In addition to MOC credits, you may be eligible to receive AMA PRA Category 1 Credit™ from Connecticut Children's Medical Center’s Office of Continuing Medical Education. Click here to learn more.

Overview

The current referral environment in pediatrics is characterized by greater numbers of children seeking subspecialty care, inadequate numbers of subspecialists providing care, and poorly structured communication between referring providers and subspecialists. Together, these factors create significant access issues nationwide among pediatric medical and surgical subspecialty areas. These causes are largely systemic and difficult to influence to a significant degree through hospital or community-based interventions. In contrast, the Referral Process between the primary care provider (PCP) and subspecialist, historically burdened by inefficiencies, ambiguity, and inadequate levels of collaboration, may be more amenable to change. Both PCPs and specialists express dissatisfaction with the current referral process in which a high unexplained variation in referral rates has been observed leading to inappropriate or ineffective use of scarce clinical resources. In response to this, our Co- Management Program (CLASP) has implemented Referral Guidelines (RGs) based on current best practices and expert consensus as a strategy to standardize PCP referral practice behavior. Each RG, developed collaboratively with PCP input, provides background information on a specific condition, as well as clear and actionable recommendations to the PCP for the initial evaluation, management, and when and how to refer pediatric patients with that condition. To date, 31 RGs have been developed among 15 subspecialty areas. This project aims to (1) increase usage of existing RGs, (2) increase adherence to RG recommendations, (3a) improve timely access to care within Primary Care, (3b) improve capacity of subspecialists by decreasing unnecessary referrals, and (4) increase actionable PCP feedback for CLASP tool improvement to the CLASP Team. 

Eligibility

Pediatricians in the state of Connecticut (will be open to additional states in the future)

Length

12 months

Project Director

Karen Rubin, MD

Supporting Documents

Project Checklist

Data Entry Tip Sheet

Practice-level Data Template

In addition to MOC credits, you may be eligible to receive AMA PRA Category 1 Credit™ from Connecticut Children's Medical Center’s Office of Continuing Medical Education. Click here to learn more.

Overview

Asthma is the most common chronic illness in children and is a leading cause of childhood hospitalizations in the United States. The inpatient burden for asthma includes approximately 190,000 hospital admissions per year, $2 billion in direct medical expenditures per year, and a readmission rate of 10% to 30%. During an inpatient stay, medical providers' attention is typically focused on treatment of the acute exacerbation. Yet a hospitalization offers an opportunity to impact outpatient outcomes as well. The challenge is to use a short hospital stay to put processes into place that are likely to have a lasting impact on asthma control after discharge.

The aim of the QI MOC project is to train and support pediatric hospitalists on the Inpatient Management Team at The Connecticut Children's Medical Center in the implementation of an inpatient asthma clinical pathway with focused quality measures to improve inpatient care of asthma, as well as future asthma control. These 4 key quality measures, or "Pathway Measures", include: pathway usage; completion of the Asthma Home Treatment Plan at discharge; initiation or continuation of inhaled corticosteroids; and faxing of the treatment plan to the primary care provider (PCP) at discharge. Since October 2010, the Connecticut Children's IMT has tracked these novel pathway measures in addition to length of stay (LOS), readmits to the hospital within 7 and 30 days and the CAC measure set. The pathway measures are tracked on all eligible patients on a monthly basis with a goal of achieving at least 80% compliance on all four quality measures. All physicians participating in this QI project receive training involving a presentation on this topic, including a thorough discussion of QI principles and how to apply the Plan-Do-Study-Act cycle in practice. Physicians will initially engage in an orientation training to learn about the pathway and the pathway measures. Participating physicians enroll all eligible patients in the pathway and appropriately document individual pathway measures. Individual and practice-level data are reviewed by all physicians on a monthly basis and strategies for improving low pathway measures are discussed at collaborative team meetings led by the Project Leader.

Eligibility

Pediatric hospitalists on the Inpatient Management Team at Connecticut Children's Medical Center

Length

At least 12 months

Project Director

Anand Sekaran, MD

Supporting Documents

Project Checklist

In addition to MOC credits, you may be eligible to receive AMA PRA Category 1 Credit™ from Connecticut Children's Medical Center’s Office of Continuing Medical Education. Click here to learn more.

Overview

Chemotherapy-induced nausea and vomiting (CINV) is one of the most distressing symptoms experienced by oncology patients. There are excellent evidence-based guidelines regarding use of antiemetics during chemotherapy which have been supported by the Connecticut Children’s Oncology Group. The Project Director assessed the antiemetic control of our patients receiving chemotherapy to establish a baseline level. Based on the Pediatric Oncology Group of Ontario (POGO)’s evidence based guidelines, the Project Director developed CINV Supportive Care Guidelines for our division. The Project Director is now assessing CINV control after dissemination of the guidelines.

Eligibility

Physicians caring for oncology patients receiving chemotherapy

Length

6 months

Project Director

Andrea Orsey, MD

Supporting Documents

Project Checklist

In addition to MOC credits, you may be eligible to receive AMA PRA Category 1 Credit™ from Connecticut Children's Medical Center’s Office of Continuing Medical Education. Click here to learn more.

