Publications by authors named "Whitney Chadwick"

12 Publications

  • Page 1 of 1

Target-Based Care: An Intervention to Reduce Variation in Postoperative Length of Stay.

J Pediatr 2021 01 10;228:208-212. Epub 2020 Sep 10.

Department of Pediatrics, Stanford University, Stanford, CA.

Objectives: To derive care targets and evaluate the impact of displaying them at the point of care on postoperative length of stay (LOS).

Study Design: A prospective cohort study using 2 years of historical controls within a freestanding, academic children's hospital. Patients undergoing benchmark cardiac surgery between May 4, 2014, and August 15, 2016 (preintervention) and September 6, 2016, to September 30, 2018 (postintervention) were included. The intervention consisted of displaying at the point of care targets for the timing of extubation, transfer from the intensive care unit (ICU), and hospital discharge. Family satisfaction, reintubation, and readmission rates were tracked.

Results: The postintervention cohort consisted of 219 consecutive patients. There was a reduction in variation for ICU (difference in SD -2.56, P < .01) and total LOS (difference in SD -2.84, P < .001). Patients stayed on average 0.97 fewer days (P < .001) in the ICU (median -1.01 [IQR -2.15, -0.39]), 0.7 fewer days (P < .001) on mechanical ventilation (median -0.54 [IQR -0.77, -0.50]), and 1.18 fewer days (P < .001) for the total LOS (median -2.25 [IQR -3.69, -0.15]). Log-transformed multivariable linear regression demonstrated the intervention to be associated with shorter ICU LOS (β coefficient -0.19, SE 0.059, P < .001), total postoperative LOS (β coefficient -0.12, SE 0.052, P = .02), and ventilator duration (β coefficient -0.21, SE 0.048, P < .001). Balancing metrics did not differ after the intervention.

Conclusions: Target-based care is a simple, novel intervention associated with reduced variation in LOS and absolute LOS across a diverse spectrum of complex cardiac surgeries.
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January 2021

Parent Perceptions and Experiences Regarding Medication Education at Time of Hospital Discharge for Children With Medical Complexity.

Hosp Pediatr 2020 08;10(8):679-686

Lucile Packard Children's Hospital Stanford, Palo Alto, California.

Background: Children with medical complexity (CMC) often require complex medication regimens. Medication education on hospital discharge should provide a critical safety check before medication management transitions from hospital to family. Current discharge processes may not meet the needs of CMC and their families. The objective of this study is to describe parent perspectives and priorities regarding discharge medication education for CMC.

Methods: We performed a qualitative, focus-group-based study, using ethnography. Parents of hospitalized CMC were recruited to participate in 1 of 4 focus groups; 2 were in Spanish. Focus groups were recorded, transcribed, and then coded and organized into themes by using thematic analysis.

Results: Twenty-four parents participated in focus groups, including 12 native English speakers and 12 native Spanish speakers. Parents reported a range of 0 to 18 medications taken by their children (median 4). Multiple themes emerged regarding parental ideals for discharge medication education: (1) information quality, including desire for complete, consistent information, in preferred language; (2) information delivery, including education timing, and delivery by experts; (3) personalization of information, including accounting for literacy of parents and level of information desired; and (4) self-efficacy, or education resulting in parents' confidence to conduct medical plans at home.

Conclusions: Parents of CMC have a range of needs and preferences regarding discharge medication education. They share a desire for high-quality education provided by experts, enabling them to leave the hospital confident in their ability to care for their children once home. These perspectives could inform initiatives to improve discharge medication education for all patients, including CMC.
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August 2020

A Quality Improvement Project to Reduce Combination Acetaminophen-opioid Prescriptions to Pediatric Orthopedic Patients.

Pediatr Qual Saf 2020 May-Jun;5(3):e291. Epub 2020 Apr 28.

Division of Pediatric Orthopedics, Department of Orthopedics, Stanford School of Medicine, Stanford, Calif.

