: Of 33,218 safety events for a 1-year period, 1247 included key words related to HIT and/or were indicated by safety managers as involving HIT. Of the 1247 events, the structured review identified 769 as involving HIT. In comparison, safety managers only identified 194 of the 769 events (25%) as involving HIT. Most events, 353 (46%), not identified by safety managers were documentation issues. Of the 1247 events, the structured review identified 478 as not involving HIT while safety managers identified and reported 81 of these 478 events (17%) as involving HIT., Conclusions: The current process of reporting safety events lacks standardization in identifying health technology contributions to safety events, which may minimize the effectiveness of safety initiatives., Competing Interests: The authors disclose no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Assessing the risk of common, complex diseases requires consideration of clinical risk factors as well as monogenic and polygenic risks, which in turn may be reflected in family history. Returning risks to individuals and providers may influence preventive care or use of prophylactic therapies for those individuals at high genetic risk., Methods: To enable integrated genetic risk assessment, the eMERGE (electronic MEdical Records and GEnomics) network is enrolling 25,000 diverse individuals in a prospective cohort study across 10 sites. The network developed methods to return cross-ancestry polygenic risk scores, monogenic risks, family history, and clinical risk assessments via a genome-informed risk assessment (GIRA) report and will assess uptake of care recommendations after return of results., Results: GIRAs include summary care recommendations for 11 conditions, education pages, and clinical laboratory reports. The return of high-risk GIRA to individuals and providers includes guidelines for care and lifestyle recommendations. Assembling the GIRA required infrastructure and workflows for ingesting and presenting content from multiple sources. Recruitment began in February 2022., Conclusion: Return of a novel report for communicating monogenic, polygenic, and family history-based risk factors will inform the benefits of integrated genetic risk assessment for routine health care., Competing Interests: Conflict of Interest N.S.A.-H. is an employee and equity holder of 23andMe; serves as a scientific advisory board member for Allelica, Inc; received personal fees from Genentech Inc, Allelica Inc, and 23andMe; received research funding from Akcea Therapeutics; and was previously employed by Regeneron Pharmaceuticals. T.W. has grant funding from Gilead Sciences, Inc. L.O. and T.R.-B are founders of a company developing MeTree. T.S., E.D.E., and E.H. are employees and stockholders of Invitae Corporation. E.M.M. has been a consultant for Avidity Bioscience, Amgen Inc, AstraZeneca, Cytokinetics, Invitae Corporation, Janssen Pharmaceuticals, Pfizer Inc, PepGen Inc, Tenaya Therapeutics, and Stealth BioTherapeutics Inc; she is also the founder of Ikaika Therapeutics. E.E.K. received personal fees from Illumina Inc, 23andMe, and Regeneron Pharmaceuticals and serves as a scientific advisory board member for Encompass Bioscience, Foresite Labs, and Galateo Bio. B.K. is an advisory board member and stockholder of Genome Medical. M.S. is a member of the Institutional Review Board of the All of Us Research Program. E.F.P. is a paid consultant for Allecia Inc. J.F.P. is a paid consultant for Natera Inc. All other authors declare no conflicts of interest., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

More than three in 10 people living in Jordan are immigrants, with the majority being Palestinian and Syrian refugees, who have a very similar non-communicable diseases (NCDs) profile to the hosting Jordanian community. We conducted a rapid review of the literature of studies, reports, and documents on the evidence of the impact of COVID-19 on vulnerable populations in Jordan with regard to NCD during the first year of the pandemic. COVID-19-related mobility constraints and often lack of awareness of NCDs put additional burden on vulnerable populations like refugees and migrants, in particular on non-registered migrants. COVID-19 pandemic and associated mitigation measures led to disruption in routine health services, significantly impacting people living with NCDs. Ensuring to deliver a people-centered and inclusive approach that works well during COVID-19 is of paramount importance toward Universal Health Coverage (all people have access to the health services they need, when and where they need them, without financial hardship).

Objective: Training disruptions, such as planned curricular adjustments or unplanned global pandemics, impact residency training in ways that are difficult to quantify. Informatics-based medical education tools can help measure these impacts. We tested the ability of a software platform driven by electronic health record data to quantify anticipated changes in trainee clinical experiences during the COVID-19 pandemic., Methods: We previously developed and validated the Trainee Individualized Learning System (TRAILS) to identify pediatric resident clinical experiences (i.e. shifts, resident provider-patient interactions (rPPIs), and diagnoses). We used TRAILS to perform a year-over-year analysis comparing pediatrics residents at a large academic children's hospital during March 15-June 15 in 2018 (Control #1), 2019 (Control #2), and 2020 (Exposure)., Results: Residents in the exposure cohort had fewer shifts than those in both control cohorts (P < .05). rPPIs decreased an average of 43% across all PGY levels, with interns experiencing a 78% decrease in Continuity Clinic. Patient continuity decreased from 23% to 11%. rPPIs with common clinic and emergency department diagnoses decreased substantially during the exposure period., Conclusions: Informatics tools like TRAILS may help program directors understand the impact of training disruptions on resident clinical experiences and target interventions to learners' needs and development., (Copyright © 2022 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Background: Ongoing management of monitor alarms is important for reducing alarm fatigue among clinicians (e.g., nurses, physicians). Strategies to enhance clinician engagement in active alarm management in pediatric acute care have not been well explored. Access to alarm summary metrics may enhance clinician engagement. Objective: To lay the foundation for intervention development, we sought to identify functional specifications for formulating, packaging, and delivering alarm metrics to clinicians. Methods: Our team of clinician scientists and human factors engineers conducted focus groups with clinicians from medical-surgical inpatient units in a children's hospital. We inductively coded transcripts, developed codes into themes, and grouped themes into "current state" and "future state." Results: We conducted five focus groups with 13 clinicians (eight registered nurses and five doctors of medicine). In the current state, information exchanged among team members about alarm burden is initiated by nurses on an ad hoc basis. For a future state, clinicians identified ways in which alarm metrics could help them manage alarms and described specific information, such as alarm trends, benchmarks, and contextual data, that would support decision-making. Conclusion: We developed four recommendations for future strategies to enhance clinicians' active management of patient alarms: (1) formulate alarm metrics for clinicians by categorizing alarm rates by type and summarizing alarm trends over time, (2) package alarm metrics with contextual patient data to facilitate clinicians' sensemaking, (3) deliver alarm metrics in a forum that facilitates interprofessional discussion, and (4) provide clinician education to establish a shared mental model about alarm fatigue and evidence-based alarm-reduction strategies.