Overview

Research consistently shows an increase in the number of children prescribed various classes and combinations of psychotropic medications for anxiety and depression. Supporting the increasing role of child health providers in addressing mental health issues is critical to meeting the needs of children. This responsibility is articulated in recent publications from the AAP, with the expectation that the role of pediatricians will expand to encompass additional competencies in a range of areas including collaboration with mental health providers. Still, few PCPs have advanced training in behavioral pediatrics and in other areas of mental health. Co-management between pediatric primary care and behavioral health services is one promising strategy for addressing the needs of a growing population of children who experience disorders such as anxiety and depression, some of whom may utilize psychotropic medications. Research on models of integrated and collaborative primary and behavioral health care suggest that this approach results in improved outcomes for patients and providers such as reduced waiting times for behavioral health services, increased screening and identification of children with possible mental health disorders, and increased options for consultation.

This project aims to improve the capacity of pediatric PCPs to effectively (1) identify, assess, treat, and manage child and adolescent anxiety disorders and depression (ages 6-18) , and (2) co-manage psychotropic medication treatment in collaboration with behavioral health care. Project aims are achieved through a training provided by physicians from ACCESS Mental Health CT.

Eligibility

Physicians in pediatric primary care settings in CT

Length

12 – 18 months

Project Director

Lisa Honigfeld, PhD

Supporting Documents

Project Checklist

Chart Audit Tip Sheet

For additional information, please click here.

In addition to MOC credits, you may be eligible to receive AMA PRA Category 1 Credit™ from Connecticut Children's Medical Center’s Office of Continuing Medical Education. Click here to learn more.

Overview

Access to subspecialty care in the field of pediatrics is becoming increasingly difficult. Given the expectation of continued shortages in subspecialty care for children, pediatric primary care providers (PCPs) must become more involved and better trained in the management of children with some relatively low-acuity, high-volume conditions previously managed exclusively by the subspecialist. To enable an expanded scope of the patient-centered medical home, primary care providers and subspecialists should collaborate to develop and use structured, evidence-based communication and care coordination tools. We refer to the model of structured, collaborative care by PCPs and pediatric subspecialists as Co-Management. Co-Managed care minimizes the number of unnecessary referrals to subspecialists by allowing PCPs to obtain the expertise and support necessary to successfully manage these conditions. Increased utilization of co-managed care could improve the quality of care delivered while improving patients' access to care and potentially reducing costs. The Co-Management plan for concussion, which incorporates tools from the CDC “Heads Up” initiative, guides the PCP in early diagnosis, management, patient/family education strategies, and when to refer to the departments of sports medicine or neurology. In addition to the Co-Management Tool-Kit, PCP training materials include a web-streamed continuing medical education (CME) presentation on the evaluation and management of the condition, an explanation of how to use the Co-Management Tool-Kit, and case studies of patient care delivered using the Co-Management plan.

Participating pediatric primary care providers obtain the core competencies necessary to participate in Co-Management by completing CME training on the Co-Management of Pediatric Concussion and a general CME orientation on the Co-Management model. Participants identify, assess, treat, and manage pediatric concussion using the Co-Management Tool-Kit and use patient outcome data from quarterly progress reports to guide practice improvements in the delivery of co-managed care.

Eligibility

Pediatricians in the state of CT

Length

12 months

Project Director

Karen Rubin, MD

Supporting Documents

Project Checklist

For additional information, please click here.

In addition to MOC credits, you may be eligible to receive AMA PRA Category 1 Credit™ from Connecticut Children's Medical Center’s Office of Continuing Medical Education. Click here to learn more.

Overview

Access to subspecialty care in the field of pediatrics is becoming increasingly difficult. Given the expectation of continued shortages in subspecialty care for children, pediatric primary care providers (PCPs) must become more involved and better trained in the management of children with some relatively low-acuity, high-volume conditions previously managed exclusively by the subspecialist. To enable an expanded scope of the patient-centered medical home, primary care providers and subspecialists should collaborate to develop and use structured, evidence-based communication and care coordination tools. We refer to the model of structured, collaborative care by PCPs and pediatric subspecialists as Co-Management. Co-Managed care minimizes the number of unnecessary referrals to subspecialists by allowing PCPs to obtain the expertise and support necessary to successfully manage these conditions. Increased utilization of co-managed care could improve the quality of care delivered while improving patients' access to care and potentially reducing costs. The Co-Management Plan for Pediatric Migraine guides the PCP in diagnosis, management, patient/family education strategies, and when to refer to the Division of Neurology. In addition to the Co-Management Plan, PCP training materials include a web-streamed continuing medical education (CME) presentation on the evaluation and management of the condition, an explanation of how to use the Co-Management Plan, and case studies of patient care delivered using the Co-Management Plan.

Participating pediatric primary care providers obtain the core competencies necessary to participate in Co-Management by completing CME training on the Co-Management of Pediatric Migraine and a general CME orientation on the Co-Management model. Participants identify, assess, treat, and manage pediatric migraine using the Co-Management Tool-Kit and use patient outcome data from quarterly progress reports to guide practice improvements in the delivery of co-managed care.

Eligibility

Pediatricians in the state of CT

Length

12 months

Project Director

Karen Rubin, MD

Supporting Documents

Project Checklist

Data Entry Form Tip Sheet

For additional information, please click here.

In addition to MOC credits, you may be eligible to receive AMA PRA Category 1 Credit™ from Connecticut Children's Medical Center’s Office of Continuing Medical Education. Click here to learn more.