Background: Acetaminophen-opioid analgesics are among the most commonly prescribed pain medications in pediatric orthopedic patients. However, these combined opioid analgesics do not allow for individual medication titration, which can increase the risk of opioid misuse and hepatoxicity from acetaminophen. The primary aim of this quality improvement project was to alter the prescribing habits of pediatric orthopedic providers at our institution from postoperative acetaminophen-opioid analgesics to independent acetaminophen and opioids.

Methods: The study took place in a level 1 trauma center at a children's hospital. A multidisciplinary team of health professionals utilized lean methodology to develop a project plan. Guided by a key driver diagram, we removed acetaminophen-oxycodone products from hospital formulary, implemented a revised inpatient and outpatient electronic order set, and conducted multiple education efforts. Outcomes included inpatient and outpatient percent combined acetaminophen-opioid orders by surgical providers over 27 months.

Results: Before the intervention, inpatient acetaminophen-opioid products accounted for an average of 46% of all opioid prescriptions for orthopedic patients. After the intervention and multiple educational efforts, we reported a reduction in the acetaminophen-opioid products to 2.9%. For outpatient prescriptions, combined analgesics accounted for 88% before the intervention, and we reported a reduction to 15% after the intervention.

Conclusions: By removing acetaminophen-oxycodone products from hospital formulary, educating the medical staff, and employing revised electronic order sets, the prescribing practice of pediatric orthopedic surgeons changed from the routine use of acetaminophen-opioid analgesics to independent medications.
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April 2020

Rapid Deployment of Inpatient Telemedicine In Response to COVID-19 Across Three Health Systems.

J Am Med Inform Assoc 2020 07;27(7):1102-1109

Department of Medicine, Stanford Medicine, 291 Campus Drive, Stanford, CA, 94305, USA.

Objective: To reduce pathogen exposure, conserve personal protective equipment, and facilitate health care personnel work participation in the setting of the COVID-19 pandemic, three affiliated institutions rapidly and independently deployed inpatient telemedicine programs during March 2020. We describe key features and early learnings of these programs in the hospital setting.

Methods: Relevant clinical and operational leadership from an academic medical center, pediatric teaching hospital, and safety net county health system met to share learnings shortly after deploying inpatient telemedicine. A summative analysis of their learnings was re-circulated for approval.

Results: All three institutions faced pressure to urgently standup new telemedicine systems while still maintaining secure information exchange. Differences across patient demographics and technological capabilities led to variation in solution design, though key technical considerations were similar. Rapid deployment in each system relied on readily available consumer-grade technology, given the existing familiarity to patients and clinicians and minimal infrastructure investment. Preliminary data from the academic medical center over one month suggested positive adoption with 631 inpatient video calls lasting an average (standard deviation) of 16.5 minutes (19.6) based on inclusion criteria.

Discussion: The threat of an imminent surge of COVID-19 patients drove three institutions to rapidly develop inpatient telemedicine solutions. Concurrently, federal and state regulators temporarily relaxed restrictions that would have previously limited these efforts. Strategic direction from executive leadership, leveraging off-the-shelf hardware, vendor engagement, and clinical workflow integration facilitated rapid deployment.

Conclusion: The rapid deployment of inpatient telemedicine is feasible across diverse settings as a response to the COVID-19 pandemic.
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July 2020

A Pilot Quality Improvement Project to Reduce Preoperative Fasting Duration in Pediatric Inpatients.

Pediatr Qual Saf 2019 Nov-Dec;4(6):e246. Epub 2019 Dec 16.

Department of Anesthesiology Perioperative and Pain Medicine, Division of Pediatric Anesthesia, Stanford University School of Medicine, Stanford, Calif.