Background: People with noncommunicable diseases (NCDs) are at a significantly higher risk of worst outcomes if infected with COVID-19 and thus amongst the main target population for vaccination. Despite prioritizing them for vaccination, the number of vaccinated patients with comorbidities stalled post vaccine introduction. Despite that the government along with partners ran a national awareness campaign to ramp up vaccination coverage, the coverage remained suboptimal. Thus, a one-to-one health counselling initiative was implemented to explore the acceptance of COVID-19 vaccines by the NCDs patients and address the main issues surrounding vaccine hesitancy. This study evaluates the impact of this intervention by analyzing the change in COVID-19 vaccine acceptance., Methods: In this analytical observational study, a random sample of 57,794 people living with NCDs were approached. Out of them, 12,144 received one-to-one counselling by a group of trained health professionals. The counselled group's vaccine acceptance was assessed on a Likert scale from 1 to 5 pre- and post- counselling. Moreover, a random sample was followed up 2 months after initial counselling to measure their vaccine acceptance and update their vaccination status., Results: 44.5% of total respondents were already registered in the vaccination platform. On a scale from 1 to 5, the overall mean confidence significantly increased by 1.63 from 2.48 pre-counselling to 4.11 post-counselling. Two-months post counselling, a random sample was contacted again and had a mean vaccine confidence of 3.71, which is significantly higher than pre-counselling confidence level despite a significant decrease to post-counselling results., Discussion: Implementing an intervention that targets all key factors impacting health decisions, such as health literacy, risk appraisal and response efficacy, helps reach an adaptive response and increase vaccine confidence. Scholars should be cautious when implementing an intervention since it could lead to maladaptive defensive responses. One-to-one interventions are more effective in population when addressing new interventions and vaccines., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: Methods of sustaining the deimplementation of overused medical practices (i.e., practices not supported by evidence) are understudied. In pediatric hospital medicine, continuous pulse oximetry monitoring of children with the common viral respiratory illness bronchiolitis is recommended only under specific circumstances. Three national guidelines discourage its use for children who are not receiving supplemental oxygen, but guideline-discordant practice (i.e., overuse) remains prevalent. A 6-hospital pilot of educational outreach with audit and feedback resulted in immediate reductions in overuse; however, the best strategies to optimize sustainment of deimplementation success are unknown., Methods: The Eliminating Monitor Overuse (EMO) trial will compare two deimplementation strategies in a hybrid type III effectiveness-deimplementation trial. This longitudinal cluster-randomized design will be conducted in Pediatric Research in Inpatient Settings (PRIS) Network hospitals and will include baseline measurement, active deimplementation, and sustainment phases. After a baseline measurement period, 16-19 hospitals will be randomized to a deimplementation strategy that targets unlearning (educational outreach with audit and feedback), and the other 16-19 will be randomized to a strategy that targets unlearning and substitution (adding an EHR-integrated clinical pathway decision support tool). The primary outcome is the sustainment of deimplementation in bronchiolitis patients who are not receiving any supplemental oxygen, analyzed as a longitudinal difference-in-differences comparison of overuse rates across study arms. Secondary outcomes include equity of deimplementation and the fidelity to, and cost of, each deimplementation strategy. To understand how the deimplementation strategies work, we will test hypothesized mechanisms of routinization (clinicians developing new routines supporting practice change) and institutionalization (embedding of practice change into existing organizational systems)., Discussion: The EMO trial will advance the science of deimplementation by providing new insights into the processes, mechanisms, costs, and likelihood of sustained practice change using rigorously designed deimplementation strategies. The trial will also advance care for a high-incidence, costly pediatric lung disease., Trial Registration: ClinicalTrials.gov, NCT05132322 . Registered on November 10, 2021., (© 2022. The Author(s).)

Objectives: To assess the current landscape of clinical decision support (CDS) tools in PICUs in order to identify priority areas of focus in this field., Design: International, quantitative, cross-sectional survey., Setting: Role-specific, web-based survey administered in November and December 2020., Subjects: Medical directors, bedside nurses, attending physicians, and residents/advanced practice providers at Pediatric Acute Lung Injury and Sepsis Network-affiliated PICUs., Interventions: None., Measurements and Main Results: The survey was completed by 109 respondents from 45 institutions, primarily attending physicians from university-affiliated PICUs in the United States. The most commonly used CDS tools were people-based resources (93% used always or most of the time) and laboratory result highlighting (86%), with order sets, order-based alerts, and other electronic CDS tools also used frequently. The most important goal providers endorsed for CDS tools were a proven impact on patient safety and an evidence base for their use. Negative perceptions of CDS included concerns about diminished critical thinking and the burden of intrusive processes on providers. Routine assessment of existing CDS was rare, with infrequent reported use of observation to assess CDS impact on workflows or measures of individual alert burden., Conclusions: Although providers share some consensus over CDS utility, we identified specific priority areas of research focus. Consensus across practitioners exists around the importance of evidence-based CDS tools having a proven impact on patient safety. Despite broad presence of CDS tools in PICUs, practitioners continue to view them as intrusive and with concern for diminished critical thinking. Deimplementing ineffective CDS may mitigate this burden, though postimplementation evaluation of CDS is rare., Competing Interests: Dr. Muthu received funding from Phrase Health. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2022 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

Background: Development of skills in diagnostic reasoning is paramount to the transition from novice to expert clinicians. Efforts to standardize approaches to diagnosis and treatment using clinical pathways are increasingly common. The effects of implementing pathways into systems of care during diagnostic education and practice among pediatric residents are not well described., Objective: To characterize pediatric residents' perceptions of the tradeoffs between clinical pathway use and diagnostic reasoning., Methods: We conducted a qualitative study from May to December 2019. Senior pediatric residents from a high-volume general pediatric inpatient service at an academic hospital participated in semi-structured interviews. We utilized a basic interpretive qualitative approach informed by a dual process diagnostic reasoning framework., Results: Nine residents recruited via email were interviewed. Residents reported using pathways when admitting patients and during teaching rounds. All residents described using pathways primarily as management tools for patients with a predetermined diagnosis, rather than as aids in formulating a diagnosis. As such, pathways primed residents to circumvent crucial steps of deliberate diagnostic reasoning. However, residents relied on bedside assessment to identify when patients are "not quite fitting the mold" of the current pathway diagnosis, facilitating recalibration of the diagnostic process., Conclusions: This study identifies important educational implications at the intersection of residents' cognitive diagnostic processes and use of clinical pathways. We highlight potential challenges clinical pathways pose for skill development in diagnostic reasoning by pediatric residents. We suggest opportunities for educators to leverage clinical pathways as a framework for development of these skills., Competing Interests: Conflict of interest: The authors declare they have no competing interests.

