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Article ; Online: Accurate Dosing Weight: When the 10% Really Matters.

Kandaswamy, Swaminathan / Thompson, Sarah / Orenstein, Evan

Studies in health technology and informatics

2024 Volume 310, Page(s) 354–358

Abstract: Introduction: Children are at increased risk of medication-associated adverse events, often due to weight-based dosing errors. We aimed to reduce the proportion of medications that were administered where the dosing weight was ≥ 10% different from the ... ...

Abstract	Introduction: Children are at increased risk of medication-associated adverse events, often due to weight-based dosing errors. We aimed to reduce the proportion of medications that were administered where the dosing weight was ≥ 10% different from the recorded weight. Methods: We adopted in-situ usability testing to iteratively improve design of clinical decision support that would enable accurate dosing weight documentation by prompting clinicians to update weight if recorded weight was > 10% different and it had been at least 7 days since the last dosing weight update. Results: The proportion of medication administrations with difference >10% between their recorded weight and dosing weight decreased from 13.1% (56,256/ 429,006) in the baseline period to 9.5% (35,560 / 372,443) in the intervention period (P < 0.001). Discussion and conclusion: User-centered design of an interruptive alert improved the accuracy of dosing weights during medication administrations without substantial alert burden. In-situ usability testing is an effective approach to rapidly obtain feedback from frontline users and iterate on the design to effect desired behavior changes.
MeSH term(s)	Child ; Humans ; Documentation ; Records ; User-Centered Design
Language	English
Publishing date	2024-01-25
Publishing country	Netherlands
Document type	Journal Article
ISSN	1879-8365
ISSN (online)	1879-8365
DOI	10.3233/SHTI230986
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Article ; Online: Impact on Emergency Department Interventions After Implementing a Guideline Based on the Pediatric Emergency Care Applied Research Network Prediction Rule for Identifying Low-Risk Febrile Infants 29 to 60 Days Old.

Mukherjee, Gargi / Orenstein, Evan / Jain, Shabnam / Hames, Nicole

Pediatric emergency care

2023 Volume 39, Issue 10, Page(s) 739–743

Abstract: Background: The Pediatric Emergency Care Applied Research Network (PECARN) prediction rule identifies febrile infants at low risk for serious bacterial infection (SBI). However, its impact on avoidable interventions in the emergency department remains ... ...

Abstract	Background: The Pediatric Emergency Care Applied Research Network (PECARN) prediction rule identifies febrile infants at low risk for serious bacterial infection (SBI). However, its impact on avoidable interventions in the emergency department remains unknown. Objective: To study the impact on lumbar puncture (LP) performance, empiric antibiotic use, and admissions after implementing a febrile infant clinical practice guideline for infants aged 29 to 60 days based on the PECARN prediction rule in the pediatric emergency department. Methods: This single center preintervention to postintervention study included infants 29 to 60 days old who presented with a chief complaint of fever from November 2018 to November 2021 and were assessed for SBI via blood culture and either urinalysis or urine culture. A new clinical practice guideline based on the PECARN prediction rule was implemented on December 2019. Lumbar puncture attempts, antibiotic administration, and admissions were compared preimplementation and postimplementation and in subgroups of low- and high-risk patients. Results: Of 1597 (PRE: 785, POST: 812) infants presenting with fever, 1032 (PRE: 500, POST: 532) met inclusion criteria. Adoption of guideline recommendations (measured as procalcitonin order rate) was 89.7% in eligible infants postimplementation. Overall, there was a significant decrease in LPs (PRE: 30.6%, POST: 22.6%, P < 0.05) and no significant change in antibiotics or admissions. Among low-risk infants, there was a significant reduction in LPs (PRE: 17.2%, POST: 4.4%, P < 0.05) and antibiotics (PRE: 14.5%, POST: 4.1%; P < 0.05). There was no change in missed SBI (PRE: 3, POST: 2, P = 0.65). No cases of missed meningitis preimplementation or postimplementation were observed. Conclusions: After implementation of a guideline based on the PECARN prediction rule, we observed a reduction of LPs and antibiotics in low-risk infants. Overall, a decrease in LPs was observed, whereas antibiotic use and admissions remained unchanged.
MeSH term(s)	Humans ; Infant ; Child ; Lipopolysaccharides ; Fever/diagnosis ; Fever/therapy ; Risk ; Bacterial Infections ; Emergency Service, Hospital ; Anti-Bacterial Agents/therapeutic use ; Retrospective Studies
Chemical Substances	Lipopolysaccharides ; Anti-Bacterial Agents
Language	English
Publishing date	2023-01-21
Publishing country	United States
Document type	Journal Article
ZDB-ID	632588-9
ISSN	1535-1815 ; 0749-5161
ISSN (online)	1535-1815
ISSN	0749-5161
DOI	10.1097/PEC.0000000000002905
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Zs.A 2083: Show issues

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Article ; Online: Clinical Decision Support Principles for Quality Improvement and Research.