Overview

The American Academy of Pediatrics, the World Health Organization and the United Nations Children’s Fund recommend that human milk be the exclusive form of nutrition for all infants, including preterm infants.  Healthy People 2020, set five indicators and goals to profile the extent to which infants are: 1) ever breastfed (goal 82%), 2) breastfeeding at 6 months (goal 60.6%), 3)breastfeeding at 12 months (goal 34%), 4) exclusively breastfeeding through 3 months (goal 46.2%) and 5) exclusively breastfeeding through 6 months (goal 25.5%).  The national rates fall far short of these goals.  As of 2011, 79% of newborns started to breastfeed, yet only 49% were breastfeeding at 6 months and 27% at 12 months.  Nationally, exclusive breastfeeding rates were 40.7% at 3 months and 18.8% at 6 months.  In Connecticut, breastfeeding rates approximate the national average, also falling short of Healthy People 2020 goals, with 83.3% of infants ever breastfed, 51.4% breastfeeding at 6 months, 27.5% breastfeeding at 12 months, 37% exclusive breastfeeding at 3 months and 19.2% exclusivity at 6 months.

The goal of the CPQC is to encourage breastfeeding and improve receipt of mother’s milk across the state, with interventions starting antenatally and continuing throughout the birth hospitalization.  This problem was chosen in recognition of the importance of mother’s milk as the nutritional source for all infants. The purpose of this statewide project is to identify barriers to breastfeeding and create interventions to improve our breastfeeding rates.

The goals for the HI-MOM project are (1) to increase the percentage of healthy newborns receiving exclusive breastmilk feeding during the entire birth hospitalization and (2) to increase the use of exclusive mother’s own milk for infants in the Neonatal Intensive Care unit, prior to discharge.

Eligibility

Pediatricians participating in the Connecticut Perinatal Quality Collaborative

Length

12 months

Project Director

Jennifer Trzaski, MD

For additional information, please click here

Supporting Documents

Project Checklist

In addition to MOC credits, you may be eligible to receive AMA PRA Category 1 Credit™ from Connecticut Children's Medical Center’s Office of Continuing Medical Education. Click here to learn more.

Overview

Reports show that only 20% to 30% of children with developmental delays are identified before entering school. Despite this late age of diagnosis, experts agree that the tools exist to identify children at younger ages when interventions can be most effective. The primary care pediatric practice setting is an optimal venue for identifying children with and at risk for developmental delays at the youngest possible age and connecting them to evaluation and intervention services. The current recommendations from the American Academy of Pediatrics (AAP) call for developmental surveillance at all of the 14 recommended well-child visits for children birth through age five. The AAP also recommends developmental screening with a standardized tool at the 9, 18 and 30 (or 24) month visits.

The Help Me Grow MOC project aims to improve the rates of 1) developmental surveillance, so that after six months of project participation at least 80% of medical charts have notations that parental concerns were solicited during the well child exam; 2) developmental screening to include at least 75% of well child exams after six months of project participation and 3) connection of 100% of young children for whom surveillance and/or screening show concerns to intervention services by the end of six months of participation. Practices will complete chart audits to assess their implementation of surveillance, screening, and connection to services at 9, 12, and 18 month old well child visits. Prior to beginning the project, practices will receive an EPIC (Educating Practices in the Community) training on surveillance, screening, and using HMG to connect children to needed services.

Eligibility

Pediatricians at select Help Me Grow sites throughout the U.S.

Length

6 months

Project Director

Lisa Honigfeld, PhD

Supporting Documents

Project Checklists: Connecticut; Kentucky; Washington; California: Alameda County; Orange County; Ventura County

Chart Audit Tip Sheet

For additional information, please click here.

In addition to MOC credits, you may be eligible to receive AMA PRA Category 1 Credit™ from Connecticut Children's Medical Center’s Office of Continuing Medical Education. Click here to learn more.

Overview

Sepsis is a systemic inflammatory response due to an infection.  Attention to early recognition, aggressive fluid management, and early administration of vasoactive agents and antibiotic treatment has improved outcomes in pediatric patients.  Connecticut Children’s Medical Center has instituted a clinical pathway that establishes clinical features for initial recognition of septic shock, an initial management algorithm and a pathway for ICU management.  This QI/MOC project monitors adherence to this pathway.

Eligibility

Emergency Medicine physicians at Connecticut Children’s Medical Center  

Length

6 months

Project Directors

Matt Laurich, MD

John Peng, MD

Supporting Documents

Project Checklist

In addition to MOC credits, you may be eligible to receive AMA PRA Category 1 Credit™ from Connecticut Children's Medical Center’s Office of Continuing Medical Education. Click here to learn more.

Overview

Asthma is the most common chronic disease of children and the leading cause of school absenteeism. In 2010, 9.4% of children in the United States had asthma and an additional 3-14% of children may have undiagnosed asthma. In 2008, asthma caused 10.5 million missed school days. Nearly 1 in 5 children with asthma went to an emergency department for asthma-related care in 2009. Nearly 1 in 2 children miss at least 1 day of school each year because of their asthma. Thus, asthma is a major cause of morbidity in the U.S.

The Easy Breathing MOC project provides pediatricians with a set of tools developed for use in the pediatrician’s office that facilitate asthma diagnosis, guide therapy decisions, and trains office personnel in its implementation. Feedback on program utilization and quality of care delivered by the pediatrician is provided by the program with additional input by the practice. The tools provided by the program include:

• An Easy Breathing Survey to improve recognition of asthma including previously undiagnosed asthma
• A Provider Assessment which provides a standardized and systematic determination of asthma severity
• An Asthma Treatment Selection Guide which provides clinicians with a menu of drug therapies based upon asthma severity and age
• Written Asthma Treatment Plans to empower parents and children to understand their therapy and to create a management partnership
• An asthma control tool to assess adequacy of control at follow up visits.

