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SECTION A: GENERAL PEDIATRICS

PLEASE NOTE: Answers to the questions in this section will be used to assess hospital capabilities and performance in one or more specialty areas. The section is called general pediatrics to avoid repeating the questions in individual specialty areas.

When responding to questions in this section, your hospital must consult with the chief of service (or equivalent) of your Pediatric program to ensure that answers are accurate and consistent with both the care delivered and the intent of the survey.

As data are reviewed, U.S. News may have questions about responses to individual questions or about an entire submission. To ensure communication with the appropriate clinical leader, please provide the following information about the chief of service (or equivalent) for your Pediatric program.

Full name:

Title:

Email:

Preferred phone:

REQUIRED: IF NAME, TITLE, EMAIL, OR PHONE=BLANK, DISPLAY: “A response is required for [Name/Title/Email/Phone] prior to submitting the survey. Click “OK” to continue with the survey and answer this question later. Click “Cancel” to provide a response to this question now.”

A1. What was the average daily pediatric (including newborns1 and neonates) inpatient census2 for the last 2 calendar years? ________ 2016 average daily inpatient census________ 2017 average daily inpatient census

A1.2 What was the total number of beds set up and staffed for use3 at the end of the past year?

________ Number of setup and staffed beds

1 For hospitals with labor and delivery services, only include newborns that were admitted to the pediatric program for care in the NICU, PICU, or one of the pediatric specialty units.2 Inpatient days divided by the number of days that the hospital was open (e.g. 365).3 Please report only operating beds, not constructed bed capacity that is not currently in use. Include all bed facilities that are set up and staffed for use by pediatric inpatient care. Exclude beds that have been newly constructed but are not yet in use and all temporary beds such as post anesthesia, postoperative recovery room beds, psychiatric holding beds, and beds that are used only as holding facilities for patient prior to a transfer to another hospital.

Last updated: 1/10/2018

A2. Indicate the number of full-time equivalent (FTE)4 on-staff RNs in your pediatric program (including the NICU and perioperative nursing staff) who are involved in direct inpatient pediatric care. (Exclude LVN, LPN, UAP NPs, PAs, contract nurses, ED staff, urgent care staff, and outpatient-only nursing staff. Include all clinical RNs who would normally be replaced if they called in ill.)

________ Number of FTEs

A3. As of January 1, 2018, was your hospital designated as a Nurse Magnet Facility by the American Nurses Credentialing Center?

Yes No

A4. Does your hospital have at least one of the following specialists available on-site (during normal business hours) and on-call5 (afterhours and weekends) for consultation in your pediatric program 24 hours a day, 7 days a week?

Yes Noa. Pediatric anesthesiologists (board certified/board eligible in Pediatric

Anesthesiology by the American Board of Anesthesiologists) ○ ○

b. Pediatric critical care specialists (board certified/board eligible6 by the American Board of Pediatrics with subspecialty certification in pediatric critical care medicine)

○ ○

c. Pediatric radiologists (board certified/board eligible by the American Board of Radiology with at least 75% of your pediatric radiologists holding a certificate of added qualification in pediatric radiology by the American Board of Radiology)

○ ○

d. Radiologists specializing in pediatric interventional radiology (board certified/board eligible by the American Board of Radiology with a certificate of added qualification in pediatric radiology or interventional radiology by the American Board of Radiology) and practicing more than 50% time in pediatric interventional radiology.

○ ○

e. Pediatric rheumatologists7(board certified/board eligible6 by the American Board of Pediatrics with subspecialty certification in pediatric rheumatology)

○ ○

f. Pediatric infectious disease specialists (board certified/board eligible6 by the American Board of Pediatrics with subspecialty certification in pediatric infectious disease)

○ ○

g. Pediatric physiatrist or rehabilitation specialist (board certified/board eligible by the by the American Board of Physical Medicine and Rehabilitation with subspecialty certification in Pediatric Rehabilitation Medicine)

○ ○

WARNING: IF A4c OR A4d=Yes, GO TO A4.1; ELSE SKIP TO A5.

4 Calculate FTEs based on total paid hours for the period of review divided by 2080.5 On-call staff must be available to attend patients on-site if required6 Note that board eligible is now defined by the American Board of Pediatrics as a care provider out of training <7 years; beyond this window, all physicians being counted in this question must be board certified to be included. If a provider does not meet the board eligible or board-certified criteria, then they may not be counted.7 May count if available 7 days a week, but not 24 hours a day.


A4.1 Please report the total FTE pediatric interventional radiologists in your pediatric program and the number of radiologists that spent ≥ 0.5 FTE practicing interventional radiology in the last calendar year? [If none, please enter 0.]

_______ Pediatric interventional radiologist FTEs_______ Number of practicing pediatric interventional radiology that spent ≥ 0.5 FTE

doing pediatric interventional radiology

VALIDATE: IF A4.1b IS NOT A WHOLE NUMBER, DISPLAY: “A4.1b: Please enter a whole number (no decimals).”