Background and Objectives: Consumer home monitors (CHM), which measure vital signs, are popular products marketed to detect airway obstruction and arrhythmia. Yet, they lack evidence of infant death prevention, demonstrate suboptimal accuracy, and may result in false alarms that prompt unnecessary acute care visits. To better understand the hospital utilization and costs of CHM, we characterized emergency department (ED) and hospital encounters associated with CHM use at a children's hospital., Methods: We used structured query language to search the free text of all ED and admission notes between January 2013 and December 2019 to identify clinical documentation discussing CHM use. Two physicians independently reviewed the presence of CHM use and categorized encounter characteristics., Results: Evidence of CHM use contributed to the presentation of 36 encounters in a sample of over 300 000 encounters, with nearly half occurring in 2019. The leading discharge diagnoses were viral infection (13, 36%), gastroesophageal reflux (8, 22%) and false positive alarm (6, 17%). Median encounter duration was 20 hours (interquartile range: 3 hours to 2 days; max 10.5 days) and median cost of encounters was $2188 (interquartile range: $255 to $7632; max $84 928)., Conclusions: Although the annual rate of CHM-related encounters was low and did not indicate a major public health burden, for individual families who present to the ED or hospital for concerns related to CHMs, there may be important adverse financial and emotional consequences., (Copyright © 2022 by the American Academy of Pediatrics.)

Objective: We aimed to develop a data-driven machine learning model for predicting critical deterioration events from routinely collected EHR data in hospitalized children., Materials: This retrospective cohort study included all pediatric inpatients hospitalized on a medical or surgical ward between 2014-2018 at a quaternary children's hospital., Methods: We developed a large data-driven approach and evaluated three machine learning models to predict pediatric critical deterioration events. We evaluated the models using a nested, stratified 10-fold cross-validation. The evaluation metrics included C-statistic, sensitivity, and positive predictive value. We also compared the machine learning models with patients identified as high-risk Watchers by bedside clinicians., Results: The study included 57,233 inpatient admissions from 34,976 unique patients. 3,943 variables were identified from the EHR data. The XGBoost model performed best (C-statistic=0.951, CI: 0.946 ∼ 0.956)., Conclusions: Our data-driven machine learning models accurately predicted patient deterioration. Future sociotechnical analysis will inform deployment within the clinical setting.

Objectives: Emergency transfers (ETs), deterioration events with late recognition requiring ICU interventions within 1 hour of transfer, are associated with adverse outcomes. We leveraged electronic health record (EHR) data to assess the association between ETs and outcomes. We also evaluated the association between intervention timing (urgency) and outcomes., Methods: We conducted a propensity-score-matched study of hospitalized children requiring ICU transfer between 2015 and 2019 at a single institution. The primary exposure was ET, automatically classified using Epic Clarity Data stored in our enterprise data warehouse endotracheal tube in lines/drains/airway flowsheet, vasopressor in medication administration record, and/or ≥60 ml/kg intravenous fluids in intake/output flowsheets recorded within 1 hour of transfer. Urgent intervention was defined as interventions within 12 hours of transfer., Results: Of 2037 index transfers, 129 (6.3%) met ET criteria. In the propensity-score-matched cohort (127 ET, 374 matched controls), ET was associated with higher in-hospital mortality (13% vs 6.1%; odds ratio, 2.47; 95% confidence interval [95% CI], 1.24-4.9, P = .01), longer ICU length of stay (subdistribution hazard ratio of ICU discharge 0.74; 95% CI, 0.61-0.91, P < .01), and longer posttransfer length of stay (SHR of hospital discharge 0.71; 95% CI, 0.56-0.90, P < .01). Increased intervention urgency was associated with increased mortality risk: 4.1% no intervention, 6.4% urgent intervention, and 10% emergent intervention., Conclusions: An EHR measure of deterioration with late recognition is associated with increased mortality and length of stay. Mortality risk increased with intervention urgency. Leveraging EHR automation facilitates generalizability, multicenter collaboratives, and metric consistency., (Copyright © 2022 by the American Academy of Pediatrics.)

Interruptive clinical decision support systems, both within and outside of electronic health records, are a resource that should be used sparingly and monitored closely. Excessive use of interruptive alerting can quickly lead to alert fatigue and decreased effectiveness and ignoring of alerts. In this review, we discuss the evidence for effective alert stewardship as well as practices and methods we have found useful to assess interruptive alert burden, reduce excessive firings, optimize alert effectiveness, and establish quality governance at our institutions. We also discuss the importance of a holistic view of the alerting ecosystem beyond the electronic health record., Competing Interests: None declared., (Thieme. All rights reserved.)

Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Guidelines discourage continuous pulse oximetry monitoring of hospitalized infants with bronchiolitis who are not receiving supplemental oxygen. Excess monitoring is theorized to contribute to increased alarm burden, but this burden has not been quantified. We evaluated admissions of 201 children (aged 0-24 months) with bronchiolitis. We categorized time ≥60 minutes following discontinuation of supplemental oxygen as "continuously monitored (guideline-discordant)," "intermittently measured (guideline-concordant)," or "unable to classify." Across 4402 classifiable hours, 77% (11,101) of alarms occurred during periods of guideline-discordant monitoring. Patients experienced a median of 35 alarms (interquartile range [IQR], 10-81) during guideline-discordant, continuously monitored time, representing a rate of 6.7 alarms per hour (IQR, 2.1-12.3). In comparison, the median hourly alarm rate during periods of guideline-concordant intermittent measurement was 0.5 alarms per hour (IQR, 0.1-0.8). Reducing guideline-discordant monitoring in bronchiolitis patients would reduce nurse alarm burden.