Molloy, Matthew J / Muthu, Naveen / Orenstein, Evan W / Shelov, Eric / Luo, Brooke T

Hospital pediatrics

2024 Volume 14, Issue 4, Page(s) e219–e224

Abstract: 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 ...

Abstract	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.
MeSH term(s)	Humans ; Child ; Quality Improvement ; Decision Support Systems, Clinical ; Electronic Health Records ; Hospitalists
Language	English
Publishing date	2024-03-13
Publishing country	United States
Document type	Review ; Journal Article
ISSN	2154-1671
ISSN (online)	2154-1671
DOI	10.1542/hpeds.2023-007540
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Article ; Online: Effectiveness of a Vendor Predictive Model for the Risk of Pediatric Asthma Exacerbation: A Difference-in-Differences Analysis.

Murugan, Avinash / Kandaswamy, Swaminathan / Ray, Edwin / Gillespie, Scott / Orenstein, Evan

Applied clinical informatics

2023 Volume 14, Issue 5, Page(s) 932–943

Abstract: Background: Asthma is a common cause of morbidity and mortality in children. Predictive models may help providers tailor asthma therapies to an individual's exacerbation risk. The effectiveness of asthma risk scores on provider behavior and pediatric ... ...

Abstract	Background: Asthma is a common cause of morbidity and mortality in children. Predictive models may help providers tailor asthma therapies to an individual's exacerbation risk. The effectiveness of asthma risk scores on provider behavior and pediatric asthma outcomes remains unknown. Objective: Determine the impact of an electronic health record (EHR) vendor-released model on outcomes for children with asthma. Methods: The Epic Systems Risk of Pediatric Asthma Exacerbation model was implemented on February 24, 2021, for volunteer pediatric allergy and pulmonology providers as a noninterruptive risk score visible in the patient schedule view. Asthma hospitalizations, emergency department (ED) visits, or oral steroid courses within 90 days of the index visit were compared from February 24, 2019, to February 23, 2022, using a difference-in-differences design with a control group of visits to providers in the same departments. Volunteer providers were interviewed to identify barriers and facilitators to model use. Results: In the intervention group, asthma hospitalizations within 90 days decreased from 1.4% (54/3,842) to 0.7% (14/2,165) after implementation with no significant change in the control group (0.9% [171/19,865] preimplementation to 1.0% [105/10,743] post). ED visits in the intervention group decreased from 5.8% (222/3,842) to 5.5% (118/2,164) but increased from 5.5% (1,099/19,865) to 6.8% (727/10,743) in the control group. The adjusted difference-in-differences estimators for hospitalization, ED visit, and oral steroid outcomes were -0.9% (95% confidence interval [CI]: -1.6 to -0.3), -2.4% (-3.9 to -0.8), and -1.9% (-4.3 to 0.5). In qualitative analysis, providers understood the purpose of the model and felt it was useful to flag high exacerbation risk. Trust in the model was calibrated against providers' own clinical judgement. Conclusion: This EHR vendor model implementation was associated with a significant decrease in asthma hospitalization and ED visits within 90 days of pediatric allergy and pulmonology clinic visits, but not oral steroid courses.
MeSH term(s)	Child ; Humans ; Asthma/drug therapy ; Emergency Service, Hospital ; Hospitalization ; Risk Factors ; Steroids/therapeutic use ; Electronic Health Records
Chemical Substances	Steroids
Language	English
Publishing date	2023-09-29
Publishing country	Germany
Document type	Journal Article
ISSN	1869-0327
ISSN (online)	1869-0327
DOI	10.1055/a-2184-6481
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Article ; Online: Current Inpatient Screening Practices for Sexual History and STIs: An Opportunity to Seize.

Mukherjee, Gargi / Zhang, Chao / Kandaswamy, Swaminathan / Gooding, Holly / Orenstein, Evan

Clinical pediatrics

2023 Volume 63, Issue 3, Page(s) 350–356

Abstract: The American Academy of Pediatrics recommends utilizing hospitalizations as an opportunity to provide sexual health screenings for adolescents. This study aimed to describe the current practice of sexual history documentation (SHxD) and sexually ... ...