A5. Does your hospital have at least one of the following pediatric surgeons (board certified/eligible from the appropriate surgical board, with a fellowship training in pediatric surgery) available to your pediatric program?

Yes Noa. Pediatric otolaryngology surgeon ○ ○b. Pediatric cardiothoracic surgeon ○ ○c. Pediatric general surgeon ○ ○d. Pediatric neurosurgeon ○ ○e. Pediatric ophthalmology surgeon ○ ○f. Pediatric orthopaedic surgeon ○ ○g. Pediatric urology surgeon ○ ○h. Pediatric plastic surgeon ○ ○


A6. Did your hospital sponsor (or host a rotation site for) at least 1 fellow in the past academic year who is enrolled in an approved Accreditation Council for Graduate Medical Education (ACGME) training program in the following subspecialties? [If hosting a rotation, please list the sponsoring institution.]

Yes No Sponsora. Child neurology8 ○ ○ _____________b. Congenital cardiac surgery ○ ○ _____________c. Neonatal-perinatal medicine ○ ○ _____________d. Neurosurgery9 (with training in pediatrics) ○ ○ _____________e. Pediatric cardiology ○ ○ _____________f. Pediatric endocrinology ○ ○ _____________g. Pediatric gastroenterology ○ ○ _____________h. Pediatric hematology-oncology ○ ○ _____________i. Pediatric nephrology ○ ○ _____________j. Neuroradiology (with training in pediatrics) ○ ○ _____________k. Pediatric pulmonology ○ ○ _____________l. Pediatric urology ○ ○ _____________m. Pediatric surgery ○ ○ _____________n. Pediatric infectious diseases ○ ○ _____________o. Orthopaedic surgery of the spine (with training in

pediatrics) ○ ○ _____________p. Pediatric critical care medicine ○ ○ _____________q. Pediatric advanced transplant hepatology ○ ○ _____________r. Pediatric rheumatology ○ ○ _____________s. Physical medicine and rehabilitation (with training

in pediatrics) ○ ○ _____________t. Pediatric radiology ○ ○ _____________

8 For this item, please count the Child Neurology residents in your program.9 While there currently is not an ACGME program for pediatric neurosurgery, there is for neurosurgery. If you have fellows in ACGME program 160 (neurosurgery) who are completing their fellowship requirements at your site they should be included. In addition, if you have fellows who are participating in an ACPNF (Accreditation Council for Pediatric Neurosurgery Fellowships) approved program onsite, they may be counted as well.


u. Interventional radiology (with training in pediatrics) ○ ○ _____________


A7. Does your hospital provide the following pediatric services either on-site or through a formal contractual relationship with another facility?

Yes Noa. Neonatal intensive care unit10 (NICU) ○ ○

b. Pediatric intensive care unit11 (PICU) ○ ○

c. Patient care rooms with protective environment12 ○ ○

d. Genetic testing/counseling 13

○ ○

e. Palliative care program 14 ○ ○

f. Rehabilitation program and consultation service 15 ○ ○

A8. Does your hospital provide the following pediatric services on-site which are available 24 hours a day, 7 days a week?

Yes Noa. Rapid response team16 ○ ○b. Pediatric anesthesia program17 ○ ○c. Pediatric pain management program18 ○ ○

10 A NICU provides mechanical ventilation, neonatal surgery, and special care for the sickest infants, including those with the lowest birth weights (below 1,500 grams), who are born in the hospital or transferred from another institution. The NICU is separate from the newborn nursery. A full-time neonatologist serves as director. 11 A PICU is staffed with specially trained personnel and has monitoring and specialized support equipment for treating pediatric patients who, because of shock, trauma, or other life-threatening conditions, require intensified, comprehensive observation and care.12 The Protective Environment incorporates the following: air exchanges > 12 per hour; central or point-of-use high-efficiency particulate (HEPA) filters, consistent positive air pressure differentials between the patient’s room and hallway and continuous monitoring of pressure differentials.13 A genetic testing/counseling service is equipped with the appropriate laboratory facilities and is directed by a physician qualified to advise parents and prospective parents on potential problems in cases of genetic defects. A genetic test is the analysis of human DNA, RNA, chromosomes, proteins, and certain metabolites to detect heritable disease-related genotypes, mutations, phenotypes, or karyotypes for clinical purposes. Genetic tests can have diverse purposes, including the diagnosis of genetic diseases in newborns, children, and adults; the identification of future health risks; the prediction of drug responses; and the assessment of risks to future children.14 A palliative care program is organized and staffed for children nearing the end of life or living with lifespan-limiting conditions. The program’s purpose is to minimize pain and discomfort, provide emotional and spiritual support for children and their families, assist with financial guidance and social services, and support decision making. Programs must include at least one physician providing direct patient care; a nurse coordinator; and a social worker, certified child-life specialist, or pastoral counselor. All program staff must have training in palliative care.15 This program provides either a rehabilitation unit and/or a consultation service within the pediatric program for patients requiring rehabilitation. The program must include a pediatric physiatrist (board certified/board eligible pediatric rehabilitation physician) as the director.16 A rapid response team, also known as a medical emergency team, is distinct from the hospital “code” team. The team of appropriately trained individuals is available 24 hours a day and has three essential characteristics: (1) The team creates tools and provides staff education for recognizing an acute deterioration in patient condition. (2) The team follows the SBAR method (for situation, background, assessment, recommendation) to communicate such a change in condition effectively and efficiently (i.e., escalation policy). (3) The team responds to the change in condition with the goal of reducing/eliminating preventable “codes.”17 This team provides anesthesia care for children before, during, and after surgery (or other medical procedures). The team provides 24-hour coverage by board-certified anesthesiologists who specialize in pediatric anesthesia.18 Administered by specially trained physicians and other clinicians, this is a recognized clinical service or program providing specialized medical care, drugs, or therapies for the management of acute or chronic pain and other distressing symptoms among children suffering from an acute illness of diverse causes.


