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

项目总结/摘要 脓毒症每年影响> 70，000名美国儿童，死亡率为5-10%，长期发病率为35%， 国家成本73亿美元。通过及时的诊断可以改善预后，这在一般情况下是不太可能的。 急诊科（ED）治疗成人和儿童。尽管高达80%的败血症儿童 在一般ED治疗中，在这些环境中的少数研究还没有确定改善诊断的策略。 脓毒症是及时诊断面临挑战的典型情况，突出了 美国国家科学院、工程院和医学院2015年报告《改善健康诊断》 在乎该项目还解决了儿科应急准备的挑战， 2007年，《成长的烦恼》。这项工作的长期目标是确定战略， 诊断ED中的高危状况。在建立能力以改善对各种紧急情况的诊断的同时， 条件下，最初的示范项目将集中在儿科败血症，使用的方法1）识别， 分析和减少诊断错误，以及2）工作系统改进。它将独特地利用 转移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 传播儿科亚专业知识。与顾问的电话联系经常用于 ED的诊断决策，很少被研究;该团队将应用会话分析， 电话录音，以确定改善沟通和诊断过程的机会。本研究将 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清单， 在儿科急诊中证明了有效性，2）改善了后续的专科咨询流程 诊断安全原则。该研究将在儿童医院转移呼叫中心进行， 每年在>100个普通急诊室接受约> 18，000名儿童的电话。目标是：SA 1：分析当前 诊断过程中，脓毒症患儿转诊中心采用混合方法。谈话 对电话录音的分析和定量分析将指导诊断准确性的评估， 诊断工作系统和过程。SA 2：使用实施映射适应过程来适应诊断 在转运中心实施的战略（具体内容清单和工作系统改进） 呼叫过程。SA 3：在18个月的实施中实施和评价脓毒症诊断安全工具包 study.这项工作将建立战略，以改善诊断的时间敏感的儿科急诊， 一般艾德设置，其中大多数儿童接受他们的关键的第一个小时的治疗。儿童医院 转移呼叫中心是一个独特的，可复制的机会，传播儿科知识的时刻， 需要，提高诊断安全的儿童在任何ED。在这项工作中确定的战略重点是 可以复制针对具体内容的清单和电话咨询过程的工作系统改进 在其他情况下，提高急诊医学的诊断和安全性。

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.