Eligibility

Pediatricians in the state of CT and throughout the U.S. who participate in the Easy Breathing© Program

Length

12 months

Project Director

Michelle Cloutier, MD

For additional information, please click here.

In addition to MOC credits, you may be eligible to receive AMA PRA Category 1 Credit™ from Connecticut Children's Medical Center’s Office of Continuing Medical Education. Click here to learn more.

Overview

A busy pediatric endocrinology provider reviews approximately 10-15 patient lab results daily, reviewing them and making clinical decisions, then communicating with the families to discuss treatment and management decisions. The time commitment to complete these tasks is significant. Patients often need to wait for the provider to have the time to review the labs and communicate with them. This leads to delay in patient care and reduction in patient satisfaction. Hypothyroidism is a common disorder and makes up about 20% of our practice. The patients commonly have only 1 condition they are managed for and often are seen once or twice per year for medication adjustments. The nurse has been trained in understanding the lab results and has been communicating with families regarding those results. With the use of our electronic health record, it has been very efficient to communicate between providers to implement medical decisions and communicate with families. To help reduce time to contacting families with hypothyroidism and allow the provider in turn time to attend to other results that will require more specialized assessment, we propose to implement a thyroid lab test algorithm that the nurse will implement with limited supervision from the physician.

Our practice, by implementing a thyroid lab test algorithm developed for use by our endocrine RN, plans to reduce time to communication to families of patients with hypothyroidism as the single diagnosis and on levothyroxine replacement medication.

Eligibility

Endocrinologists at Connecticut Children’s Medical Center

Length

6 months

Project Director

Paola Palma Sisto, MD

Supporting Documents

Project Checklist

In addition to MOC credits, you may be eligible to receive AMA PRA Category 1 Credit™ from Connecticut Children's Medical Center’s Office of Continuing Medical Education. Click here to learn more.

Overview

The average age of identification of Autism Spectrum Disorders in children has been shown to vary from 3.1 years to 5.7 years, even though tools exist to identify children at younger ages, when interventions can be most effective. The primary care pediatric practice setting, or medical home, is an optimal venue for identifying children with and at risk for developmental delays at the youngest possible age. The pediatric medical home provides services to the vast majority of children and can take advantage of frequent and longitudinal relationships with families to monitor development over time and in the context of the family environment. The AAP recommends administration of the Checklist for Autism in Children (CHAT) or Modified Checklist for Autism in Children (M-CHAT) at 18 and 24 month visits.

The ASD MOC project aims to improve the rate of screening for ASD and follow-up care. A trained pediatric primary care provider will visit pediatric practices and present the ASD EPIC (Educating Practices in the Community) module. Following the presentation, practices can participate in a self-completed chart audit of well child visits for 18 and 24 month old children.

Eligibility

Physicians in pediatric primary care settings in CT

Length

6 months

Project Director

Lisa Honigfeld, PhD

Supporting Documents

Project Checklist

Chart Audit Tip Sheet

In addition to MOC credits, you may be eligible to receive AMA PRA Category 1 Credit™ from Connecticut Children's Medical Center’s Office of Continuing Medical Education. Click here to learn more.

Overview

When mothers are depressed or suffer from other serious mental health conditions they may experience difficulties nurturing their babies to ensure lifelong health, and psychosocial and cognitive development. Ten to twenty percent of the nearly four million women giving birth each year in the United States experience mental health challenges that affect their ability to nurture children. Research shows that fewer than half of all affected mothers are diagnosed and only 15% seek professional mental health services following diagnosis. Identification of depression by physicians can be increased by approximately 30% through the routine use of standardized screening tools. In addition to identifying mothers who may benefit from intervention, formal mental health screening reminds providers and parents to focus on the family, not just the child, and to discuss parental well-being during the early well-child appointments.  Once screening occurs it is important for pediatricians to connect mothers directly to behavioral health resources. Further, the AAP Bright Futures Guidelines for Health Supervision of Infants, Children and Adolescents highlights the importance of attending to parental concerns, specifically about mother well-being and infant development and behavior.

This project aims to 1) engage providers in implementing and improving screening for postpartum depression, 2) ensure that providers document referral to community services/resources, 3) encourage pediatricians to maintain a child and family mental health history, and 4) increase providers’ routine solicitation of parental concerns about development and behavior during the first six months of well-child exams. This project uses two modules from an academic detailing program, Educating Practices in the Community (EPIC). The Maternal Depression module focuses on implementing maternal depression screening procedures. The Infant Mental Health module focuses on the importance of maintaining child and family mental health history, as well as surveillance and monitoring questions that pediatricians can use in well-child visits to help identify families and children at-risk for behavioral, developmental and mental health issues.

Eligibility

Physicians in pediatric primary care settings in CT

Length

6 months

Project Director

Lisa Honigfeld, PhD

Please Note

The Connecticut Children’s MOC Program charges a fee of $50 per physician for participation in an  MOC project. The Child Health and Development Institute will cover the registration fee for the first 20 participants.

For additional information, please click here.