d. Multidisciplinary pediatric acute pain/sedation service19 ○ ○A9. Is your ECMO program currently designated as a Center of Excellence by the

Extracorporeal Life Support Organization (ELSO)?

Yes No Not applicable—we do not have an ECMO program

A10. Does your hospital provide on-site access20 to the following technologies or services to pediatric patients?

Yes No a. Positron emission tomography21/magnetic resonance imaging

(PET/MRI) single-console combined scanning unit ○ ○

b. Positron emission tomography/computed tomography (PET/CT) single-console combined scanning unit22 ○ ○

c. Intraoperative magnetic resonance imaging (ioMRI)23 ○ ○d. 3 Tesla magnetic resonance imaging (3T MRI)24 ○ ○e. Image-guided radiation therapy (IGRT)25 ○ ○f. Intensity-modulated radiation therapy (IMRT)26 ○ ○g. Portable CT scanning unit 27 ○ ○h. 24/7 availability of ultrasound for suspected appendicitis in

pediatric patients ○ ○

i. Fast shunt magnetic resonance imaging MRI for hydrocephalus28 ○ ○j. Dedicated interventional radiology (IR) team (techs and nurses) to

support IR procedures ○ ○

19 This service provides monitored anesthesia care and sedation within the hospital (but not within an operating room or PICU), as well as emergency airway management and acute and chronic pain management for neonates and pediatric patients on a 24-hour basis. A qualified program must have at least an identified medical director (e.g., general pediatrician, pediatric subspecialist, or anesthesiologist) with documented education in conscious sedation and an RN coordinator (or pain management clinical nurse specialist).20 For purposes of this question, these technologies would need to be available within the pediatric facility, a physically connected medical center, or an affiliated medical center within the same city. If available at another location beyond this, hospitals should answer no to this question. 21 PET scanning is a computerized nuclear medicine imaging technology that uses radioactive (positron-emitting) isotopes created in a cyclotron or generator to produce composite images of the brain and heart activity. The scans are sectional images depicting metabolic activity or blood flow rather than anatomy.22 PET/CT combines the capabilities of PET and CT scanning into a single integrated device, which provides metabolic functional information for monitoring chemotherapy, radiotherapy, and surgical planning.23 ioMRI uses a uniform magnetic field and radio frequencies to study tissue and structure of the body. It enables visualization of biochemical cellular activity in vivo without the use of ionizing radiation, radioisotopes, or ultrasound.24 3T MRI is a higher-powered version of MRI that offers improved morphological and functional studies of the brain compared with the more common field strength of 1.5T.25 IGRT is an automated system that produces high-resolution x-ray images to pinpoint tumor sites, adjust patient positioning, and generally make treatment more effective and efficient.26 IMRT is a three-dimensional radiation therapy that improves the targeting of treatment delivery in a way that is likely to decrease damage to normal tissues and allows for varying intensities.27 CT scanning unit that can be moved to where patient care is being provided rather than having a fixed unit in a single location. The portable unit is particularly helpful in delivering care in the ICU, emergency department, and in operating room environments. 28 Fast MRI shunt scans are exams performed in under 10 minutes as an alternative to CT scans to assess ventricular size when shunt tube malfunction is suspected.


A10.1 Which of the following does your pediatric program offer to ensure quality and patient safety (e.g., reduce exposure to radiation)?

Yes No a. Designated medical director of radiology who oversees quality and

safe practice in the pediatric program ○ ○

b. Iterative reconstruction software on all computed tomography (CT) scanners ○ ○

c. An MRI safety program compliant with the American College of Radiology (ACR) guidelines ○ ○

d. Participation in the ACR CT dose index registry OR use of dose monitoring software for tracking pediatric patients undergoing CT scans

○ ○

A10.2 Does your pediatric program use computerized tomography (CT) protocols that adjust milliampere-second (mAs) and peak kilovoltage (kVp) based on patient size and/or weight?

Yes No

A10.3 Does your pediatric program currently maintain the following certifications?