Despite guidelines allowing clear liquids up to 2 hours before anesthesia, preoperative fasting for pediatric inpatients is often unnecessarily prolonged. This delay can lead to prolonged recovery time and increased postoperative pain. Efforts to reduce fasting duration in pediatric surgical patients is an evolving standard in pediatric anesthesiology. The primary aim of this quality improvement project was to reduce the average inpatient fasting duration undergoing anesthesia by 25% within a year of our pilot intervention. Secondary aims included measuring the adoption rate of the intervention and comparing aspiration rates as a balancing measure.

Methods: At an academic pediatric hospital, we created the preanesthesia diet order, a standardized, clear liquid diet for eligible inpatients undergoing anesthesia to decrease preoperative fasting duration. After implementation in January 2018, a statistical process control chart was used to measure the fasting duration of all eligible inpatients by month, and the Wilcoxon rank-sum test assessed differences. A Poisson test was used to determine differences in aspiration rates.

Results: Over the first year of our pilot intervention, 127 inpatients received the preanesthesia diet. The average fasting duration before its implementation was 12.5 and 5.7 hours postimplementation. The average adoption rate for eligible inpatients was 17.6%, and there was no difference in aspiration rates.

Conclusion: This quality improvement project demonstrated that a standardized, clear liquid diet on the morning of surgery could reduce preoperative fasting times among pediatric inpatients. The adoption of this pilot intervention was limited, highlighting the challenges of implementing a practice change.
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December 2019

An Improvement Effort to Optimize Electronically Generated Hospital Discharge Instructions.

Hosp Pediatr 2019 07;9(7):523-529

Divisions of Pediatric Hospital Medicine and.

Objectives: The purpose of hospital discharge instructions (HDIs) is to facilitate safe patient transitions home, but electronic health records can generate lengthy documents filled with irrelevant information. When our institution changed electronic health records, a cumbersome electronic discharge workflow produced low-value HDI and contributed to a spike in discharge delays. Our aim was to decrease these delays while improving family and provider satisfaction with HDI.

Methods: We used quality improvement methodology to redesign the electronic discharge navigator and HDI to address the following issues: (1) difficulty preparing discharge instructions before time of discharge, (2) suboptimal formatting of HDI, (3) lack of standard templates and language within HDI, and (4) difficulties translating HDI into non-English languages. Discharge delays due to HDI were tracked before and after the launch of our new discharge workflow. Parents and providers evaluated HDI and the electronic discharge workflow, respectively, before and after our intervention. Providers audited HDI for content.

Results: Discharge delays due to HDI errors decreased from a mean of 3.4 to 0.5 per month after our intervention. Parents' ratings of how understandable our HDIs were improved from 2.35 to 2.74 postintervention ( = .05). Pediatric resident agreement that the electronic discharge process was easy to use increased from 9% to 67% after the intervention ( < .001).

Conclusions: Through multidisciplinary collaboration we facilitated advance preparation of more standardized HDI and decreased related discharge delays from the acute care units at a large tertiary care hospital.
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July 2019

Use of electronic medical record templates improves quality of care for patients with infantile spasms.

Health Inf Manag 2021 Jan-May;50(1-2):47-54. Epub 2018 Aug 19.

Stanford University School of Medicine, USA.

Background: Infantile spasms (IS) is a neurologic disorder of childhood where time to treatment may affect long-term outcomes. Due to the clinical complexity of IS, care can be delayed.

Objective: To determine if the use of electronic medical record templates (EMRTs) improved care quality in patients treated for IS.

Method: Records of patients newly diagnosed with IS were retrospectively reviewed both before and after creation of an EMRT for the workup and treatment of IS. Quality of care measures reviewed included delays in treatment plan, medication administration, obtaining neurodiagnostic studies and discharge. The need for repeat neurodiagnostic studies was also assessed. Resident physicians were surveyed regarding template ease of use and functionality.

Results: Of 17 patients with IS, 7 received template-based care and 10 did not. Patients in the non-template group had more delays in treatment ( = 0.010), delay in medication administration ( = 0.10), delay in diagnostic studies ( = 0.01) and delay in discharge ( = 0.39). Neurodiagnostic studies needed to be repeated in 5 out of 10 patients in the non-template group and none of the 7 patients in the template group ( = 0.04). Surveyed resident physicians reported improved coordination in care, avoidance of delays in discharge and improved ability to predict side effects of treatment with template use.

