866-987-2000 (toll-free). Seattle Children's complies with applicable federal and other civil rights laws and does not discriminate, exclude people or treat them differently based on race, color, religion (creed), sex, gender identity or expression, sexual orientation, national origin (ancestry), age, disability, or any other status protected by applicable federal, state or local law. dDifference between pre- and postpathway period intercepts is the calculated difference in time periodspecific intercepts, indicated the mean value for the outcome at the beginning of the time period. Six additional primary care sites joined the program in 2021. WazekaA, ValacerDJ, CooperM, CaplanDW, DiMaioM. Impact of a pediatric asthma clinical pathway on hospital cost and length of stay. The https:// ensures that you are connecting to the Additional resources: Clinical Standard Work Pathways. We'll help you find the best provider for your child. Seattle Childrens has updated the clinical standard work pathway for Urinary Tract Infection (UTI). Mental health care is one of the greatest unmet needs in pediatric health, said Dr. Sheryl Morelli, chief medical officer for SCCN. ECHO (early if signs of cardiac CXR (if resp sx)dysfunction) Consider SepsisSepsis PathwayPathway Caution with boluses; monitor for cardiac dysfunction Lab Evidence of MIS-C? Extraordinary kid care For patients with multiple admissions within the study time frame, only the first admission per 30-day period was eligible. A, Numbers of admissions meeting pathway criteria, before and after each pathway was implemented. All included pathways were implemented during the study time period, so the study included pathway-eligible admissions, both before and after implementation, for each of the 15 pathway conditions. For teens, self-report was used when available; otherwise, parent proxy report was used. Development and implementation of a clinical pathway for patients undergoing total laryngectomy: impact on cost and quality of care. Because of the alarming statistics for children, and the fact that suicide risk is both under-identified and under-reported, we knew as healthcare providers that we were responsible for change, saidDr. Molly Adrian, Seattle Childrens psychologist and co-leader of the ZSI team. We also tested whether the pre- and postpathway period intercepts and slopes were statistically different from one another, using the lincom command in Stata. From asthma exacerbations to febrile seizures, pediatric emergency medicine clinical pathways ensure we deliver high-quality care. One of the most common misconceptions about youth suicide is the idea that talking about suicide will plant the seed of suicidal thoughts that werent already there especially in younger children. For more information, please reference our Urinary Tract Infection CSW Pathway. Effect of a clinical pathway on the hospitalisation rates of children with asthma: a prospective study. Seattle Childrens complies with applicable federal and other civil rights laws and does not discriminate, exclude people or treat them differently based on race, color, religion (creed), sex, gender identity or expression, sexual orientation, national origin (ancestry), age, disability, or any other status protected by applicable federal, state or local law. Compared with the costs per patient predicted by the prepathway slope trajectory, the actual postpathway costs were $155 lower per month (95% CI $246 to $64; P = .001). His parents are scared and unsure of what could be causing their son's pulse to spike. Inclusion criteria were met for 3808 prepathway admissions and 2902 postpathway admissions. Age > 60 days Gestational age Born 32 weeks gestation and post-conception age 45 weeks No cardiopulmonary resuscitation (CPR) by trained medical provider Event lasted < 1 minute First event No repeat events No concerning history Baseline exam for infant Any of the lower-risk criteria not met Concerning history, physical examination findings These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioners professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located. B, Number of months included in study by pathway, before and after implementation. Pathways are reviewed periodically to ensure they remain consistent with current medical literature and national guidelines. KimberlyJ, de PourourvilleG, dAunnoT. The Globalization of Managerial Innovation in Health Care. Financial assistance for medically necessary services is based on family income and hospital resources and is provided to children under age 21 whose primary residence is in Washington, Alaska, Montana or Idaho. Procedure prep. The aim is to improve quality of care through the standardization of management based on evidence in published medical literature and/or expert opinion. While theres no data to support this misleading theory, NIMH research showsthat the suicide rate for children ages 10 to 12 has substantially risen over the past 10 years. Therefore, our results are unlikely to merely reflect a change in study population. DKA, diabetic ketoacidosis. The objective of this study was to assess whether implementation of the CSW system was associated with hospitalization costs, length of stay (LOS), degree of physical functioning improvement after hospital discharge, and readmissions. The effectiveness of implementing a care pathway for femoral neck fracture in older people: a prospective controlled before and after study. Rationale This protocol was developed by a consensus group of ACH hospitalists, EC physicians, and pediatric intensivists