Background: Excessive electronic health record (EHR) alerts reduce the salience of actionable alerts. Little is known about the frequency of interruptive alerts across health systems and how the choice of metric affects which users appear to have the highest alert burden., Objective: (1) Analyze alert burden by alert type, care setting, provider type, and individual provider across 6 pediatric health systems. (2) Compare alert burden using different metrics., Materials and Methods: We analyzed interruptive alert firings logged in EHR databases at 6 pediatric health systems from 2016-2019 using 4 metrics: (1) alerts per patient encounter, (2) alerts per inpatient-day, (3) alerts per 100 orders, and (4) alerts per unique clinician days (calendar days with at least 1 EHR log in the system). We assessed intra- and interinstitutional variation and how alert burden rankings differed based on the chosen metric., Results: Alert burden varied widely across institutions, ranging from 0.06 to 0.76 firings per encounter, 0.22 to 1.06 firings per inpatient-day, 0.98 to 17.42 per 100 orders, and 0.08 to 3.34 firings per clinician day logged in the EHR. Custom alerts accounted for the greatest burden at all 6 sites. The rank order of institutions by alert burden was similar regardless of which alert burden metric was chosen. Within institutions, the alert burden metric choice substantially affected which provider types and care settings appeared to experience the highest alert burden., Conclusion: Estimates of the clinical areas with highest alert burden varied substantially by institution and based on the metric used., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background and Objectives: Continuous pulse oximetry (oxygen saturation [Spo 2 ]) monitoring in hospitalized children with bronchiolitis not requiring supplemental oxygen is discouraged by national guidelines, but determining monitoring status accurately requires in-person observation. Our objective was to determine if electronic health record (EHR) data can accurately estimate the extent of actual Spo 2 monitoring use in bronchiolitis., Methods: This repeated cross-sectional study included infants aged 8 weeks through 23 months hospitalized with bronchiolitis. In the validation phase at 3 children's hospitals, we calculated the test characteristics of the Spo 2 monitor data streamed into the EHR each minute when monitoring was active compared with in-person observation of Spo 2 monitoring use. In the application phase at 1 children's hospital, we identified periods when supplemental oxygen was administered using EHR flowsheet documentation and calculated the duration of Spo 2 monitoring that occurred in the absence of supplemental oxygen., Results: Among 668 infants at 3 hospitals (validation phase), EHR-integrated Spo 2 data from the same minute as in-person observation had a sensitivity of 90%, specificity of 98%, positive predictive value of 88%, and negative predictive value of 98% for actual Spo 2 monitoring use. Using EHR-integrated data in a sample of 317 infants at 1 hospital (application phase), infants were monitored in the absence of oxygen supplementation for a median 4.1 hours (interquartile range 1.4-9.4 hours). Those who received supplemental oxygen experienced a median 5.6 hours (interquartile range 3.0-10.6 hours) of monitoring after oxygen was stopped., Conclusions: EHR-integrated monitor data are a valid measure of actual Spo 2 monitoring use that may help hospitals more efficiently identify opportunities to deimplement guideline-inconsistent use., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. [Dr. Al-Shaikh, Dr Muthu, Dr Aidyralieva, Dr Profili, and Dr Bellizzi are all technical officers working for the Jordan WHO Country Office, which actively supported the Jordan Ministry of Health in the planning of the National COVID-19 Deployment and Vaccination Plan.]

Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

The evolution of the COVID-19 pandemic in Jordan during the first 10 months of the epidemic was peculiar and can be easily categorized in three different phases: a first period featuring a very low number of reported cases, a second period with exponential growth from August with up to 8000 cases on the 18th November 2020, and a third phase with steady and progressive decline of the epidemiological curve. With the aim of better determine the entity of the population exposed to SARS-CoV-2, the Jordan Ministry of Health with the support of the WHO launched three rounds of the nationwide sero-prevalence survey. Using population proportionate to size (PPS) methodology, around 5000 individuals were selected from all Jordan governorates. Blood samples were collected from all participants and ELISA assays for total IgM, IgG antibodies to COVID-19 were used for testing at the National Public Health Laboratory. Results revealed that seroprevalence dramatically increased over time, with only a tiny fraction of seropositive individuals in August (0.3%), to increase up to more than 20-fold in October (7.0%) and to reach one-third of the overall population exposed by the end of 2020 (34.2%). While non age-specific trends were detected in infection rates across different age categories, in all three rounds of the seroprevalence study two out of three positive participants did not report any sign and/or symptom compatible with COVID-19. The serial cross-sectional surveys experience in Jordan allowed to gain additional insights of the epidemic over time in combination with context-specific aspects like adherence to public health and social measures (PHSM). On the other hand, such findings would be helpful for planning of public health mitigation measures like vaccinations and tailored restriction policies., Competing Interests: No competing interests., (© 2021 Published by Elsevier B.V.)

Background and Objectives: Physiologic monitor alarms occur at high rates in children's hospitals; ≤1% are actionable. The burden of alarms has implications for patient safety and is challenging to measure directly. Nurse workload, measured by using a version of the National Aeronautics and Space Administration Task Load Index (NASA-TLX) validated among nurses, is a useful indicator of work burden that has been associated with patient outcomes. A recent study revealed that 5-point increases in the NASA-TLX score were associated with a 22% increased risk in missed nursing care. Our objective was to measure the relationship between alarm count and nurse workload by using the NASA-TLX., Methods: We conducted a repeated cross-sectional study of pediatric nurses in a tertiary care children's hospital to measure the association between NASA-TLX workload evaluations (using the nurse-validated scale) and alarm count in the 2 hours preceding NASA-TLX administration. Using a multivariable mixed-effects regression accounting for nurse-level clustering, we modeled the adjusted association of alarm count with workload., Results: The NASA-TLX score was assessed in 26 nurses during 394 nursing shifts over a 2-month period. In adjusted regression models, experiencing >40 alarms in the preceding 2 hours was associated with a 5.5 point increase (95% confidence interval 5.2 to 5.7; P < .001) in subjective workload., Conclusion: Alarm count in the preceding 2 hours is associated with a significant increase in subjective nurse workload that exceeds the threshold associated with increased risk of missed nursing care and potential patient harm., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

Evaluating the clinical impacts of healthcare alarm management systems plays a critical role in assessing newly implemented monitoring technology, exposing latent threats to patient safety, and identifying opportunities for system improvement. We describe a novel, accurate, rapidly implementable, and readily reproducible in situ simulation approach to measure alarm response times and rates without the challenges and expense of video analysis. An interprofessional team consisting of biomedical engineers, human factors engineers, information technology specialists, nurses, physicians, facilitators from the hospital's simulation center, clinical informaticians, and hospital administrative leadership worked with three units at a pediatric hospital to design and conduct the simulations. Existing hospital technology was used to transmit a simulated, unambiguously critical alarm that appeared to originate from an actual patient to the nurse's mobile device, and discreet observers measured responses. Simulation observational data can be used to design and evaluate quality improvement efforts to address alarm responsiveness and to benchmark performance of different alarm communication systems., (© Copyright AAMI 2020. Single user license only. Copying, networking, and distribution prohibited.)

