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Keeping Young Patients Safe
July 1, 2008
Children’s hospitals face some special challenges in keeping their young patients safe. Some children may be victims of child abuse and need to be protected from certain family members. Others may be gang members facing the risk of being targets of violence. Some are runaways who risk a decline in health if they flee the hospital. And some may have parents with drug or alcohol abuse problems or who are involved in bitter custody disputes.
“Children cannot speak up for themselves in terms of identifying risk or feeling free to talk about the risk,” says Marlene Miller, M.D., vice president for quality at the National Association of Children’s Hospitals and Related Institutions, Alexandria, Va. “For many of our patients, we’re dependent on the people who bring them here. And not every child in America has a nuclear family with mom and dad and a dog.”
To help ensure that all their patients remain safe, a nurse on the I.T. team at one children’s hospital devised a clever customization of the organization’s clinical information system to alert all clinicians about special safety risks and provides tips on appropriate action.
Triggering Incident
The automation effort at Children’s Hospital and Regional Medical Center in Seattle was triggered by an incident when a parent inappropriately attempted to leave the hospital with their child, says Danica Pytte, R.N., a clinical analyst who devised the system.
The Clinical Action Safety Plan Evaluating Risk, or CASPER, formerly was a paper-based process with limited information, she notes. The alert system was developed using the PowerForm tool within the clinical information system from Cerner Corp., Kansas City, Mo.
“We weren’t automating a broken system; we were making it better and putting it online,” Pytte says.
Miller laments that many health care information systems are not designed with children’s hospitals in mind. That means that in many cases, these hospitals have to tweak the systems they buy to meet their needs.
“The really important message here is ‘why are all these children’s hospitals having to create these logical programs for themselves?’” she says.
One consultant notes, however, that the PowerForms tool within Cerner’s clinical information system is designed to enable all kinds of hospitals to customize templates and apply rules to generate alerts that meet their needs.
“The PowerForms have standard content, and you can customize them to do a variety of things,” says Lawrence “Chip” Quammen, president of the Quammen Group, a Winter Park, Fla.-based consulting firm.
Thanks to Pytte’s development work, clinicians at the Seattle children’s hospital now get alerts of a CASPER case when they sign onto the system to view a chart or place an order through the computerized physician order entry component. The hospital’s separate admission/discharge/transfer system, soon to be replaced, also flags CASPER cases with a brief summary that alerts staff members who greet guests.
Pytte made sure the hospital’s 60 social workers had multiple opportunities to provide feedback on the design of the new online system because these staff members as well as security staff create the CASPER reports. In addition to helping improve patient safety, the reports also contribute to the safety of caregivers by warning them about the potential behaviors of patients and family members, she adds.
The CASPER online forms include a mix of point-and-click templates, such as for selecting the person who is the focus of the concern (patient, father, friend) as well as free text descriptions of risks. The forms also spell out the social workers and others assigned to the case and offer suggestions for action, such as what to do if an abusive parent shows up at the hospital.
CASPER alerts are issued with three levels of urgency. About 90% of these cases get a standard alert. A CASPER Plus alert is used to notify caregivers of situations involving very serious domestic violence as well as high-profile cases getting news media attention or involving a local celebrity. A Coded CASPER alert is for those rare cases that require complete patient anonymity, such as “a situation where the child would be at risk if the parent knows we are watching them,” Pytte says.
Since launching the CASPER project with paper forms in 1996, the hospital has created more than 4,200 alerts, she says. Today, the hospital has about 750 active cases, with about 400 CASPER alerts prepared annually.
The automated alerts, which went live in March 2007, have greatly simplified patient safety functions for the hospital’s social workers, says Christine Baker, program coordinator of the hospital’s child protection program.
“With the old paper-based system, if a social worker changed the name of one staff member on the case, he had to rewrite the entire report. Now, they just bring up the patient’s record in the clinical information system and modify the online CASPER form.”
The CASPER program has streamlined multidisciplinary communication, Pytte adds.
“It allows care providers to spend more time on patient care by providing current information in an easily accessible and intuitive place.”
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