to standardize the management of children diagnosed with acute bronchiolitis. Validity and responsiveness of the pediatric quality of life inventory (PedsQL) 4.0 generic core scales in the pediatric inpatient setting. The program also includes components of the University of Washingtons Advancing Integrated Mental Health Solutions Center Collaborative Care Model, an evidence-based treatment approach for common mental health conditions such as depression and anxiety that has led to better patient outcomes, better patient and provider satisfaction, and reductions in health care costs. Seattle Children's Clinical Pathways URL: https://www.seattlechildrens.org/healthcare-professionals/gateway/clinical-resources/pathways/ Date Uploaded: Tuesday, January 22, 2019 - 11:00am Category: Pediatric Stewardship Type of Resource: Toolkit or Generic Resource All dates and times are in the PDT timezone. After pathway implementation, there was a significant increasing trend over time, at a rate of 0.5 points per month (95% CI 0.1 to 0.8), or 6 points per year, which exceeds the minimal clinically important difference of 4.5. There were 3808 and 2902 admissions in the pre- and postpathway groups, respectively. Total charges per hospital stay, excluding physician professional fees, and LOS data were obtained from hospital administrative data. Segmented linear regression was used to evaluate differences in intercept and trend over time before and after pathway implementation. Federal government websites often end in .gov or .mil. We wanted to incorporate a more accessible approach to behavioral health care, explained Dr. Rick Levine, a pediatrician at Skagit Pediatrics. Inclusion in an NLM database does not imply endorsement of, or agreement with, *Inclusion criteria for this pathway depends on clinical documentation of fever, which was not available in the electronic medical record until February 2012, which is why there are fewer months of data for this pathway than others. So, we implemented the pathway to ensure our patients are asked about their risk and that we follow-up accordingly.. While their patient and visit volume data is not yet available, the SCCN program team has seen provider comfort in managing behavioral health concerns increase in five of the six focus areas across the 12 participating sites. Seattle Childrens Care Network Integrated Behavioral Health Program is part of the national Johns Hopkins Pediatric Integrated Care Collaborative, which promotes integrated healthcare and mental and behavioral health services. Date of pathway implementation is indicated next to the pathway name. For more than 100 years, we have been dedicated to providing top-quality care to every child in our region who needs us, regardless of the family's ability to pay. By evaluating clinical pathways in aggregate, our findings support an association between evidence-based standardization and the outcomes studied. Bureau of Labor Statistics Consumer Price Index. aDepartment of Pediatrics, University of Washington, Seattle, Washington; bCenter for Child Health, Behavior, and Development, Seattle Childrens Research Institute, Seattle, Washington; and, dSeattle Childrens Hospital, Seattle, Washington. A, Monthly average unplanned hospital readmissions within 30 days of index admission. We did not include admissions eligible for pathways that predated this time period because no preintervention data would be available, nor did we include admissions eligible for pathways for children with complex, uncommon subspecialty conditions, such as inflammatory bowel disease. We've got you covered. While Seattle Childrens began screening ED patients with mental health-related complaints in May 2017, patients who presented with medical complaints like broken bones or stomach aches were not screened. NewmanRE, HedicanEB, HerigonJC, WilliamsDD, WilliamsAR, NewlandJG. At Seattle Children's, a clinical standard work (CSW) pathway is a documented approach to the management and treatment of a particular population or clinical condition. Pathway implementation was associated with a steady decrease in LOS, at a rate of 0.03 days (or 43 minutes) per admission per month (95% CI 0.05 to 0.02; P value for slope difference between time periods = .02; R2 = 0.97), which amounts to 8.6 hours over the course of a year. It addresses the following clinical questions or problems: Decrease routine use of unnecessary diagnostic testing 3401 Civic Center Blvd. If you have questions about any of the clinical pathways or about the process of creating a clinical pathway pleasecontact us. While Seattle Childrens has provided in-person suicide prevention training for nurses over the past three years, the ZSI team offers additional training to help both nurses and providers feel better equipped to talk about suicide with younger children and provides safe spaces for them to share their personal experiences and feelings with their colleagues. Address correspondence to K. Casey Lion, MD, MPH, University of Washington, and Center for Child Health, Behavior and Development, Seattle Childrens Research Institute; M/S CW8-6, PO Box 5371, Seattle, WA 98145-5005. Interrupted time series analysis of admissions to a tertiary care childrens hospital from December 1, 2009 through March 30, 2014. Even if their kids dont screen positive, families appreciate knowing what resources are available before a crisis happens.. Because included pathways were all intended for general pediatric populations, we excluded admissions involving patients with complex chronic conditions. Use of this