Objectives: To evaluate the translation of a paper high-risk checklist for PICU patients at risk of clinical deterioration to an automated clinical decision support tool., Design: Retrospective, observational cohort study of an automated clinical decision support tool, the PICU Warning Tool, adapted from a paper checklist to predict clinical deterioration events in PICU patients within 24 hours., Setting: Two quaternary care medical-surgical PICUs-The Children's Hospital of Philadelphia and Cincinnati Children's Hospital Medical Center., Patients: The study included all patients admitted from July 1, 2014, to June 30, 2015, the year prior to the initiation of any focused situational awareness work at either institution., Interventions: We replicated the predictions of the real-time PICU Warning Tool by retrospectively querying the institutional data warehouse to identify all patients that would have flagged as high-risk by the PICU Warning Tool for their index deterioration., Measurements and Main Results: The primary exposure of interest was determination of high-risk status during PICU admission via the PICU Warning Tool. The primary outcome of interest was clinical deterioration event within 24 hours of a positive screen. The date and time of the deterioration event was used as the index time point. We evaluated the sensitivity, specificity, positive predictive value, and negative predictive value of the performance of the PICU Warning Tool. There were 6,233 patients evaluated with 233 clinical deterioration events experienced by 154 individual patients. The positive predictive value of the PICU Warning Tool was 7.1% with a number needed to screen of 14 patients for each index clinical deterioration event. The most predictive of the individual criteria were elevated lactic acidosis, high mean airway pressure, and profound acidosis., Conclusions: Performance of a clinical decision support translation of a paper-based tool showed inferior test characteristics. Improved feasibility of identification of high-risk patients using automated tools must be balanced with performance.

Influenza like pandemics are a severe threat to any established health care system as many thousands of patients would need emergency ventilator support during the acute respiratory failure stage, and this quickly overloads the existing facilities. The present article addresses the design and development of a human breathing assist machine (ventilator) prototype for use by qualified medical professionals in the emergency room, as well as in other locations, where a regular ventilator machine cannot be made available. The ventilator has been designed using readily available locally sourced materials, which can be assembled in a short time. This ensures the minimum required features to ventilate a patient in emergency conditions. The popular crank-rocker mechanism has been used to meet some of the vital design requirements of the emergency ventilator. The size of the links has been chosen to maintain a fixed inspiratory-to-expiratory (I:E) time ratio of 1:2. The kinematic linkage design has been kept modular by introducing a feature to adjust the location of the rocker tip to control the tidal volume from 100 ml to 600 ml of oxygenated air per breath. A virtual CAD model, based on the above-mentioned linkage design, has been designed to assess the variation of the position and velocity with time. Finally, a working prototype has been made, and it was observed that the I:E time ratio of 1:2 was achieved satisfactorily., (© Indian National Academy of Engineering 2020.)

Objectives: In 2014, the American Academy of Pediatrics published bronchiolitis guidelines recommending against the use of bronchodilators. For the winter of 2015 to 2016, we aimed to reduce the proportion of emergency department patients with bronchiolitis receiving albuterol from 43% (previous winter rate) to <35% and from 18% (previous winter rate) to <10% in the inpatient setting., Methods: A team identified key drivers of albuterol use and potential interventions. We implemented changes to our pathway and the associated order set recommending against routine albuterol use and designed education to accompany the pathway changes. We monitored albuterol use through weekly automated data extraction and reported results back to clinicians. We measured admission rate, length of stay, and revisit rate as balancing measures for the intervention., Results: The study period included 3834 emergency department visits and 1119 inpatient hospitalizations. In the emergency department, albuterol use in children with bronchiolitis declined from 43% to 20% and was <3 SD control limits established in the previous year, meeting statistical thresholds for special cause variation. Inpatient albuterol use decreased from 18% to 11% of patients, also achieving special cause variation and approaching our goal. The changes in both departments were sustained through the entire bronchiolitis season, and admission rate, length of stay, and revisit rates remained unchanged., Conclusions: Using a multidisciplinary group that redesigned a clinical pathway and order sets for bronchiolitis, we substantially reduced albuterol use at a large children's hospital without impacting other outcome measures., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2020 by the American Academy of Pediatrics.)

Objective: Phenotyping patients using electronic health record (EHR) data conventionally requires labeled cases and controls. Assigning labels requires manual medical chart review and therefore is labor intensive. For some phenotypes, identifying gold-standard controls is prohibitive. We developed an accurate EHR phenotyping approach that does not require labeled controls., Materials and Methods: Our framework relies on a random subset of cases, which can be specified using an anchor variable that has excellent positive predictive value and sensitivity independent of predictors. We proposed a maximum likelihood approach that efficiently leverages data from the specified cases and unlabeled patients to develop logistic regression phenotyping models, and compare model performance with existing algorithms., Results: Our method outperformed the existing algorithms on predictive accuracy in Monte Carlo simulation studies, application to identify hypertension patients with hypokalemia requiring oral supplementation using a simulated anchor, and application to identify primary aldosteronism patients using real-world cases and anchor variables. Our method additionally generated consistent estimates of 2 important parameters, phenotype prevalence and the proportion of true cases that are labeled., Discussion: Upon identification of an anchor variable that is scalable and transferable to different practices, our approach should facilitate development of scalable, transferable, and practice-specific phenotyping models., Conclusions: Our proposed approach enables accurate semiautomated EHR phenotyping with minimal manual labeling and therefore should greatly facilitate EHR clinical decision support and research., (© The Author(s) 2019. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Medical errors in blood product orders and administration are common, especially for pediatric patients. A failure modes and effects analysis in our health care system indicated high risk from the electronic blood ordering process., Objectives: There are two objectives of this study as follows:(1) To describe differences in the design of the original blood product orders and order sets in the system (original design), new orders and order sets designed by expert committee (DEC), and a third-version developed through user-centered design (UCD).(2) To compare the number and type of ordering errors, task completion rates, time on task, and user preferences between the original design and that developed via UCD., Methods: A multidisciplinary expert committee proposed adjustments to existing blood product order sets resulting in the DEC order set. When that order set was tested with front-line users, persistent failure modes were detected, so orders and order sets were redesigned again via formative usability testing. Front-line users in their native clinical workspaces were observed ordering blood in realistic simulated scenarios using a think-aloud protocol. Iterative adjustments were made between participants. In summative testing, participants were randomized to use the original design or UCD for five simulated scenarios. We evaluated differences in ordering errors, time on task, and users' design preference with two-sample t -tests., Results: Formative usability testing with 27 providers from seven specialties led to 18 changes made to the DEC to produce the UCD. In summative testing, error-free task completion for the original design was 36%, which increased to 66% in UCD (30%, 95% confidence interval [CI]: 3.9-57%; p  = 0.03). Time on task did not vary significantly., Conclusion: UCD led to substantially different blood product orders and order sets than DEC. Users made fewer errors when ordering blood products for pediatric patients in simulated scenarios when using the UCD orders and order sets compared with the original design., Competing Interests: A.B.C. reports personal fees from American Medical Informatics Association, outside the submitted work. N.M. reports equity in Phrase Health, a clinical decision support analytics company. E.W.O. reports other from Phrase Health, outside the submitted work. J.B. has nothing to disclose. M.R. has nothing to disclose., (Georg Thieme Verlag KG Stuttgart · New York.)