Yes No a. Accreditation in computerized tomography (CT) imaging from the

American College of Radiology (ACR) ○ ○

b. Accreditation in nuclear medicine from the American College of Radiology (ACR) ○ ○

c. Pediatric sonographer accreditation by the American Registry for Diagnostic Medical Sonographers (ARDMS) or ultrasound accreditation by the American Registry of Radiologic Technologists (ARRT)

○ ○

d. Program accreditation in ultrasound from the ACR or AIUM○ ○

e. Accreditation in MRI from the ACR ○ ○f. American Registry of Radiologic Technologists (ARRT)

certification for all x-ray technologists ○ ○

A10.4 Does your pediatric program have regularly scheduled multidisciplinary case conferences with pediatric radiologists to review the following test results?

Yes Noa. Review all abnormal brain and pituitary MRIs with a pediatric

neuroradiologist ○ ○

b. Review abnormal abdominal and pelvic ultrasounds with a pediatric radiologist ○ ○

c. Review thyroid ultrasounds for suspected or confirmed thyroid cancer with a pediatric radiologist ○ ○


A10.5 Do patients undergoing MRI, CT, or voiding cystourethrogram (VCUG) scans meet with or are they provided access to a certified child life specialist to discuss the procedure and alleviate patient stress?

Yes No

A11. Does your hospital provide at least one of the following technologies for pediatric patients, either on-site or through an arrangement with another facility29: Linac or other linear particle accelerator, Gamma knife, Cyberknife, or other shaped-beam stereotactic radiation therapy?

Yes No

A12. Do pediatric patients and their families have direct access to the following providers via a telephone number, paging system, or electronic means such as email rather than first requiring a referral?

Yes Noa. Certified child-life specialists ○ ○b. Family support specialists30 ○ ○c. Pediatric psychologists or psychiatrists ○ ○

A12.1 Do pediatric patients and their families have direct access to in-person interpreters for medical and surgical discussions when needed?

Yes No

A13. Do pediatric patients and their families have direct access to the following inpatient services?

Yes Noa. Family resource center31 ○ ○b. Sleep areas for parents or siblings ○ ○c. School intervention program32 ○ ○d. Ronald McDonald House or other residential facility for parents

convenient to the hospital ○ ○

29 To respond “yes” to this item, the arrangements for use of these tools with another facility should be based on a formal contractual relationship.30 Family support specialists help families meet practical needs (e.g., school coordination, transportation, lodging, etc.), information needs (e.g., family resource center, access information, etc.), and in some cases making appropriate connections back to their child's clinical treatment team. The primary goal of the family support specialist is to facilitate meeting the practical and information needs of families of patients being seen for care at your hospital.31 Family resource centers should provide patients and families access to a wide variety of information about child and maternal health and well-being. To receive credit, a hospital must have paid staff that are designated to run and support the center.32 A school intervention program works with the patient, the family, and the school to sensitize schools to the needs of the patient. The school intervention program must include a) a provision for providing education services during prolonged hospitalizations, and b) transition services for return to school after change in medical, functional, or cognitive status.


A14. Do you have a parent advisory committee that meets at regular intervals?

Yes – Go to A14.1 No – Skip to A15

A14.1 If “yes” to A14, how frequently does your parent advisory committee meet during the year?

1 time 2 or 3 times 4 or 5 times 6 or 7 times 8 times or more Not applicable

A15. Please answer the following questions about parent/family member involvement in your pediatric program.

Yes Noa. Does at least one parent or family member of a current or former patient

serve as an active voting member on the strategic or facility planning committee for your pediatric program?

○ ○

b. Does at least one parent or family member of a current or former patient serve as an active voting member on one or more standing committees (e.g., quality, patient safety, and ethics)?

○ ○

c. Can parents or family members participate in clinical care decision making processes such as care conferences in your pediatric program? ○ ○

d. Can parents or family members participate in family-centered rounds in all services of your pediatric program? ○ ○

A15.1 If “yes” to any part of A15, please describe what roles parents or family members serve in on committees and clinical decision-making process, and what kind of an impact this has had on your pediatric program in the last year:

A16. Does your pediatric program publicly report performance data on one or more quality metrics by displaying the data on the hospital's or program's website?

Yes No

A16.1 If “yes” to A16, please describe the data reported, the frequency of updates, and the means by which the information can be accessed by the public:


A17. Does the hospital sponsor quality improvement activities (projects) that provide credit to physicians for maintenance of certification33 (MOC) Part IV (Performance in Practice)? [Check all that apply.]

Yes, the hospital is approved by the ABMS as a multispecialty portfolio program (MSPP) sponsor

Yes, the hospital is approved by ABP as a pediatric portfolio sponsor Yes, the hospital sponsors one or more projects that are approved by the ABP No

A18. Does your pediatric program have an external review process for determining patient/parent satisfaction with the care provided by your institution (e.g., surveys, review committee, etc.) that is conducted on an annual (or more frequent) basis?

Yes No

A18.1 If “yes” to A18, please briefly describe how your pediatric program is externally reviewed, and 2 (or more) action plans that were developed to address issues identified in the past calendar year:

A19. As of January 1, 2018, was your hospital designated a Level 1 or 2 Pediatric Trauma Center by the American College of Surgeons or by your state licensing board?