Conclusion: In a single centre, the use of protocolised EMRTs decreased treatment delays and the need for repeated invasive procedures in patients with newly diagnosed IS and was reported as easy to use by resident physicians.

Implications: The use of protocolised EMRTs may improve the quality of patient care in IS and other rare diseases.
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August 2018

Got spirit? The spiritual climate scale, psychometric properties, benchmarking data and future directions.

BMC Health Serv Res 2017 02 11;17(1):132. Epub 2017 Feb 11.

Duke Patient Safety Center, Duke University Health System, Durham, NC, USA.

Background: Organizations that encourage the respectful expression of diverse spiritual views have higher productivity and performance, and support employees with greater organizational commitment and job satisfaction. Within healthcare, there is a paucity of studies which define or intervene on the spiritual needs of healthcare workers, or examine the effects of a pro-spirituality environment on teamwork and patient safety. Our objective was to describe a novel survey scale for evaluating spiritual climate in healthcare workers, evaluate its psychometric properties, provide benchmarking data from a large faith-based healthcare system, and investigate relationships between spiritual climate and other predictors of patient safety and job satisfaction.

Methods: Cross-sectional survey study of US healthcare workers within a large, faith-based health system.

Results: Seven thousand nine hundred twenty three of 9199 eligible healthcare workers across 325 clinical areas within 16 hospitals completed our survey in 2009 (86% response rate). The spiritual climate scale exhibited good psychometric properties (internal consistency: Cronbach α = .863). On average 68% (SD 17.7) of respondents of a given clinical area expressed good spiritual climate, although assessments varied widely (14 to 100%). Spiritual climate correlated positively with teamwork climate (r = .434, p < .001) and safety climate (r = .489, p < .001). Healthcare workers reporting good spiritual climate were less likely to have intentions to leave, to be burned out, or to experience disruptive behaviors in their unit and more likely to have participated in executive rounding (p < .001 for each variable).

Conclusions: The spiritual climate scale exhibits good psychometric properties, elicits results that vary widely by clinical area, and aligns well with other culture constructs that have been found to correlate with clinical and organizational outcomes.
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February 2017

The associations between work-life balance behaviours, teamwork climate and safety climate: cross-sectional survey introducing the work-life climate scale, psychometric properties, benchmarking data and future directions.

BMJ Qual Saf 2017 Aug 22;26(8):632-640. Epub 2016 Dec 22.

Division of Neonatology, Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, California, USA.

Background: Improving the resiliency of healthcare workers is a national imperative, driven in part by healthcare workers having minimal exposure to the skills and culture to achieve work-life balance (WLB). Regardless of current policies, healthcare workers feel compelled to work more and take less time to recover from work. Satisfaction with WLB has been measured, as has work-life conflict, but how frequently healthcare workers engage in specific WLB behaviours is rarely assessed. Measurement of behaviours may have advantages over measurement of perceptions; behaviours more accurately reflect WLB and can be targeted by leaders for improvement.

Objectives: 1. To describe a novel survey scale for evaluating work-life climate based on specific behavioural frequencies in healthcare workers.2. To evaluate the scale's psychometric properties and provide benchmarking data from a large healthcare system.3. To investigate associations between work-life climate, teamwork climate and safety climate.

Methods: Cross-sectional survey study of US healthcare workers within a large healthcare system.

Results: 7923 of 9199 eligible healthcare workers across 325 work settings within 16 hospitals completed the survey in 2009 (86% response rate). The overall work-life climate scale internal consistency was Cronbach α=0.790. t-Tests of top versus bottom quartile work settings revealed that positive work-life climate was associated with better teamwork climate, safety climate and increased participation in safety leadership WalkRounds with feedback (p<0.001). Univariate analysis of variance demonstrated differences that varied significantly in WLB between healthcare worker role, hospitals and work setting.