Clinical decision support (CDS) systems delivered through the electronic health record are an important element of quality and safety initiatives within a health care system. However, managing a large CDS knowledge base can be an overwhelming task for informatics teams. Additionally, it can be difficult for these informatics teams to communicate their goals with external operational stakeholders and define concrete steps for improvement. We aimed to develop a maturity model that describes a roadmap toward organizational functions and processes that help health care systems use CDS more effectively to drive better outcomes. We developed a maturity model for CDS operations through discussions with health care leaders at 80 organizations, iterative model development by four clinical informaticists, and subsequent review with 19 health care organizations. We ceased iterations when feedback from three organizations did not result in any changes to the model. The proposed CDS maturity model includes three main "pillars": "Content Creation," "Analytics and Reporting," and "Governance and Management." Each pillar contains five levels-advancing along each pillar provides CDS teams a deeper understanding of the processes CDS systems are intended to improve. A "roof" represents the CDS functions that become attainable after advancing along each of the pillars. Organizations are not required to advance in order and can develop in one pillar separately from another. However, we hypothesize that optimal deployment of preceding levels and advancing in tandem along the pillars increase the value of organizational investment in higher levels of CDS maturity. In addition to describing the maturity model and its development, we also provide three case studies of health care organizations using the model for self-assessment and determine next steps in CDS development., Competing Interests: M.Z. and M.C.T. have equity in and are employees of Phrase Health, a health care governance and analytics company. E.W.O., N.M., and D.F. have equity in Phrase Health, a health care governance and analytics company. They receive no direct revenue. A.O.W., E.S., and J.S. declare no competing interests., (Georg Thieme Verlag KG Stuttgart · New York.)

Objective: The risk of medical errors increases upon transfer out of the intensive care unit (ICU). Discrepancies in the documented care plan between notes at the time of transfer may contribute to communication errors. We sought to determine the frequency of clinically meaningful discrepancies in the documented care plan for patients transferred from the pediatric ICU to the medical wards and identified risk factors., Materials and Methods: Two physician reviewers independently compared the transfer note and handoff document of 50 randomly selected transfers. Clinically meaningful discrepancies in the care plan between these two documents were identified using a coding procedure adapted from healthcare failure mode and effects analysis. We assessed the influence of risk factors via multivariable regression., Results: We identified 34 clinically meaningful discrepancies in 50 patient transfers. Fourteen transfers (28%) had ≥1 discrepancy, and ≥2 were present in 7 transfers (14%). The most common discrepancy categories were differences in situational awareness notifications and documented current therapy. Transfers with handoff document length in the top quartile had 10.6 (95% CI: 1.2-90.2) times more predicted discrepancies than transfers with handoff length in the bottom quartile. Patients receiving more medications in the 24 hours prior to transfer had higher discrepancy counts, with each additional medication increasing the predicted number of discrepancies by 17% (95% CI: 6%-29%)., Conclusion: Clinically meaningful discrepancies in the documented care plan pose legitimate safety concerns and are common at the time of transfer out of the ICU among complex patients., (© The Author(s) 2019. Published by Oxford University Press on behalf of the American Medical Informatics Association.)