Yes, as a Level 1 Pediatric Trauma Center Yes, as a Level 2 Pediatric Trauma Center No

A20. Does your pediatric program currently have an implemented computerized physician order entry (CPOE) system?

Yes—Go to Question A21 No—Skip to Question A22

33 Certification of quality improvement programs and projects by the American Board of Pediatrics requires a detailed submission of plans that meet criteria for planning, data collection, measurement and follow-up on quality projects. See: https://www.aap.org/en-us/continuing-medical-education/mocportfolio/Pages/home.aspx


A21. Does your implemented (CPOE) system currently provide the following features?

Yes No NAa. System documents 95% or more of inpatient medication

orders ○ ○ ○

b. System identifies orders for medications where there is a documented allergy to the medication ○ ○ ○

c. System includes alerts for dosing errors of high-risk medications ○ ○ ○

A21.1 If “yes” to A21c, please briefly describe 2 current projects with the CPOE system focused on dosing errors for high-risk medications. In your description, please mention what problems the system is used to help identify and how you are using the data to improve the quality of care:

A22. Question removed from the survey.

A23. Does your pediatric program currently use an electronic medical record (EMR) system to provide automated identification and reporting of “triggers”34 that reflect potential adverse events to patients?

Yes No Not applicable—Pediatric program does not have an EMR system

SKIP LOGIC: IF A23 = “Yes” or “No” go to A23.2. Else skip to A24.

A23.1 Question removed from the survey.

34 Triggers are predetermined flags in an EMR that are used to identify possible adverse events with patients. Some examples include flags for post-operative complications, nausea following procedures, readmissions, potential adverse drug events, etc.


A23.2 Does your pediatric program’s electronic medical record system have the ability to exchange patient health information (e.g., test results, summary of care records) with other healthcare organizations?

No, we cannot exchange patient health information with other organizations Yes, we can exchange patient health information with other organizations that have

the same electronic medical record system vendor (Epic, Cerner, etc.) Yes, we can exchange patient health information with other organizations that have a

different electronic medical record system vendor (Epic, Cerner, etc.)

A23.3 Which of the following patient engagement features are currently implemented in your pediatric program’s electronic medical record system?

Yes Noa. Patients have online access to medical notes or records ○ ○b. Patients may request a revision to medical notes or records online ○ ○c. Patients are able to schedule visits online ○ ○d. Patients can send/receive electronic messages to medical

providers ○ ○

A24. For inpatient care (excluding the Emergency Department), does your pediatric program audit hand hygiene compliance rates by electronic monitoring or direct observation35 (including secret shoppers) using a tool/form that is standard across your institution?

Yes, via electronic monitoring – Go to Question A25 Yes, via direct observation (including secret shoppers) – Go to Question A25 Yes, via a hybrid of direct observation and electronic monitoring – Go to Question A25 No – Skip to Question A26

A25. What were the numbers for the total hand hygiene compliance opportunities completed for the inpatient care areas (excluding Emergency Department) in your pediatric program in the last calendar year?

Valuesa. Number of compliant hand hygiene opportunities observed ________b. Total number of hand hygiene opportunities observed ________

WARNING: IF A24=Yes (either electronic or direct monitoring) AND A25b = (0 OR BLANK), DISPLAY: “A25b: Please enter a value greater than 0 or answer No to A24.”

VALIDATE: IF A25x IS NOT A WHOLE NUMBER, DISPLAY: “A25x: Please enter a whole number (no decimals).”IF A25a > A25b, DISPLAY: “A25: Please check your responses. The number of compliant opportunities cannot be greater than the number of opportunities observed.”

35 Direct observers (including secret shoppers) are individuals who are trained hand hygiene monitors. This should not include patient or family observations.


A26. Does your pediatric program currently provide financial support (e.g., salary support or contract agreements) for a pediatric infectious disease specialist physician to serve as a dedicated medical director of your infection prevention program (exclude salary support for medical director of antimicrobial stewardship or emergency preparedness programs)?

Yes No – Skip to A27

A26.1 Please provide the amount of FTE support for the medical director of your infection prevention program?

_______ FTE

WARNING: IF A26=Yes AND A26.1=0, DISPLAY: “If no financial support is provided, you must answer No to A26.”

A27. How many Infection Preventionist (IP) FTEs do you have in your pediatric program? [If none, please enter 0.]

________ IP FTEs

SKIP LOGIC: IFA27=0, SKIP TO A28

A27.1. How many of the IPs36 in your pediatric program are certified in infection control by the Certification Board in Infection Control (CBIC)? [Please report the number of staff and not a percentage or FTE count.] [If none, please enter 0.]

________ Number of Certified IPs (report # of staff, not FTE)VALIDATE: IF A27.1 IS NOT A WHOLE NUMBER, DISPLAY: “A27.1:

Please enter a whole number (no decimals).”