site is subject to theTerms of Use. Discharge. Individual pathways contributed 7 to 44 months of prepathway data and 7 to 45 months of postpathway data (Fig 1). Childrens Hospital of Philadelphia is a charitable 501(c)(3) nonprofit organization. Washington, DC: US Department of Labor; 2013. Seattle Children's complies with applicable federal and other civil rights laws and does not discriminate, exclude people or treat them differently based on race, color, religion (creed), sex, gender identity or expression, sexual orientation, national origin (ancestry), age, disability, or any other status protected by applicable federal, state or local law. The CSW approach applied a standard process to develop and implement evidence-based clinical pathways, aiming to improve outcomes while reducing unnecessary utilization. Unplanned 30-day readmissions were assessed from hospital administrative data. Last Updated: March 2022 Next Expected Review: December 2025 For questions concerning this pathway, contact: bronchiolitis@seattlechildrens.org ACH is not responsible for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient. Seattle Children's Hospital specializes in meeting the unique physical, emotional and developmental needs of children from infancy through young adulthood. A 10-year-old girl enters the ED with a sprained elbow after taking a tumble on the soccer field. Implementation of 15 standardized pathways across multiple general pediatric conditions was associated with increased value of care, through decreased length of stay and a halt in rising costs without negatively affecting patient physical functioning improvement or readmissions. Seattle Children's complies with applicable federal and other civil rights laws and does not discriminate, exclude people or treat them differently based on race, color, religion (creed), sex, gender identity or expression, sexual orientation, national origin (ancestry), age, disability, or any other status protected by applicable federal, state or local law. FUNDING: This work was funded by the Department of Clinical Effectiveness, through hospital operations at Seattle Childrens Hospital. There were no significant differences by time period in 30-day readmissions, either in trend over time or intercepts based on segmented regression (Fig 3A). Providers at the 12 participating primary care practices were assessed when they joined the program and about 10 months later. Prior to discharging the patient, a mental health evaluator shares resources and information about suicide with the family, and the provider contacts the patients therapist and asks the girls suicidal thoughts be addressed in their next appointment. All estimates are followed by 95% CIs in parentheses. Order-set use varies by condition, from 100% order-set activation for eligible patients over time (eg, neonatal jaundice), to lower levels of use, especially immediately after implementation (eg, croup, 38% use in the initial 3 months and 68% use in the most recent 3 months; Table 1). Please consult your local hospital resources as appropriate. Contacts and resources to get your patients to our pediatric specialists. A, Monthly average hospital costs per admission in 2013 US dollars. As healthcare providers, we need to do more, Miller said. By clicking Accept All Cookies, you agree to the storing of cookies on your device to enhance site navigation, analyze site usage and assist in marketing efforts. However, the most prevalent pathway (depressive disorders) contributed <15% of admissions to both the pre- and postimplementation periods, making it unlikely to have disproportionately influenced the results. 206-987-7777 The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at the Advocate Childrens Hospital (ACH) and are current at the time of publication. They translate national guidelines and the best available evidence for clinical application into local context. 2013;309(10):986]. However, multifaceted interventions like pathway implementation are more likely to be effective than those with only a single component,38 so isolating the impact of individual steps within pathways may not be useful. KellyCS, AndersenCL, PestianJP, et al.. For questions, please contact Dr. Israel Green-Hopkins. Firefox. Seventeen million dollars were budgeted over 5 years for the initiative (mostly for salary support), including 1000 person-hours dedicated to developing and implementing each pathway and 1000 person-hours for pathway maintenance and improvement. The ZSI team hopes to implement the next evolution of the pathway in Seattle Childrens ambulatory settings in the future. MitchellEA, DidsburyPB, KruithofN, et al.. A randomized controlled trial of an asthma clinical pathway for children in general practice. When no significant slope exists during the time period, the intercept is equal to the mean value for the time period. In 2010, Seattle Childrens Hospital (SCH) undertook a hospital-wide initiative to develop and implement clinical standard work (CSW) pathways for a range of pediatric conditions. The program helps primary care clinics like Skagit Pediatrics implement standard behavioral health screenings to identify patients and families who need support sooner, offer appropriate, short-term services with a behavioral health specialist at their clinic, and provide a seamless transition to long-term services when needed. Being able to intervene sooner for our kids is just one step in the right direction.. For example, whereas 21% of patients eligible for the urinary tract infection pathway had order-set activation, 