Abstract	The American Academy of Pediatrics recommends utilizing hospitalizations as an opportunity to provide sexual health screenings for adolescents. This study aimed to describe the current practice of sexual history documentation (SHxD) and sexually transmitted infection (STI) testing among adolescents admitted to a pediatric hospital medicine service. Retrospective cross-sectional study of adolescents (14-19 years old) admitted to the PHM service from 2017-2019 was performed at an academic children's health system. Patient (demographics, history of complex chronic condition, and insurance), hospitalization (length of stay, diagnosis, STI tests ordered/results), and physician (level of training and gender) characteristics were extracted for each encounter. A natural language processing algorithm identified the presence of SHxD. Univariate analysis and multivariable analysis were performed to detect factors associated with SHxD and STI screening. The prevalence of STIs was calculated for those who were tested. Out of 2242 encounters, SHxD and STI testing rates were 40.9% and 17.2%, respectively. Patient gender, race, lack of complex chronic condition, and resident involvement were predictive of SHxD and STI testing. SHxD increased the odds of STI testing significantly (OR 5.06, CI 3.90-6.58). Among those who were tested, the prevalence of STIs was highest for chlamydia (37/329, 11.2%). Overall, sexual health screening rates remain low in the hospital setting and future improvement initiatives are needed.
MeSH term(s)	Adolescent ; Humans ; Child ; Young Adult ; Adult ; Inpatients ; Cross-Sectional Studies ; Retrospective Studies ; Sexually Transmitted Diseases/diagnosis ; Sexually Transmitted Diseases/epidemiology ; Sexually Transmitted Diseases/prevention & control ; Sexual Behavior ; Mass Screening/methods ; Chronic Disease
Language	English
Publishing date	2023-07-10
Publishing country	United States
Document type	Journal Article
ZDB-ID	207678-0
ISSN	1938-2707 ; 0009-9228
ISSN (online)	1938-2707
ISSN	0009-9228
DOI	10.1177/00099228231183501
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Zs.A 454: Show issues

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Article ; Online: A method to advance adolescent sexual health research: Automated algorithm finds sexual history documentation.

Robertson, Caryn / Mukherjee, Gargi / Gooding, Holly / Kandaswamy, Swaminathan / Orenstein, Evan

Frontiers in digital health

2022 Volume 4, Page(s) 836733

Abstract: Background: We aimed to develop and validate a rule-based Natural Language Processing (NLP) algorithm to detect sexual history documentation and its five key components [partners, practices, past history of sexually transmitted infections (STIs), ... ...

Abstract	Background: We aimed to develop and validate a rule-based Natural Language Processing (NLP) algorithm to detect sexual history documentation and its five key components [partners, practices, past history of sexually transmitted infections (STIs), protection from STIs, and prevention of pregnancy] among adolescent encounters in the pediatric emergency and inpatient settings. Methods: We iteratively designed a NLP algorithm using pediatric emergency department (ED) provider notes from adolescent ED visits with specific abdominal or genitourinary (GU) chief complaints. The algorithm is composed of regular expressions identifying commonly used phrases in sexual history documentation. We validated this algorithm with inpatient admission notes for adolescents. We calculated the sensitivity, specificity, negative predictive value, positive predictive value, and F1 score of the tool in each environment using manual chart review as the gold standard. Results: In the ED test cohort with abdominal or GU complaints, 97/179 (54%) provider notes had a sexual history documented, and the NLP algorithm correctly classified each note. In the inpatient validation cohort, 97/321 (30%) admission notes included a sexual history, and the NLP algorithm had 100% sensitivity and 98.2% specificity. The algorithm demonstrated >97% sensitivity and specificity in both settings for detection of elements of a high quality sexual history including protection used and contraception. Type of sexual practice and STI testing offered were also detected with >97% sensitivity and specificity in the ED test cohort with slightly lower performance in the inpatient validation cohort. Conclusion: This NLP algorithm automatically detects the presence of sexual history documentation and its key components in ED and inpatient settings.
Language	English
Publishing date	2022-07-22
Publishing country	Switzerland
Document type	Journal Article
ISSN	2673-253X
ISSN (online)	2673-253X
DOI	10.3389/fdgth.2022.836733
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Article ; Online: A Case of Lethargy Followed by New Abnormal Movements in an Infant With a History of HSV Encephalitis.