36 IPs are typically nurses or medical technicians who play specific roles in hospital infection prevention. Include all IPs, not just those eligible to sit for certification. The intent of the question is to examine the certification rate of everyone doing the work, not just those who are eligible.


A28. For each of the following categories of health care providers, please indicate if influenza immunization rates are tracked. If rates are tracked, how many eligible37 health care providers were continuously employed or providing care between October 1, 2017 and December 31, 2017? Of those continuously employed or providing care during this time period, how many received influenza immunization?

Influenza immunization Yes No

Total Number of Eligible

Health Care Providers

Number of Healthcare

Providers Who Received

Immunizationa. Physicians who routinely

practice at your pediatric facilities (include attendings, fellows, and residents)

○ ○ ________ ________

b. Nursing staff and mid-level providers (e.g. physician assistants, nurse practitioners) providing pediatric clinical care

○ ○ ________ ________

VALIDATE: IF A28x1=Yes AND A28x2=(0 OR BLANK), DISPLAY: “Please provide a value greater than 0 for eligible providers or answer No to tracking.IF A28x2 or A28x3 IS NOT A WHOLE NUMBER, DISPLAY: “A28x (Total Providers / Immunized): Please enter a whole number (no decimals).”If A28x3 > A28x2, DISPLAY: “A28x: Number of providers receiving immunizations cannot be greater than total providers.”

37 Include staff who refuse immunizations for personal reasons as eligible healthcare providers. For more information see NHSN guidelines: https://www.cdc.gov/nhsn/pdfs/hps-manual/vaccination/hps-flu-vaccine-protocol.pdf


https://www.cdc.gov/nhsn/pdfs/hps-manual/vaccination/hps-flu-vaccine-protocol.pdf

A29. For each of the following categories of health care providers, please indicate if the adult Tdap booster38 (combined Tetanus, Diphtheria and Pertussis) immunization rates are tracked. If rates are tracked, how many eligible health care providers were employed or providing care as of December 31, 2017. Of this group, how many have evidence of Tdap vaccination as of December 31, 2017?

Tdap immunization Yes No

Total Number of Eligible

Health Care Providers

Number of Healthcare

Providers Who Had Evidence of Immunization

a. Physicians who routinely practice at your pediatric facilities (include attendings, fellows, and residents)

○ ○ ________ ________

b. Nursing staff and mid-level providers (e.g. physician assistants, nurse practitioners) providing pediatric clinical care

○ ○ ________ ________

VALIDATE: IF A29x1=Yes AND A29x2=(0 OR BLANK), DISPLAY: “Please provide a value greater than 0 for eligible providers or answer No to tracking.IF A29x2 or A29x3 IS NOT A WHOLE NUMBER, DISPLAY: “A29x (Total Providers / Immunized): Please enter a whole number (no decimals).”If A29x3 > A29x2, DISPLAY: “A29x: Number of providers receiving immunizations cannot be greater than total providers.”

A29.1 Between October 1, 2017 and December 31, 2017, did your pediatric program require all volunteers to receive or provide documentation of influenza vaccination?

Yes No

A29.2 Does your pediatric program require all volunteers to receive or provide documentation of Tdap vaccination?

Yes No

38 The adult TdaP booster refers to the immunization that has been available since 2005 and does not refer to childhood immunization


A29.3 Does your pediatric program offer an influenza vaccination program for patients’ families/primary caregivers?

Yes No

A29.4 Does your pediatric program offer an adult TdaP booster program for patients’ families/primary caregivers?

Yes No

A30. Does your pediatric program participate in each of the following quality and safety programs?

Yes Noa. American College of Surgeons (ACS) National Surgical Quality

Improvement Program (NSQIP) ○ ○

b. Children’s Hospital Solutions for Patient Safety learning network (CHSPS)39 ○ ○

c. Children’s Hospital Association sepsis project ○ ○d. Other national quality and safety collaborative ○ ○

SKIP LOGIC: IFA30d = “Yes”, GO TO A30.1. ELSE SKIP TO A31

A30.1 Please list the “other national quality and safety collaborative” that you are currently participating in. For each organization, please identify what the focus of the activities your facility has engaged in with the collaborative over the past year:

39 This program was previously known as the Ohio Children’s Hospital Solutions for Patient Safety learning network (OCHSPS). The program focuses on an array of hospital quality measures and is available to hospitals nationally.


A31. Does your hospital have any of the following elements of an antimicrobial stewardship program (ASP) currently implemented in your pediatric program?

Yes Noa. Actively reporting either AU (antibiotic use) or antimicrobial resistance

(AR) to NHSN ○ ○

b. Restriction or pre-authorization of selected antimicrobials ○ ○c. Prospective review and real-time intervention regarding antimicrobial use

or “handshake stewardship” ○ ○

d. At least 0.5 FTE support for a dedicated pharmacist to ASP program ○ ○e. At least 0.3 FTE support for the role of medical director of the pediatric

ASP program ○ ○

f. Use of clinical guidelines in prescribing antimicrobials ○ ○g. At least 0.2 FTE support for a dedicated data analyst to support ASP

program ○ ○

h. IV to PO conversion program available to ensure correct dosage ○ ○

A32. Does your hospital have any of the following elements of an ASP as recommended by the CDC currently implemented in your pediatric program?