Conclusions: The work-life climate scale exhibits strong psychometric properties, elicits results that vary widely by work setting, discriminates between positive and negative workplace norms, and aligns well with other culture constructs that have been found to correlate with clinical outcomes.
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August 2017

Burnout in the NICU setting and its relation to safety culture.

BMJ Qual Saf 2014 Oct 17;23(10):806-13. Epub 2014 Apr 17.

Department of Psychiatry, Duke University School of Medicine, Duke University Health System, Durham, USA Duke Patient Safety Center, Duke University Health System, Durham, USA.

Background: Burnout is widespread among healthcare providers and is associated with adverse safety behaviours, operational and clinical outcomes. Little is known with regard to the explanatory links between burnout and these adverse outcomes.

Objectives: (1) Test the psychometric properties of a brief four-item burnout scale, (2) Provide neonatal intensive care unit (NICU) burnout and resilience benchmarking data across different units and caregiver types, (3) Examine the relationships between caregiver burnout and patient safety culture.

Research Design: Cross-sectional survey study.

Subjects: Nurses, nurse practitioners, respiratory care providers and physicians in 44 NICUs.

Measures: Caregiver assessments of burnout and safety culture.

Results: Of 3294 administered surveys, 2073 were returned for an overall response rate of 62.9%. The percentage of respondents in each NICU reporting burnout ranged from 7.5% to 54.4% (mean=25.9%, SD=10.8). The four-item burnout scale was reliable (α=0.85) and appropriate for aggregation (intra-class correlation coefficient-2=0.95). Burnout varied significantly between NICUs, p<0.0001, but was less prevalent in physicians (mean=15.1%, SD=19.6) compared with non-physicians (mean=26.9%, SD=11.4, p=0.0004). NICUs with more burnout had lower teamwork climate (r=-0.48, p=0.001), safety climate (r=-0.40, p=0.01), job satisfaction (r=-0.64, p<0.0001), perceptions of management (r=-0.50, p=0.0006) and working conditions (r=-0.45, p=0.002).

Conclusions: NICU caregiver burnout appears to have 'climate-like' features, is prevalent, and associated with lower perceptions of patient safety culture.
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October 2014

HER2 drives luminal breast cancer stem cells in the absence of HER2 amplification: implications for efficacy of adjuvant trastuzumab.

Cancer Res 2013 Mar 26;73(5):1635-46. Epub 2013 Feb 26.

University of Michigan Comprehensive Cancer Center, Ann Arbor, MI, USA.

Although current breast cancer treatment guidelines limit the use of HER2-blocking agents to tumors with HER2 gene amplification, recent retrospective analyses suggest that a wider group of patients may benefit from this therapy. Using breast cancer cell lines, mouse xenograft models and matched human primary and metastatic tissues, we show that HER2 is selectively expressed in and regulates self-renewal of the cancer stem cell (CSC) population in estrogen receptor-positive (ER(+)), HER2(-) luminal breast cancers. Although trastuzumab had no effects on the growth of established luminal breast cancer mouse xenografts, administration after tumor inoculation blocked subsequent tumor growth. HER2 expression is increased in luminal tumors grown in mouse bone xenografts, as well as in bone metastases from patients with breast cancer as compared with matched primary tumors. Furthermore, this increase in HER2 protein expression was not due to gene amplification but rather was mediated by receptor activator of NF-κB (RANK)-ligand in the bone microenvironment. These studies suggest that the clinical efficacy of adjuvant trastuzumab may relate to the ability of this agent to target the CSC population in a process that does not require HER2 gene amplification. Furthermore, these studies support a CSC model in which maximal clinical benefit is achieved when CSC targeting agents are administered in the adjuvant setting. Cancer Res; 73(5); 1635-46. ©2012 AACR.
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March 2013