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

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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.