Introduction: Quitlines are effective in helping smokers quit, but pediatrician quitline referral rates are low, and few parents who smoke use the service. This study compared enrollment of parents who smoke in the quitline using electronic referral with that using manual referral., Study Design: The study was designed as a pragmatic RCT., Setting/participants: Participants were recruited from one large, urban pediatric primary care site in Philadelphia, Pennsylvania with a high percentage of low-income families. Participants included adult parents who smoked and were present at their child's healthcare visit., Intervention: Pediatricians screened for tobacco use; smokers were given brief advice to quit and, if interested in quitting, were referred to the quitline. The eReferral ("warm handoff") involved electronically sending parent information to the quitline (parent received a call within 24-48 hours). Control group procedures were identical to eReferral, except the quitline number was provided to the parent. Data were collected between March 2017 and February 2018 and analyzed in 2018., Main Outcome Measures: The primary outcome was the proportion of parents enrolled in quitline treatment. Secondary outcomes included parent factors (e.g., demographics, nicotine dependence, and quitting motivation) associated with successful enrollment. Number of quitline contacts was also explored., Results: During the study period, in the eReferral group, 10.3% (24 of 233) of parents who smoked and were interested in quitting enrolled in the quitline, whereas only 2.0% (5 of 251) of them in the control group enrolled in the quitline-a difference of 8.3% (95% CI=4.0, 12.6). Parents aged ≥50 years enrolled in the quitline more frequently. Although more parents in the eReferral group connected to the quitline, among parents who had at least one quitline contact, there was no significant difference in the mean number of quitline contacts between eReferral and control groups (mean, 2.04 vs 2.40 calls; difference, 0.36 [95% CI=0.35, 1.06])., Conclusions: Smoking parent eReferral from pediatric primary care may increase quitline enrollment and could be adopted by practices interested in increasing rates of parent treatment., Trial Registration: This study is registered at www.clinicaltrials.gov NCT02997735., (Copyright © 2019 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Background: With the advent of minimally invasive techniques, the standard approaches to many surgeries have changed. We compared the financial costs and health care outcomes between standard thymectomy via sternotomy and video assisted thoracoscopic surgery (VATS)., Methods: A 3-year review [2010-2012] of the National Inpatient Sample (NIS) was performed. All patients undergoing thymectomy were included. Patients undergoing VATS thymectomy were identified. Outcomes measured were hospital length of stay (LOS), hospital charges, and mortality. Univariate and multivariate analyses were performed to control for demographics and comorbidities., Results: The results of 2,065 patients who underwent thymectomy were analyzed, of which 373 (18.1%) had VATS thymectomy and 1,692 (81.9%) had standard thymectomy. Mean age was 52.8±16, 42.5% were male, and 65.5% were Caucasian. There was a significant interval increase in number of patients undergoing VATS thymectomy (10% in 2010 vs . 19.2% in 2012, P<0.001). Patients undergoing standard thymectomy had longer hospital LOS (6.8±6.6 vs . 3.3d±3.4 d, P<0.001), hospital charges $88,838±$120,892 vs . $57,251±$54,929) and hospital mortality (0.9% vs . 0%, P=0.01). In multivariate analysis, thymectomy via sternotomy was independently associated with increased hospital LOS B =1.6 d, P<0.001) and charges (B = $13,041, P=0.041)., Conclusions: Our study demonstrates decreased hospital length of stay and reduced hospital charges in patients undergoing VATS thymectomy compared to standard thymectomy. Our data demonstrates that the prevalence of VATS thymectomies is increasing, likely related to improved healthcare and financial outcomes., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Low-value health care is pervasive in the United States, and clinicians need to be trained to be stewards of health care resources. Despite a mandate by the Accreditation Council for Graduate Medical Education to educate trainee physicians on cost awareness, only 10% of pediatric residency programs have a high-value care (HVC) curriculum. To meet this need, we set out to develop and evaluate the impact of High-Value Pediatrics, an open-access HVC curriculum. High-Value Pediatrics is a 3-part curriculum that includes 4 standardized didactics, monthly interactive morning reports, and an embedded HVC improvement project. Curriculum evaluation through an anonymous, voluntary survey revealed an improvement in the self-reported knowledge of health care costs, charges, reimbursement, and value ( P < .05). Qualitative results revealed self-reported behavior changes, and HVC improvement projects resulted in higher-value patient care. The implementation of High-Value Pediatrics is feasible and reveals improved knowledge and attitudes about HVC. HVC improvement projects augmented curricular knowledge gains and revealed behavior changes. It is imperative that formal high-value education be taught to every pediatric trainee to lead the culture change that is necessary to turn the tide against low-value health care. In addition, simultaneous work on faculty education and attention to the hidden curriculum of low-value care is needed for sustained and long-term improvements., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

Pediatric populations are uniquely vulnerable to the usability and safety challenges of electronic health records (EHRs), particularly those related to medication, yet little is known about the specific issues contributing to hazards. To understand specific usability issues and medication errors in the care of children, we analyzed 9,000 patient safety reports, made in the period 2012-17, from three different health care institutions that were likely related to EHR use. Of the 9,000 reports, 3,243 (36 percent) had a usability issue that contributed to the medication event, and 609 (18.8 percent) of the 3,243 might have resulted in patient harm. The general pattern of usability challenges and medication errors were the same across the three sites. The most common usability challenges were associated with system feedback and the visual display. The most common medication error was improper dosing.

Background: Surveillance for surgical site infections (SSIs) after ambulatory surgery in children requires a detailed manual chart review to assess criteria defined by the National Health and Safety Network (NHSN). Electronic health records (EHRs) impose an inefficient search process where infection preventionists must manually review every postsurgical encounter (< 30 days). Using text mining and business intelligence software, we developed an information foraging application, the SSI Workbench, to visually present which postsurgical encounters included SSI-related terms and synonyms, antibiotic, and culture orders., Objective: This article compares the Workbench and EHR on four dimensions: (1) effectiveness, (2) efficiency, (3) workload, and (4) usability., Methods: Comparative usability test of Workbench and EHR. Objective test metrics are time per case, encounters reviewed per case, time per encounter, and retrieval of information meeting NHSN definitions. Subjective measures are cognitive load using the National Aeronautics and Space Administration (NASA) Task Load Index (NASA TLX), and a questionnaire on system usability and utility., Results: Eight infection preventionists participated in the test. There was no difference in effectiveness as subjects retrieved information from all cases, using both systems, to meet the NHSN criteria. There was no difference in efficiency in time per case between the Workbench and EHR (8.58 vs. 7.39 minutes, p  = 0.36). However, with the Workbench subjects opened fewer encounters per case (3.0 vs. 7.5, p  = 0.002), spent more time per encounter (2.23 vs. 0.92 minutes, p  = 0.002), rated the Workbench lower in cognitive load (NASA TLX, 24 vs. 33, p  = 0.02), and significantly higher in measures of usability., Conclusion: Compared with the EHR, the Workbench was more usable, short, and reduced cognitive load. In overall efficiency, the Workbench did not save time, but demonstrated a shift from between-encounter foraging to within-encounter foraging and was rated as significantly more efficient. Our results suggest that infection surveillance can be better supported by systems applying information foraging theory., Competing Interests: None., (Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: Preclinical studies performed in our laboratory have shown that high-dose selenium inhibits the development of carboplatin drug resistance in an ovarian cancer mouse xenograft model. Based on these data, as well as the potential serious toxicities of supranutritional doses of selenium, a phase I trial of a combination of selenium/carboplatin/paclitaxel was designed to determine the maximum tolerated dose, safety, and effects of selenium on carboplatin pharmacokinetics in the treatment of chemo-naive women with gynecologic cancers. Correlative studies were performed to identify gene targets of selenium., Methods: Chemo-naïve patients with gynecologic malignancy received selenious acid IV on day 1 followed by carboplatin IV and paclitaxel IV on day 3. A standard 3 + 3 dose-escalating design was used for addition of selenium to standard dose chemotherapy. Concentrations of selenium in plasma and carboplatin in plasma ultrafiltrate were analyzed., Results: Forty-five patients were enrolled and 291 treatment cycles were administered. Selenium was administered as selenious acid to 9 cohorts of patients with selenium doses ranging from 50 μg to 5000 μg. Grade 3/4 toxicities included neutropenia (66.7%), febrile neutropenia (2.2%), pain (20.0%), infection (13.3%), neurologic (11.1%), and pulmonary adverse effects (11.1%). The maximum tolerated dose of selenium was not reached. Selenium had no effect on carboplatin pharmacokinetics. Correlative studies showed post-treatment downregulation of RAD51AP1, a protein involved in DNA repair, in both cancer cell lines and patient tumors., Conclusion: Overall, the addition of selenium to carboplatin/paclitaxel chemotherapy is safe and well tolerated, and does not alter carboplatin pharmacokinetics. A 5000 μg dose of elemental selenium as selenious acid is suggested as the dose to be evaluated in a phase II trial., (Published by Elsevier Inc.)