Yes Noa. Formal policy on the use of antimicrobials ○ ○b. Letter of support for the ASP by hospital administration ○ ○c. An ASP committee that meets at least quarterly ○ ○d. Regular tracking and reporting of ASP data to hospital clinicians ○ ○e. Annual and ongoing education to hospital staff regarding ASP ○ ○


A33. Please report your central line-associated bloodstream infection (CLABSI) rates in the last calendar year for all pediatric ICUs tracked.40 [Calculate as follows: (1) Determine the number of CLABSI events according to current NHSN guidelines.41 (2) Determine the total number of central line days42 in the last calendar year. (3) Divide CLABSI events by central line days, and multiply by 1,000. Round your result to 2 decimals.]

________ (1) CLABSI events ________ (2) Central line days

________ (3) CLABSI rate

VALIDATE: IF A33(1) or A33(2) IS NOT A WHOLE NUMBER, DISPLAY: “Please enter a whole number (no decimals).”IF A33(1) > A33(2) DISPLAY, “A33: The number of CLABSI events cannot be greater than the number of central line days.”

AUTOCALC:A33(3) = [(A33(1) / A33(2)) *1000]

A34. Does your hospital track and report indwelling urinary catheter utilization in your non-NICU ICU settings?

Yes, we track and report for all ICU settings that use indwelling urinary catheters Yes, we track and report for some of the ICU settings that use indwelling urinary catheters No

A34.1 Does your hospital use any of the following interventions to reduce indwelling urinary catheter utilization in your ICU settings?

Yes Noa. Written indications for insertion and/or removal of indwelling urinary

catheters ○ ○

b. Routine removal of urinary catheters following surgery ○ ○c. Bladder scanning ○ ○d. Non-indwelling catheter (e.g., in and out or straight catheter) for

urinary retention ○ ○

40 Exclude numbers from NICU, oncology ICUs, and non-PICU stem cell transplant units.41 For the most recent NHSN definition of CLABSI, see the following: https://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf. As per these instructions, only include lab-confirmed CLABSI cases (do not include clinical sepsis) and exclude MBI-CLABSI.42 According to NHSN guidelines, a patient with one or more central lines on a given day equals 1 central line day.


https://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf

A35. Does your hospital offer a multidisciplinary Vascular Tumor (or Vascular Anomalies Program) with representation from pediatric hematology, pediatric surgery, dermatology, diagnostic pediatric radiology, and pediatric interventional radiology to address vascular non-malignant tumors?43

Yes No

A36. Does your pediatric program have a formal program to prevent hospital-acquired pressure injury (see code list)?

Yes No

A37. Does your pediatric program track the rate of hospital-acquired pressure injuries (see code list) for patients seen on an inpatient basis?

Yes—Go to Question A38.1 No—Skip to Question A39 N/A, we treat only NICU patients – Skip to Question A39

A38.1 Please provide the total number of pediatric inpatients in your hospital at the time of each of your quarterly 1-day surveys or assessments. Of those, how many were assessed during 1-day surveys or assessments of hospital-acquired pressure injuries conducted each quarter in the last calendar year? [Note: If the same patient is present in multiple quarterly surveys, he/she may be counted only once per quarter. If your hospital participates in NDNQI or the Nurse Magnet program, please provide numbers based on your submission to those programs.]

Number of pediatric

inpatients at the time of assessment

Number of pediatric inpatients assessed

a. Patients from the first quarter (Q1) _____ _____b. Patients from the second quarter (Q2) _____ _____c. Patients from the third quarter (Q3) _____ _____d. Patients from the fourth quarter (Q4) _____ _____

WARNING: IF A37=Yes AND A38.1x2 = (0 OR BLANK), DISPLAY: “A38.1x (Inpatients assessed): Please provide a value greater than 0 for inpatients assessed or answer No to A37.”

VALIDATE: IF A38.1x IS NOT A WHOLE NUMBER, DISPLAY: “A38.1x: Please enter a whole number (no decimals).”

43 This program brings together a multidisciplinary team of specialists to diagnose and ensure the most effective treatment for optimal functioning and quality of life for children with vascular anomalies (tumors or malformations). To be eligible, a program must have at least one of each of the following as part of the team: pediatric surgeon, pediatric hematologist/oncologist, diagnostic radiologist with expertise in vascular anomalies, interventional radiologist with expertise in vascular anomalies, vascular pathologist, and support from physical or occupational therapy for rehabilitation following vascular surgery.


If A38.1x2 > A38.1x1, DISPLAY: “The number of inpatients assessed cannot be greater than the number of inpatients at time of assessment.”