48% received pathway-recommended discharge antibiotics. Financial assistance for medically necessary services is based on family income and hospital resources and is provided to children under age 21 whose primary residence is in Washington, Alaska, Montana or Idaho. NortonSP, PusicMV, TahaF, HeathcoteS, CarletonBC. We were also unable to identify which particular steps within individual pathways had the greatest association with outcomes. The innovative program aims to empower primary care teams to identify, manage and coordinate mental and behavioral health services within their community settings with the long-term goal of alleviating pressure on hospitals and specialty care practices. Development of each CSW pathway begins with a literature review. To explore the relative contribution of each pathway to the overall findings, we stratified the segmented regression for each outcome by individual pathway. A clinical pathway is a structured, evidence-based, multidisciplinary plan that details steps in the care of patients with a specific condition. For example, the prepathway cost regression line has a slope of +126, meaning average per-patient costs were increasing by $126 per month during the prepathway period. Disruptive Behavior and Aggression Care Guide, Crisis Prevention and Home Safety Recommendations (Alaska), Crisis Prevention and Home Safety Recommendations (Washington), Crisis Prevention and Home Safety Recommendations (Wyoming), Ayuda para el plan para la prevencin de crisis (Crisis Prevention and Home Safety Recommendations) (Alaska), Ayuda para el plan para la prevencin de crisis (Crisis Prevention and Home Safety Recommendations) (Washington), Ayuda para el plan para la prevencin de crisis (Crisis Prevention and Home Safety Recommendations) (Wyoming), Consejos para la terapia de relajacin (Relaxation Therapy), Fuentes de informacin para controlar ansiedad (Anxiety Resources), Fuentes de informacin sobre el autism (Autism Resources) (Alaska), Fuentes de informacin sobre el autism (Autism Resources) (Washington), Fuentes de informacin sobre el autism (Autism Resources) (Wyoming), Fuentes de informacin sobre el Trastorno por Dficit de Atencin e Hiperactividad (ADHD Resources), Fuentes de informacin sobre los trastornos alimenticios (Eating Disorders Resources), Fuentes de informacin sobre los trastornos de mala conducta y agresividad (Behavior and Aggression Resources), Orden en el sueo de los nios (Sleep Hygiene), Recursos para el abuso de sustancias (Substance Use Resources) (Alaska), Recursos para el abuso de sustancias (Substance Use Resources) (Washington), Recursos para el abuso de sustancias (Substance Use Resources) (Wyoming), Recursos para la depresin (Depression Resources) (Alaska), Recursos para la depresin (Depression Resources) (Washington), Recursos para la depresin (Depression Resources) (Wyoming), Abnormal Involuntary Movement Scale (AIMS), Pediatric Symptoms Checklist -17, General Mental Health Screen (PSC-17), Screen for Child Anxiety Related Disorders (SCARED), Short Mood and Feelings Questionnaire (SMFQ), Subscribe to the Washington PAL newsletter, See the Washington PAL newsletter archives, Depression Assessment and Treatment in Pediatric Primary Care, Psychiatric Management of Child and Adolescent Anxiety. Pathway eligibility was based on pathway-specific inclusion and exclusion criteria, including diagnosis, age, and comorbid conditions based on International Classification of Disease Ninth Revision, Clinical Modification (ICD-9) codes. Gestational age < 40 weeks. DesaiAD, ZhouC, StanfordS, HaalandW, VarniJW, Mangione-SmithRM. A teenage boy arrives at Seattle Childrens Emergency Department (ED) with an increased heart rate. AmbroggioL, ThomsonJ, Murtagh KurowskiE, et al. A teenage boy arrives at Seattle Children's Emergency Department (ED) with an increased heart rate. Jaundice in 1st 24 hrs after birth. Cannabis Use in the Perinatal Period: What Do We Know? RobertsHC, PickeringRM, OnslowE, et al.. and transmitted securely. However, the difference between the pre- and postpathway period slopes was not statistically significant (P = .22; model R2 = 0.86). Patients with pathway eligible admissions were similar in both time periods (Table 2). Pathways are monitored after implementation, with periodic review and alterations as needed. The individual results for cost generally mirrored the overall results: 8 pathways had significantly increasing costs pre-pathway, of which 2 demonstrated a statistically significant decrease in slope between pre- and postpathway period, whereas 5 showed a decrease that approached significance (P = .05 to 0.1). Shortened IV antibiotic duration for infants 0-1 month of age with, Shortened IV antibiotic duration for bacteremic, Shortened total antibiotic duration for children 2 months of age and older, Criteria for obtaining a renal bladder ultrasound (RBUS), Criteria for obtaining a voiding cystourethrogram (VCUG). Its difficult to think about young kids wanting to hurt themselves, Rutman said. We truncated groups at 36 months pre- and postpathway implementation, creating a 36 months category given fewer observations at the tails. To compare all pathways we considered time on a relative scale, with the month and year of pathway implementation as the 0-point (t0) for each of the 15 included pathways. A system of clinical pathways, integrating the best available evidence using a rigorous process, holds promise for meeting the challenges facing our health care system today: to enhance the value of care by decreasing costs and resource utilization while