Supporting Documents

Project Checklist

Chart Audit Tip Sheet

Family Mental Health History Form

Overview

The 2001, the Institute of Medicine report, Crossing the Quality Chasm: A New Health System for the 21st Century, emphasized the need to ensure the involvement of patients and families in their own health care decisions, to better inform patients of treatment options, and to improve patients’ and families’ access to information. The American Academy of Pediatrics (AAP) recommended that in the inpatient setting, complete case discussion and presentation should occur in the presence of patients and family to involve them in the decision making. As a result, FCRs have gained substantial momentum, and bedside rounds have returned to the inpatient setting, this time with focus on family-centered care. In a recent Pediatric Research in the Inpatient Network (PRIS) survey, over half the pediatric hospitalists reported conducting FCRs, and academic centers were more likely to conduct them. (Mittal, Family Centered Rounds Review, Pediatr Clin N Am 61 (2014) 663–670)

In a study of patient care rounds in the ICU, “rounds conducted using a standardized structure and a best practices checklist by a multidisciplinary group of providers, with explicitly defined roles and a goal-oriented approach, had the strongest supporting evidence.” (Lane. A Systematic Review of Evidence-Informed Practices for Patient Care Rounds in the ICU. Crit Care Med 2013; 41:2015–2029)

This project aims for 1) rounding to engage the patients and families in creating the plan for the day, 2) rounding to be productive, safe, and effective, driving patient flow in moving care forward, 3) each participant to work to the best of their license, capabilities and availability, 4) each clinical leader to facilitate process, teaching, evaluation, prompting, and read-backs as appropriate.

Eligibility

Participants must be 3rd year pediatric residents and attending physicians in the following departments: IMT hospitalists, hematology-oncology, gastroenterology, nephrology, cardiology, pulmonology, neurology.

Length

6 months and 4 weeks on inpatient clinical service

Project Director

Christine Skurkis, MD

Supporting Documents

Project Checklist

In addition to MOC credits, you may be eligible to receive AMA PRA Category 1 Credit™ from Connecticut Children's Medical Center’s Office of Continuing Medical Education. Click here to learn more.

Overview

Physical abuse of infants is a prevalent and serious problem. Unfortunately, the diagnosis of physical abuse in infancy is difficult, with history often absent and early presentations with medically minor injuries whose significance may escape examiners. There is a growing body of literature demonstrating that in infants diagnosed with serious physical abuse injuries such as fractures and head trauma, approximately 30% of them have had prior injury episodes (Jenny, Sheets, Berger). This has led to the concept of “sentinel injuries” in infancy and the idea that early diagnosis of physical abuse at the time of sentinel injury presentation may prevent more serious injuries. Investigators have also recently shown that when infants under 6 months with bruises undergo thorough evaluation for physical abuse, 50% of them have additional injuries identified (Harper).

To date, published screening efforts in Emergency Departments have focused on use of checklists at triage or recognition of red flags by evaluating MDs to trigger abuse evaluation. There is an urgent need to improve the standardization of screening efforts to identify physically abused infants. The electronic medical record presents an opportunity incorporate screening into routine care. SCAN and Pediatric ED MDs at Connecticut Children’s Medical Center plan to work together to develop and test a screening approach using EPIC that will start with a focus on injuries to infants

Eligibility

Physicians at Connecticut Children’s Medical Center

Length

6 months

Project Director

Nina Livingston, MD

Supporting Documents

Project Checklist

In addition to MOC credits, you may be eligible to receive AMA PRA Category 1 Credit™ from Connecticut Children's Medical Center’s Office of Continuing Medical Education. Click here to learn more.

Overview

Physical abuse is a prevalent pediatric condition presenting to all areas of Connecticut Children’s Medical Center. Most recent yearly national Child Protective Services data show 679,000 maltreatment substantiations, with 7,287 unique victims in CT. This means that 1 in 100 children in CT have substantiation of maltreatment each year, and 6.5% of these are physical abuse substantiations. Multiple data sources show that there is significant under-reporting by mandated reporters, that only 33% of reports are investigated by CPS, and only 17 percent of those substantiated, so we know that true rates of physical abuse are much higher. Unexplained or poorly explained injuries are a frequent presenting complaint in our Emergency department.

Child Abuse Pediatrics is a young field, and most current practicing pediatric providers have received little training regarding identification and management of suspected physical abuse. This leads to significant variation in practice. Studies show that even the long-recommended intervention of obtaining a skeletal survey for children under 2 is variably completed on a national scale. There are also multiple studies demonstrating that provider biases regarding race, SES, or marital status of parents leads to variation in practice during suspected abuse evaluation. Given that there is now an evidence base to guide  best practice regarding evaluation of suspected physical abuse, colleagues in multiple specialties at CT Children’s (Child Abuse, ED, Trauma surgery, and Inpatient Management Team) have worked together over the past year to create an evidence based clinical pathway to guide clinical management in cases of suspected physical abuse. The pathway is intended to promote safe, effective, and consistent patient care and to reduce variation in practice. This project describes plans for a QI project regarding its implementation. The project aims to (1) Increase utilization of suspected physical abuse pathway for patients undergoing suspected physical abuse evaluation at Connecticut Children’s and (2) achieve completion of three process measures within the pathway (SCAN consult, Trauma Surgery consult for those admitted, and completion of skeletal survey for patients

Eligibility

Physicians at Connecticut Children’s Medical Center

Length

6 months

Project Director

Nina Livingston, MD

Supporting Documents

Project Checklist

In addition to MOC credits, you may be eligible to receive AMA PRA Category 1 Credit™ from Connecticut Children's Medical Center’s Office of Continuing Medical Education. Click here to learn more.