Roome, Kerryn / Tutmaher, Michelle / Jenkins, Elan / Orenstein, Evan / Gombolay, Grace

Clinical pediatrics

2022 Volume 61, Issue 9, Page(s) 645–648

MeSH term(s)	Acyclovir/therapeutic use ; Dyskinesias ; Encephalitis, Herpes Simplex/complications ; Encephalitis, Herpes Simplex/diagnosis ; Encephalitis, Herpes Simplex/drug therapy ; Herpes Simplex/complications ; Herpes Simplex/diagnosis ; Herpes Simplex/drug therapy ; Humans ; Infant ; Lethargy/etiology
Chemical Substances	Acyclovir (X4HES1O11F)
Language	English
Publishing date	2022-05-20
Publishing country	United States
Document type	Case Reports ; Journal Article
ZDB-ID	207678-0
ISSN	1938-2707 ; 0009-9228
ISSN (online)	1938-2707
ISSN	0009-9228
DOI	10.1177/00099228221098652
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Article ; Online: Integrating structured and unstructured data for timely prediction of bloodstream infection among children.

Tabaie, Azade / Orenstein, Evan W / Kandaswamy, Swaminathan / Kamaleswaran, Rishikesan

Pediatric research

2022 Volume 93, Issue 4, Page(s) 969–975

Abstract: Background: Hospitalized children with central venous lines (CVLs) are at higher risk of hospital-acquired infections. Information in electronic health records (EHRs) can be employed in training deep learning models to predict the onset of these ... ...

Abstract	Background: Hospitalized children with central venous lines (CVLs) are at higher risk of hospital-acquired infections. Information in electronic health records (EHRs) can be employed in training deep learning models to predict the onset of these infections. We incorporated clinical notes in addition to structured EHR data to predict serious bloodstream infections, defined as positive blood culture followed by at least 4 days of new antimicrobial agent administration, among hospitalized children with CVLs. Methods: Structured EHR information and clinical notes were extracted for a retrospective cohort including all hospitalized patients with CVLs at a single tertiary care pediatric health system from 2013 to 2018. Deep learning models were trained to determine the added benefit of incorporating the information embedded in clinical notes in predicting serious bloodstream infection. Results: A total of 24,351 patient encounters met inclusion criteria. The best-performing model restricted to structured EHR data had a specificity of 0.951 and positive predictive value (PPV) of 0.056 when the sensitivity was set to 0.85. The addition of contextualized word embeddings improved the specificity to 0.981 and PPV to 0.113. Conclusions: Integrating clinical notes with structured EHR data improved the prediction of serious bloodstream infections among pediatric patients with CVLs. Impact: Developed an advanced infection prediction model in pediatrics that integrates the structured and unstructured EHRs. Extracted information from clinical notes to do timely prediction in a clinical setting. Developed a deep learning model framework that can be employed in predicting rare events in a complex and dynamic environment.
MeSH term(s)	Humans ; Child ; Retrospective Studies ; Sepsis
Language	English
Publishing date	2022-07-19
Publishing country	United States
Document type	Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	4411-8
ISSN	1530-0447 ; 0031-3998
ISSN (online)	1530-0447
ISSN	0031-3998
DOI	10.1038/s41390-022-02116-6
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Zs.A 564: Show issues			Location: Je nach Verfügbarkeit (siehe Angabe bei Bestand) bis Jg. 1994: Bestellungen von Artikeln über das Online-Bestellformular Jg. 1995 - 2021: Lesesall (1.OG) ab Jg. 2022: Lesesaal (EG)
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Article ; Online: A single-center model for implementation of SLEDAI documentation adherence in childhood-onset systemic lupus erythematosus (cSLE).

Nelson, Meghan Corrigan / Mosley, Colleen / Bennett, Tonya / Orenstein, Evan / Rouster-Stevens, Kelly

Lupus

2023 Volume 32, Issue 12, Page(s) 1447–1452

Abstract: Background: Childhood-onset systemic lupus erythematosus (cSLE) is an autoimmune disease with variable disease expression but noted association with significant disease-related damage, morbidity, and mortality. The European Alliance of Associations for ... ...