maintaining or improving patient-centered outcomes. Seattle Children's complies with applicable federal and other civil rights laws and does not discriminate, exclude people or treat them differently based on race, color, religion (creed), sex, gender identity or expression, sexual orientation, national origin (ancestry), age, disability, or any other status protected by applicable federal, state or local law. Supporting documents and tools such as policies and procedures; patient and family educational materials; and order sets are developed or modified to match the pathway recommendations. The P value indicates whether the 2 slopes are statistically different from one another. Her parents have been taking her to therapy to help with her anxiety, and the therapist communicates his findings with them often. Seattle Childrens complies with applicable federal and other civil rights laws and does not discriminate, exclude people or treat them differently based on race, color, religion (creed), sex, gender identity or expression, sexual orientation, national origin (ancestry), age, disability, or any other status protected by applicable federal, state or local law. Interrupted time series analysis results for readmissions and physical functioning improvement scores, before and after implementation of pathways. For the best experience, tryChrome or [emailprotected] You can find these resources easily any time via mobile phone using our QR code; print and post our flyer (full-sheet or half-sheet) in a visible spot at your workplace. These crucial catches were made with help from a new clinical pathway known as Seattle ChildrensZero Suicide Initiative (ZSI), a universal screening method to help identify and treat youth at risk of suicide. HannaE, SchultzS, DoctorD, VuralE, SternS, SuenJ. During the prepathway period, hospital costs per admission were steadily rising at a rate of $126 per month (95% confidence interval [CI] $60 to $191; Fig 2A). > 0.2 mg/dL per hour thereafter. Impact of a guideline on management of children hospitalized with community-acquired pneumonia. This approach allows for detection of differences in both trends over time (ie, the slope) and intercepts. The CSW approach applied a standard process to develop and implement evidence-based clinical pathways, aiming to improve outcomes while reducing unnecessary . Hemolysis from any cause, or rapid rate of increase of TSB or TcB: > 0.3 mg/dL per hour in the 1st 24 hrs or. To determine whether changes in patient medical complexity or frequency of observation stays over time influenced our findings, we used segmented regression to evaluate changes in the proportion of study admissions per month with no chronic conditions (vs noncomplex chronic conditions) and, in a separate model, with an inpatient stay (vs an observation stay). When developing these pathways, committees of experts from different disciplines review the evidence to reach a consensus about treatments that result in the best outcomes for all patients. The pathway first went live in December 2011 and completed its last periodic review in April 2015. Pediatric medical complexity algorithm: a new method to stratify children by medical complexity. An inclusive and anti-racist framework guides the team to consider the impact of social determinants of health and reduce health disparities for the pathway patient population. WolffM, SchinasiDA, LavelleJ, BoorsteinN, ZorcJJ. For example, for the croup pathway, LOS, order-set usage, and percent of patients receiving dexamethasone are tracked quarterly. If were not addressing all aspects of our patients health, including their mental health, then were not truly caring for kids to the best of our ability.. RomeES, MoszczenskiSA, CraighillM, et al.. A clinical pathway for pelvic inflammatory disease for use on an inpatient service. Their behavioral health team helps break down common barriers that prevent patients from accessing behavioral health care, including social stigma, limited access and challenges navigating the healthcare system. Philadelphia, PA 19104, Clinical Pathway for Patient with Suspected Preseptal or Orbital Cellulitis. Before Seattle Childrens Care Network (SCCN) and Seattle Childrens Psychiatry and Behavioral Medicine launched a Pediatric Integrated Behavioral Health Program in 2020 to provide children and their families with the mental and behavioral health support they need earlier and closer to home. 866-987-8899 (toll-free), Seattle Childrens Hospital The PedsQL as a pediatric patient-reported outcome: reliability and validity of the PedsQL Measurement Model in 25,000 children. These results suggest an approach that could be implemented broadly. Implementation of a large-scale system for developing and applying standardized care pathways across several health conditions was associated with decreased LOS and costs of care, while maintaining levels of improvement in patient postdischarge physical functioning. This was a retrospective cohort study examining admissions eligible for 1 of 15 general pediatric pathways between December 1, 2009, and March 30, 2014. In addition, we found a simultaneous increase in inpatient versus observation hospitalizations, which would be expected to exert the opposite effect on our outcomes (ie, increased LOS and higher costs). A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z, Ductal dependent systemic blood flow (pre-operative), Hem/Onc BMT suspected infection fever in community ED, IBD Acute severe ulcerative colitis medical management, Substance Use Screening and Management (SUSM).