The Right Call: Implementing a Sepsis Diagnostic Safety Toolkit in a Pediatric Transfer Call Center to Improve Diagnosis of Children in General Emergency Settings

项目摘要/摘要 败血症每年影响70,000名美国儿童，死亡率为5-10%，长期发病率为35%，每年 国家成本为73亿美元。通过及时诊断可以改善结果，这在一般情况下不太可能发生 治疗成人和儿童的急诊科(ED)。尽管高达80%的败血症儿童是 在普通急症治疗中，在这些环境中的少数研究没有确定改善诊断的策略。 脓毒症是一种难以及时诊断的典型情况，突出了在 美国国家科学院、工程院和医学研究院2015年的报告《改善健康诊断》 关心。该项目还解决了儿科应急准备方面的挑战，该研究所指出 医学2007年的报告《成长的烦恼》。这项工作的长期目标是确定改进的战略 急诊室高危疾病的诊断。同时建立能力以提高紧急情况下的诊断能力 最初的示范项目将侧重于儿童脓毒症，使用1)鉴定方法， 分析和减少诊断错误，以及2)工作系统改进。它将独一无二地利用 转接呼叫中心和简短的咨询电话，作为应用诊断安全策略的机会 传播儿科专科知识。与咨询师的电话经常用于 急诊室中的诊断决策，很少被研究；该团队将应用对话分析来 录音通话，以确定改善沟通和诊断过程的机会。这项研究将 调整和实施诊断安全工具包，包括：1)内容特定的脓毒症诊断核对表 证明了儿科急诊的有效性，2)后续专科会诊流程的改进 诊断安全原则。这项研究将在儿童医院转院呼叫中心进行， 每年接到约18,000名儿童的来电，这些儿童来自100个普通急救中心。目标是：SA1：分析当前 儿童脓毒症的诊断过程转至转运中心采用混合方法。对话 对电话录音的分析和定量分析将指导对诊断准确性和 诊断工作系统和流程。SA2：使用实施映射适应流程来适应诊断 在中转中心实施的战略(具体内容清单和工作系统改进) 呼叫流程。SA3：在18个月内实施和评估脓毒症诊断安全工具包 学习。这项工作将建立战略，以改善对时间敏感型儿科紧急情况的诊断 普通急诊室，大多数儿童在这里接受关键的第一个小时的治疗。儿童医院 转接呼叫中心是目前传播儿科知识的独特、可复制的机会 需要，提高任何急诊室儿童的诊断安全性。这项工作中确定的战略侧重于 具体内容清单和工作系统对电话咨询流程的改进可以复制 在其他情况下，提高急诊医学的诊断率和安全性。

PROJECT SUMMARY/ABSTRACT Sepsis affects >70,000 U.S. children annually with 5-10% mortality, 35% long-term morbidity, and annual national costs of $7.3 billion. Outcomes are improved by timely diagnosis, which is less likely in general Emergency Departments (EDs) which treat adults and children. Although up to 80% of children with sepsis are treated in general EDs, the few studies in these settings have not identified strategies to improve diagnosis. Sepsis is an exemplar condition for challenges to timely diagnosis, highlighting diagnostic complexities noted in the National Academies of Sciences, Engineering, and Medicine’s 2015 report Improving Diagnosis in Health Care. This project also addresses challenges in pediatric emergency preparedness noted in the Institute of Medicine’s 2007 report, Growing Pains. The long-term goals of this work are to identify strategies to improve diagnosis of high-risk conditions in EDs. While establishing capacity to improve diagnosis across emergency conditions, the initial demonstration project will focus on pediatric sepsis, using methods of 1) identification, analysis, and reduction of diagnostic errors, and 2) work system improvements. It will uniquely leverage the transfer call center and the brief consultative phone call as an opportunity to apply diagnostic safety strategies and disseminate pediatric subspecialty knowledge. Phone calls with consultants are frequently used in diagnostic decision-making in EDs and have rarely been studied; this team will apply conversation analysis to recorded calls to identify opportunities to improve communication and the diagnostic process. This study will adapt and implement a diagnostic safety toolkit including: 1) a content-specific sepsis diagnostic checklist with demonstrated effectiveness in pediatric EDs, 2) improvement in subspecialty consultation processes to follow diagnostic safety principles. The study will be conducted in a children’s hospital transfer call center that receives calls about >18,000 children in >100 general EDs yearly. The aims are: SA1: Analyze the current diagnostic process in children with sepsis referred to the transfer center using mixed methods. Conversation analysis of recorded phone calls and quantitative analysis will guide evaluation of diagnostic accuracy and the diagnostic work system and process. SA2: Use the Implementation Mapping Adapt process to adapt diagnostic strategies (content-specific checklist and work system improvements) for implementation in the transfer center call process. SA3: Implement and evaluate the sepsis diagnostic safety toolkit in an 18-month implementation study. This work will establish strategies for improving the diagnosis of time-sensitive pediatric emergencies in general ED settings, where most children receive their critical first hours of treatment. Children’s hospitals’ transfer call centers are a unique, replicable opportunity to disseminate pediatric knowledge at the moment it is needed, improving diagnostic safety for children in any ED. Strategies identified in this work focused on content-specific checklists and work system improvements to the phone consultation process can be replicated in other conditions, improving diagnosis and safety in emergency medicine.