Abstract	Background: Childhood-onset systemic lupus erythematosus (cSLE) is an autoimmune disease with variable disease expression but noted association with significant disease-related damage, morbidity, and mortality. The European Alliance of Associations for Rheumatology (EULAR) recommends routine monitoring of SLE through validated disease activity and chronicity indices, including the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI). Despite this, physician adherence with SLEDAI documentation remains elusive at various academic institutions. The aim of our study was to determine baseline SLEDAI documentation rates at our center and assess the change in adherence in SLEDAI documentation rate with electronic clinical decision support (CDS) reminders facilitated through the electronic medical record (EMR) over a 2-year period. Methods: All SLE encounters over a 24-month period at a pediatric academic center were reviewed in order to obtain baseline SLEDAI documentation percentages. Physicians subsequently received monthly email reminders, initiated at month 4 of project initiation, with subsequent CDS reminder 13 months after project initiation prompted by anti-dsDNA lab result. Chart review was repeated continuously for each provider, and SLEDAI documentation rates were emailed to each provider monthly. Physicians completed a post-intervention survey regarding barriers to SLEDAI documentation at the end of the study. Results: A total of 1980 SLE encounters were reviewed for this study. Baseline SLEDAI documentation rates were 10%. Following the introduction of monthly emails reminding physicians to document SLEDAI, rates increased to 55%. After the initiation of electronic in-basket reminders prompted by lab results, rates increased to 60%. Noted barriers to documentation were cited to be forgetfulness (67%) and lack of time (33%). Conclusion: Our study demonstrates that monthly email reminders as well as EMR-mediated electronic in-basket reminders increased SLEDAI documentation rates at an academic center. Noted barriers to documentation were reported to be forgetfulness (67%) and lack of time (33%).
MeSH term(s)	Child ; Humans ; Lupus Erythematosus, Systemic/diagnosis ; Age of Onset ; Severity of Illness Index
Language	English
Publishing date	2023-10-09
Publishing country	England
Document type	Journal Article
ZDB-ID	1154407-7
ISSN	1477-0962 ; 0961-2033
ISSN (online)	1477-0962
ISSN	0961-2033
DOI	10.1177/09612033231206451
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Article ; Online: User-Centered Design and Evaluation of Clinical Decision Support to Improve Early Peanut Introduction: Formative Study.

Nguyen, Thinh Hoang / Cunha, Priscila Pereira / Rowland, Annabelle Friedman / Orenstein, Evan / Lee, Tricia / Kandaswamy, Swaminathan

JMIR formative research

2023 Volume 7, Page(s) e47574

Abstract: Background: Peanut allergy has recently become more prevalent. Peanut introduction recommendations have evolved from suggesting peanut avoidance until the age of 3 years to more recent guidelines encouraging early peanut introduction after the Learning ... ...

Abstract	Background: Peanut allergy has recently become more prevalent. Peanut introduction recommendations have evolved from suggesting peanut avoidance until the age of 3 years to more recent guidelines encouraging early peanut introduction after the Learning Early about Peanut Allergy (LEAP) study in 2015. Guideline adherence is poor, leading to missed care opportunities. Objective: In this study, we aimed to develop a user-centered clinical decision support (CDS) tool to improve implementation of the most recent early peanut introduction guidelines in the primary care clinic setting. Methods: We edited the note template of the well-child check (WCC) visits at ages 4 and 6 months with CDS prompts and point-of-care education. Formative and summative usability testing were completed with pediatric residents in a simulated electronic health record (EHR). We estimated task completion rates and perceived usefulness of the CDS in summative testing, comparing a test EHR with and without the CDS. Results: Formative usability testing with the residents provided qualitative data that led to improvements in the build for both the 4-month and 6-month WCC note templates. During summative usability testing, the CDS tool significantly improved discussion of early peanut introduction at the 4-month WCC visit compared to scenarios without the CDS tool (9/15, 60% with CDS and 0/15, 0% without CDS). All providers except one at the 4-month WCC scenario gave at least an adequate score for the ease of use of the CDS tool for the history of present illness and assessment and plan sections. During the summative usability testing with the 6-month WCC new build note template, providers more commonly provided comprehensive care once obtaining a patient history concerning for an immunoglobulin E-mediated peanut reaction by placing a referral to allergy/immunology (P=.48), prescribing an epinephrine auto-injector (P=.07), instructing on how to avoid peanut products (P<.001), and providing an emergency treatment plan (P=.003) with CDS guidance. All providers gave at least an adequate score for ease of use of the CDS tool in the after-visit summary. Conclusions: User-centered CDS improved application of early peanut introduction recommendations and comprehensive care for patients who have symptoms concerning for peanut allergy in a simulation.
Language	English
Publishing date	2023-08-22
Publishing country	Canada
Document type	Journal Article
ISSN	2561-326X
ISSN (online)	2561-326X
DOI	10.2196/47574
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