A38.2 Of the total pediatric inpatients assessed (sum of Q1 – Q4), how many had conventional and device-related hospital-acquired pressure injuries by stage (see code list)? [Note: For patients assessed in one quarter who have multiple stages of pressure injuries (i.e. more than one), assign this patient to the highest stage. If a patient is present for more than one quarter AND has a stage III, IV, or unstageable pressure injuries when assessed, he/she should be included in the count for each quarter in which he/she has a pressure injury.] [If none, please enter 0.]

______ Pediatric inpatients assessed in Q1-Q4 with a stage III pressure injury ______ Pediatric inpatients assessed in Q1-Q4 with a stage IV pressure injury ______ Pediatric inpatients assessed in Q1-Q4 with an unstageable pressure injury

WARNING: IF A37=Yes AND A38.2x = (BLANK), DISPLAY: “A38.2x: Please provide a value or answer No to A37. If none, please enter 0.”

VALIDATE: IF A38.2x IS NOT A WHOLE NUMBER, DISPLAY: “A38.2x: Please enter a whole number (no decimals).”If A38.2x > (A38.1 inpatients assessed Q1 –Q4), DISPLAY: “A38.2x: The number of patients with a pressure injury cannot be greater than the number of inpatients assessed (A38.1x).”

A39. Has your pediatric program engaged in any of the following activities designed to ensure “high reliability” and safety of all in-patient services to patients? These activities may occur every 6 months to 2 years.

Yes Noa. All clinical staff (physicians, nurses, etc.) are trained in code

response using simulations or other team trainings ○ ○

b. Trainings include clear instructions and demonstration of roles and lines of communication ○ ○

c. Trainings are video-taped to allow for review of performance and needs for improvement ○ ○

d. Trainings include critical event debriefing or team discussions that focus on identifying what worked well and where improvement is needed

○ ○

e. Trainings end with the development of an action plan to address problems identified during the training or simulation ○ ○

SKIP LOGIC: IF A39a or A39b or A39c or A39d or A39e = “Yes”, GO TO A39.1. ELSE SKIP TO A40.

A39.1 Please briefly describe the components of your pediatric program’s “high reliability” plan. In your response also identify at least 2 action items that have been identified in the last year that will affect patient services in the coming year:


A40. In which of the following ways are your nurses, physician assistants, nurse practitioners, and others who provide bedside care encouraged to participate in quality and or safety initiatives in your pediatric program? Check all that apply.

Staff are encouraged to conduct mini-Root Cause Analyses (RCA) meetings with paid time

allotted to the effort Staff are encouraged to participate in a quality improvement teams with paid time allotted to

the effort Staff are expected to participate in quality improvement and safety initiatives, and this is part

of their annual performance evaluation

A41. Does your pediatric program have a physician serving as a designated Chief Quality Officer and/or a Chief Safety Officer? If yes, how much of their time is designated to cover this role?

Yes, > 0.75 FTE Yes, 0.50-0.74 FTE Yes, 0.25-0.49 FTE Yes, < 0.25 FTE No

The following are being collected for information purposes only. They will not be factored into the rankings in 2018-19.

A42. Has your pediatric program reported any of the following rates and data to NHSN?

Yes, it is required by

the state

Yes, but it’s not required by the state No

a. Central line associated bloodstream infections ○ ○ ○b. Catheter-associated urinary tract infections ○ ○ ○c. Surgical Site Infections ○ ○ ○d. Multidrug resistant organisms/C diff infections ○ ○ ○e. Antimicrobial use ○ ○ ○


A43. Please indicate whether your pediatric program could provide the following information if requested on the 2019-20 survey:

Yes, with no

difficulty

Yes, with some

difficulty

Yes, with great

difficulty Noa. Reporting of the NHSN Standardized

Infection Ratio (SIR) for CLABSI infections for your facility

○ ○ ○ ○

b. Availability of a hand surgeon ○ ○ ○ ○c. Availability of additional fellowships

in Adolescent Medicine, Allergy/Immunology, Anesthesiology, Child abuse, Pediatric emergency medicine, Pediatric Palliative Care, Sleep

○ ○ ○ ○

d. Availability of a maternal fetal medicine or fetal treatment program ○ ○ ○ ○

e. Availability of nuclear medicine SPECT/CT ○ ○ ○ ○

f. Percentage of patients get an ultrasound first for suspected appendicitis

○ ○ ○ ○

g. Availability of dedicated radiology child life specialist to meet with pediatric patients and families undergoing MRI, CT, and VCUG scans

○ ○ ○ ○

h. Availability of electronic interpreters ○ ○ ○ ○i. Availability of image-guided

percutaneous treatment of vascular anomalies

○ ○ ○ ○

j. Availability of a formal antimicrobial stewardship program (ASP) in the outpatient setting

○ ○ ○ ○

k. Percentage of imaging studies for Emergency Department patients that are interpreted by an attending radiologist within 2 hours of exam completion

○ ○ ○ ○

COMMENTS FOR SECTION A:If needed, you may provide clarifications to the responses you provided to the questions asked in this section only. All other comments, suggestions or questions should be sent to [email protected].


mailto:[email protected]

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