Background and Objective: Pediatric in-hospital cardiac arrest most commonly occurs in the pediatric intensive care unit (PICU) and is frequently preceded by early warning signs of clinical deterioration. In this study, we describe the implementation and evaluation of criteria to identify high-risk patients from a paper-based checklist into a clinical decision support (CDS) tool in the electronic health record (EHR)., Materials and Methods: The validated paper-based tool was first adapted by PICU clinicians and clinical informaticians and then integrated into clinical workflow following best practices for CDS design. A vendor-based rule engine was utilized. Littenberg's assessment framework helped guide the overall evaluation. Preliminary testing took place in EHR development environments with more rigorous evaluation, testing, and feedback completed in the live production environment. To verify data quality of the CDS rule engine, a retrospective Structured Query Language (SQL) data query was also created. As a process metric, preparedness was measured in pre- and postimplementation surveys., Results: The system was deployed, evaluating approximately 340 unique patients monthly across 4 clinical teams. The verification against retrospective SQL of 15-minute intervals over a 30-day period revealed no missing triggered intervals and demonstrated 99.3% concordance of positive triggers. Preparedness showed improvements across multiple domains to our a priori goal of 90%., Conclusion: We describe the successful adaptation and implementation of a real-time CDS tool to identify PICU patients at risk of deterioration. Prospective multicenter evaluation of the tool's effectiveness on clinical outcomes is necessary before broader implementation can be recommended., Competing Interests: None., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Outpatient providers often do not receive discharge summaries from acute care providers prior to follow-up visits. These outpatient providers may use the after-visit summaries (AVS) that are given to patients to obtain clinical information. It is unclear how effectively AVS support care coordination between clinicians., Objectives: Goals for this effort include: (1) developing usability heuristics that may be applied both for assessment and to guide generation of medical documents in general, (2) conducting a heuristic evaluation to assess the use of AVS for communication between clinicians, and (3) providing recommendations for generating AVS that effectively support both patient/caregiver use and care coordination., Methods: We created a 17-item heuristic evaluation instrument for assessing usability of medical documents. Eight experts used the instrument to assess each of four simulated AVS. The simulations were created using examples from two hospitals and two pediatric patient cases developed by the National Institute of Standards and Technology., Results: Experts identified 224 unique usability problems ranging in severity from mild to catastrophic. Content issues (e.g., missing medical history, marital status of a 2-year-old) were rated as most severe, but widespread formatting and structural problems (e.g., inconsistent indentation, fonts, and headings; confusing ordering of information) were so distracting that they significantly reduced readers' ability to efficiently use the documents. Overall, issues in the AVS from Hospital 2 were more severe than those in the AVS from Hospital 1., Conclusion: The new instrument allowed for quick, inexpensive evaluations of AVS. Usability issues such as unnecessary information, poor organization, missing information, and inconsistent formatting make it hard for patients, caregivers, and clinicians to use the AVS. The heuristics in the new instrument may be used as guidance to adapt electronic health record systems so that they generate more useful and usable medical documents., Competing Interests: None., (Georg Thieme Verlag KG Stuttgart · New York.)

Plants are very complex organisms that produce medicinally important natural products. The Star-fruit producing plant (Averrhoa carambola L.) is a species of woody plant in the family Oxalidaceae native to the Philippines, Indonesia, Malaysia, Vietnam, India, Bangladesh and Sri Lanka; but, cultivated in many parts of the world. Star-fruits are popular tropical fruits and used commonly in Ayurvedic and Traditional Chinese Medicines (TCM) in India, China, and Brazil to relieve ailments such as chronic headache, fever, cough, gastro-enteritis, diarrhoea, ringworm infections, and skin inflammations. However, this fruit contains high amount of oxalate, which is hazardous for uremic patients, and caramboxin (CBX), which is neurotoxic. The aim of this review is to highlight the nutritional, medicinal and toxicological traits of the star-fruits.

Here we demonstrate that a ubiquitin E3-ligase, FBXO21, targets the multidrug resistance transporter, ABCB1, also known as P-glycoprotein (P-gp), for proteasomal degradation. We also show that the Ser291-phosphorylated form of the multifunctional protein and stem cell marker, CD44, inhibits FBXO21-directed degradation of P-gp. Thus, CD44 increases P-gp mediated drug resistance and represents a potential therapeutic target in P-gp-positive cells.

Buprofezin is an insect growth regulator and widely used insecticide in Malaysia. The present study evaluated the toxic effects of buprofezin on the embryo and larvae of African catfish (Clarias gariepinus) as a model organism. The embryos and larvae were exposed to 7 different concentrations (0, 0.05, 0.5, 5, 25, 50 and 100 mg/L) of buprofezin. Each concentration was assessed in five replicates. Eggs were artificially fertilized and 200 eggs and larvae were subjected to a static bath treatment for all the concentrations. The mortality of embryos was significantly increased with increasing buprofezin concentrations from 5 to 100 mg/L (p< 0.05). However, the mortality was not significantly different (p<0.05) among the following concentrations: 0 (control), 0.05, 0.5 and 5 mg/L. Data obtained from the buprofezin acute toxicity tests were evaluated using probit analysis. The 24 h LC50 value (with 95% confidence limits) of buprofezin for embryos was estimated to be 6.725 (3.167-15.017) mg/L. The hatching of fish embryos was recorded as 68.8, 68.9, 66.9, 66.4, 26.9, 25.1 and 0.12% in response to 7 different concentrations of buprofezin, respectively. The mortality rate of larvae significantly (p<0.05) increased with increasing buprofezin concentrations exposed to 24-48 h. The 24 and 48 h LC50 values (with 95% confidence limits) of buprofezin for the larvae was estimated to be 5.702 (3.198-8.898) and 4.642 (3.264-6.287) mg/L respectively. There were no significant differences (p>0.05) in the LC50 values obtained at 24 and 48 h exposure times. Malformations were observed when the embryos and larvae exposed to more than 5 mg/L. The results emerged from the study suggest that even the low concentration (5 mg/L) of buprofezin in the aquatic environment may have adverse effect on the early embryonic and larval development of African catfish.