Overview

Antimicrobial usage is an international problem, with a large proportion of antimicrobials (up to 50% in some surveys) being used inappropriately. Inappropriate use may include: using antimicrobials to treat viral infections; using broad-spectrum antimicrobials when narrow-spectrum antimicrobials will suffice; not narrowing or expanding coverage in response to culture results; prolonged duration of therapy. Inappropriate antimicrobial use is associated with prolonged hospitalizations, increased antimicrobial resistance in bacteria, increased side effects in patients and increased rates of antimicrobial-associated Clostridium difficile infections - all of which increase healthcare costs and utilization. There are national data available on the rates and patterns of antimicrobials in children’s hospitals across the USA. Wide variation exists in terms of usage rates.

The goal of the project is to reduce inappropriate antimicrobial usage across the hospital. Specifically, we aim to decrease overall antimicrobial usage by 20% over a year. The target may be different at the individual division level but each sub-project should demonstrate a significant reduction one or more of: percent of children receiving antimicrobials; number of antimicrobials administered simultaneously; proportion of antimicrobials being broad versus narrow-spectrum; length of therapy.

Eligibility

Physicians at Connecticut Children's Medical Center (will be available to physicians outside of Connecticut Children’s starting Summer 2015)

Length

6-9 months

Project Director

Nicholas Bennett, MBBChir, PhD

Supporting Documents

Project Checklist

In addition to MOC credits, you may be eligible to receive AMA PRA Category 1 Credit™ from Connecticut Children's Medical Center’s Office of Continuing Medical Education. Click here to learn more.

Overview

Delay in provider engagement with the patient is a source of patient dissatisfaction and drives the wait time up for the whole stay.  Early interaction can help to ensure that emergent conditions are recognized and decrease waste for the patient in terms of wait.  For patients arriving to be seen in the Emergency Department at Connecticut Children’s Medical Center, this QI project aims to reduce the mean time from arrival to being seen by a medical provider (resident physician, midlevel provider, pediatrician or Pediatric Emergency Medicine attending) to less than or equal to 30 minutes within 6 months.

Eligibility

Medical providers working in the Emergency Department at Connecticut Children’s Medical Center

Length

6 months  

Project Director

John Peng, MD

Supporting Documents

Project Checklist

In addition to MOC credits, you may be eligible to receive AMA PRA Category 1 Credit™ from Connecticut Children's Medical Center’s Office of Continuing Medical Education. Click here to learn more.

Overview

Access to lactation support can directly influence a mother’s ability to continue to breastfeed effectively when complications arise. Neonatal jaundice is a common complication during the neonatal period, especially in breastfed neonates. Support to continue breastfeeding during the treatment of neonatal jaundice is often varied from provider to provider.

The project is based on a clinical pathway for management of hyperbilirubinemia in the neonate implemented in the Inpatient Unit. The purpose of the pathway is to guide appropriate management for neonates with hyperbilirubinemia, who require phototherapy, re-establish and preserve human milk supply for breastfeeding mothers, promote and support successful breastfeeding, and provide lactation support and education to every breastfeeding mother on admission (for all breastfed neonates admitted for hyperbilirubinemia). The pathway implements standardized care for neonates with hyperbilirubinemia guided by American Academy of Pediatrics and Academy of Breastfeeding Medicine guidelines. Key elements of the pathway include: total serum bilirubin (TSB) monitoring, rebound TSB testing, discontinuation of phototherapy, and enteral supplementation.

Eligibility

Pediatric hospitalists on the Inpatient Management Team at Connecticut Children's Medical Center

Length

12 months

Project Director

Ilana Waynik, MD

In addition to MOC credits, you may be eligible to receive AMA PRA Category 1 Credit™ from Connecticut Children's Medical Center’s Office of Continuing Medical Education. Click here to learn more.

Overview

High levels of lead exposure (blood lead level (BLL) ≥ 5 µg/dL) can lead to a number of adverse human health effects but are particularly detrimental to the neurological development of children under the age of six. While elevated BLLs among children have declined over the past few decades, disparities persist .  Greater proportions of black non-Hispanic or low-income children, as well as those living in homes constructed before 1960, have elevated BLLs. Second-hand smoke exposure is also associated with elevated BLLs in youth and adults, greater than BLLs found in persons who smoke.

The American Academy of Pediatrics recommends universal blood lead screening for children 9 to 72 months of age except in communities with sufficient data to conclude that children will not be at risk of exposure. The Connecticut Department of Public Health requires lead screening for all children:

• between 9 to 36 months of age, and each year for elevated BLLs
• between 25 to 72 months of age, if not previously tested and regardless of risk of lead poisoning;
• greater than 72 months of age for children with developmental delays (especially if associated with pica).

Despite those requirements, lead poisoning remains a common, preventable, pediatric health problem in Connecticut. CHDI has the infrastructure to help pediatric primary care professionals improve lead screening in their practice.

The specific aim of this QI project is to improve the capacity of pediatric primary care practices to conduct universal blood lead screening by the 15 month well-child visit to 80% over 18 months. The project also aims to improve the capacity of pediatric primary care providers to evaluate and manage elevated blood levels through follow-up diagnostic blood level testing and lead education via anticipatory guidance for families.

Eligibility

Physicians in pediatric primary care settings in CT

Length

12-18 months

Project Director

Lisa Honigfeld, PhD

Supporting Documents

Project Checklist

Chart Audit Tip Sheet

In addition to MOC credits, you may be eligible to receive AMA PRA Category 1 Credit™ from Connecticut Children's Medical Center’s Office of Continuing Medical Education. Click here to learn more.

Overview

The ambulatory clinic team is comprised of attendings, nurses, staff members and other stakeholders. Additionally, resident physicians routinely rotate through the subspecialty ambulatory clinics in 4 week blocks throughout the year, as well as more frequently in the primary care clinics. These resident physicians are a valuable part of the workforce with the ability to help develop and execute quality improvement interventions, given their direct participation in patient care and ability to observe inefficiencies and opportunities for improvement. They can also have a direct impact on the implementation of change.

In addition to the benefits residents can provide to the improvement needs of the various ambulatory clinics, it is also critical to the mission and requirements of an academic teaching hospital to train the next generation of physicians in the importance and methodology of quality improvement projects.

These issues can both be addressed through the implementation of a longitudinal ambulatory clinic-based quality improvement project curriculum with a focus on resident engagement, mentored by content expert attending physicians within the ambulatory clinics and the Quality and Patient Safety Department. While residents are readily available and able to learn about and engage in quality improvement efforts during their rotations, these 4 week blocks are not sufficient to conduct a full quality improvement project. The residents will accordingly be handing off the project to the incoming residents at the end of each block. Thus, the attending physician leaders within each clinic and the content experts will be responsible for the education and mentorship of the residents involved related to quality improvement activities, as well as the long-term management and organization of the project, ongoing data review and analysis, and implementation of appropriate interventions.

Eligibility

Participation is limited to attending physicians who are acting as the ambulatory clinic attending leader/mentor for the project.

Length

12 months

Project Director

Heather Tory, MD

Supporting Documents

Project Checklist

In addition to MOC credits, you may be eligible to receive AMA PRA Category 1 Credit™ from Connecticut Children's Medical Center’s Office of Continuing Medical Education. Click here to learn more.

Overview

The rheumatic diseases comprise a group of systemic inflammatory disorders resulting from disordered activation of the immune system. Untreated, these disorders can lead to significant morbidity and mortality, but appropriate treatment with immunosuppressive agents can mitigate these risks. Many rheumatic diseases have an increased prevalence in females, and are common in the post-pubertal period. Thus, women of childbearing age constitute a large percentage of these patients. Many of the medications that are frequently used for treatment of these conditions are classified as FDA pregnancy category D (evidence of human fetal risk of medication, but benefits may outweigh risks in some patients) or X (evidence of human fetal risk or anomalies, and risks involved clearly outweigh any potential benefits).

The teratogenic risks of these medications are of particular importance in pediatric rheumatology, as the teenage pregnancy rate in the United States is higher than many other developed countries (in 2014, there were 24.2 births for every 1,000 adolescent females aged 15-19), and 77% of these pregnancies are unplanned. Accordingly, appropriate education, prevention strategies, and longitudinal follow-up is critical for preventing any adverse results of pregnancy in this population; however, there is currently no standard model for implementing effective education in pediatric rheumatology clinics. Furthermore, routine pregnancy screening is suggested as a best practice by the FDA for patients on high-risk medications. Accordingly, we aim to assess and improve our performance and documentation of education for female adolescent patients on teratogenic medications (at initiation and follow-up), and institute routine urine hCG testing on female patients of childbearing age.

Eligibility

Physicians in ambulatory subspecialty practices routinely prescribing medications with teratogenic potential

Length

6 months

Project Director

Heather Tory, MD

Supporting Documents

Project Checklist

In addition to MOC credits, you may be eligible to receive AMA PRA Category 1 Credit™ from Connecticut Children's Medical Center’s Office of Continuing Medical Education. Click here to learn more.

Overview

Of approximately 40,000 live births in Connecticut each year, an estimated 70 babies are born with, or quickly acquire, hearing loss. In 2007, the AAP put forth several guidelines for identification, intervention, monitoring and service needs for infants who have hearing loss. The AAP recommends screening of all babies by one month of age. This is accomplished at birth prior to hospital discharge for 99% of babies born in the state. Universal hearing is one of the few pediatric screenings that is endorsed by the United States Preventive Services task force, largely because early hearing intervention is so effective. AAP guidelines also recommend a three month time frame for follow up diagnostic testing for babies who do not pass newborn hearing screening. In 2009, approximately 80% of babies who did not pass newborn hearing screening in Connecticut received follow up diagnostic testing by three months of age. Babies who fail follow up diagnostic testing and have significant hearing loss should be enrolled in early intervention by six months of age, per AAP guidelines.

This project aims to train and support Connecticut primary care pediatricians (PCPs) in the implementation of AAP Early Hearing Detection and Intervention (EHDI) guidelines to ensure that infants in their patient panel with hearing loss are (1) Enrolled in early intervention, and (2) Connected to Otolaryngology (ENT), Genetics, Ophthalmology and family support services. The project also is designed to improve Connecticut's rate of enrollment in early intervention by 6 months of age for infants diagnosed with hearing loss. The Connecticut EHDI Coach, Brenda Balch, M.D., receives information about all infants diagnosed with hearing loss from the Department of Public Health, which is responsible for the state's EHDI program. Dr. Balch will contact the PCP listed for each infant, offer coaching services, and invite the PCP to participate in this project. If the PCP chooses to participate in this activity, Dr. Balch will discuss the case with the PCP, fax or email a data sheet of recommended services, offer assistance in helping the practice locate services, and provide ongoing follow-up via phone, fax or email. The PCP will receive a dashboard for each infant, which will serve as an ongoing progress record of service provision. Participating pediatricians also will 1) review quarterly aggregate statewide data on enrollment of infants with hearing loss into early intervention services and 2) contribute to quarterly conference calls to make recommendations for improvement in the state's rate of enrollment to 90% of infants enrolled in early intervention by 6 months of age.

Eligibility

Restricted to pediatricians in the state of CT who care for an infant diagnosed with hearing loss

Length

At least 12 months

Project Director

Brenda Balch, MD

Supporting Documents

Project Checklist

In addition to MOC credits, you may be eligible to receive AMA PRA Category 1 Credit™ from Connecticut Children's Medical Center’s Office of Continuing Medical Education. Click here to learn more.

Overview

Access to subspecialty care in the field of pediatrics is becoming increasingly difficult as evidenced by long wait times. Given the expectation of continued shortages in subspecialty care for children, pediatric primary care providers (PCPs) must become more involved and better trained in the management of children with some relatively low-acuity, high-volume conditions previously managed exclusively by the subspecialist. One approach to expanding the scope of the patient-centered medical home, is for primary care providers and subspecialists to co- develop and use structured, evidence-based communication and care coordination tools. One example of this type of structured tool is a Referral Guideline. Referral Guidelines minimize the number of referrals to subspecialists by allowing PCPs to obtain the expertise and support necessary to more independently manage some common conditions, thereby freeing up subspecialists to those patients that require their level of care. Increased utilization of Referral Guidelines improves the quality of care delivered while improving patients' access to care and potentially reducing costs.

The Referral Guideline for Pediatric Obesity guides the PCP in diagnosis, management, patient/family education strategies, and on when to refer to the Division of Endocrinology for treatment for a significant endocrine obesity co-morbidity. In an effort to link PCPs to the Referral Guideline in close to real time, a novel triage process was implemented in Endocrinology, in which referrals for conditions for which a Referral Guideline exists are reviewed by the on-call subspecialist. If the referral meets the criteria outlined in the guideline, the patient appointment is scheduled. If the referral does not meet criteria or if not enough information is sent with the referral to make a determination, the PCP is sent 1) a letter describing the Referral Guideline initiative and the referral review process and 2) a copy of the Referral Guideline. Patients can still be referred despite not meeting criteria, but PCPs are asked in these instances to provide the reason for referral (e.g. parent preference).

The aims of this QI intervention are for participating pediatric primary care providers to, over the course of a 12-month period: 1) Prescribe care for 20 patients or more who present with obesity. This includes patients whom you refer to Endocrinology and are found to meet referral criteria, patients you refer to Endocrinology and are referred back to you requesting more information and/or not meeting referral criteria, patients referred back to you but that you request to be seen, and those patients who you do not refer and for whom you initiate initial evaluation and management 2) use data from monthly progress reports to guide improvements in the delivery of care to patients with obesity.

Eligibility

All primary care pediatricians are invited to participate. Practice-wide participation is recommended.

Length

At least 12 months

Project Director

Karen Rubin, MD

Supporting Documents

Project Checklist

In addition to MOC credits, you may be eligible to receive AMA PRA Category 1 Credit™ from Connecticut Children's Medical Center’s Office of Continuing Medical Education. Click here to learn more.

Overview

  The goal of this project is to improve access to resources about epilepsy and seizure disorders for primary care physicians.  There is nationwide shortage of pediatric neurologists which requires improved coordination of care between pediatricians and subspecialists to ensure high quality care.    Significant improvements in medical care and treatment of epilepsy have been made in the last decade with new medications and treatment options available. Because the majority of epilepsy patients are seen by general practitioners, more training and education is needed.  Action steps towards narrowing the gap between neurologists and pediatricians include:  creating collaborative care agreements that specify the tasks that each are responsible for, usage of a fax back form between pediatrician and neurologist, offering a training to pediatricians on how to manage common problems that affect children and youth with epilepsy, and teaching quality improvement principles and processes to establish a foundation that can be used towards sustainability of this project.

Epilepsy is more common than cerebral palsy, multiple sclerosis, muscular dystrophy, and Parkinson’s combined. It affects an estimated 3 million people in the United States. Thirty percent of those people are children under the age of 18 with 125,000 new cases reported each year. The Institute of Medicines (IOM) 2012 report entitled “Epilepsy Across the Spectrum” states that 1 in 26 children will develop epilepsy in the course of their lifetime. Although the IOM report contains valuable information and statistics, it does not contain pertinent information about children and youth with epilepsy (CYE). The report states that the most catastrophic forms of epilepsy occur in childhood.  The IOM’s recommendations of improving the early identification of epilepsy and its co-morbid health conditions and improving the delivery and coordination of community services supports the need for the care coordination agreement and fax back forms to be used between pediatrician and neurologist.     

Eligibility

Pediatricians in NJ, CT, and Northeastern NY

Length

12 months

Project Director

Jennifer Madan Cohen, MD

Supporting Documents

Project Checklist

Chart Audit Tip Sheet

Additional Comments Template

Management of Teratogenic Medications in Ambulatory Clinics: Improving Education and Communication to Patients and Enhancing Screening Practices