Pub Date : 2023-05-01DOI: 10.1097/pq9.0000000000000661
Virginia Cox, S. Hart, Diane Hersey, Jennifer Gauntt, S. Carrillo, P. McConnell, J. Simsic
Introduction: Patients following the Fontan procedure have a physiology that results in prolonged pleural effusion, often delaying hospital discharge. The hospital length of stay (LOS) of patients following the Fontan procedure at our institution was significantly longer than the Society of Thoracic Surgery benchmark. This quality improvement project aimed to decrease hospital LOS in patients following the Fontan procedure from a baseline of 23 days to 7 days by January 1, 2021, and sustain indefinitely. Methods: We implemented standardized postoperative clinical practice guidelines in April 2020. We designed guidelines using previously published protocols. Key features included an ambulatory PleurX drain (BD, Franklin Lakes, N.J.), diuresis with fluid restriction, and pulmonary vasodilation with supplemental oxygen and sildenafil. All patients were discharged from the hospital with a PleurX drain in place. We compared clinical outcome variables before and after guideline implementation. As a balancing measure, we tracked 30-day readmissions. Results: One hundred seven patients underwent the Fontan procedure before guideline implementation from January 2015 to January 2020, with an average hospital LOS of 23 days. Postguideline implementation, 35 patients underwent the Fontan procedure from April 2020 to July 2022, with an average hospital LOS of 8 days in 2020, which further improved to an average hospital LOS of 7 days. There was no change in 30-day readmission after guideline implementation (24% pre versus 23% post; P = 0.86). Conclusion: Implementing clinical practice guidelines for patients following the Fontan procedure led to an over 50% reduction in hospital LOS without increasing 30-day readmission.
简介:Fontan手术后患者的生理机能导致胸腔积液延长，通常延迟出院。我院Fontan手术患者的住院时间(LOS)明显长于胸外科学会的基准。该质量改进项目旨在到2021年1月1日，将Fontan手术后患者的住院时间从基线的23天减少到7天，并无限期维持下去。方法:我们于2020年4月实施标准化的术后临床实践指南。我们使用先前发表的协议设计指南。主要特征包括动态胸腔引流术(BD, Franklin Lakes, N.J.)，限制液体的利尿，补充氧气和西地那非的肺血管扩张。所有患者均在胸膜引流管就位后出院。我们比较了指南实施前后的临床结果变量。作为一项平衡措施，我们追踪了30天内的再入院情况。结果:2015年1月至2020年1月，指南实施前有107例患者接受了Fontan手术，平均住院时间为23天。指南实施后，从2020年4月到2022年7月，35例患者接受了Fontan手术，2020年平均住院时间为8天，进一步提高到平均住院时间为7天。指南实施后30天再入院率没有变化(实施前为24%，实施后为23%;P = 0.86)。结论:对Fontan手术患者实施临床实践指南可使医院LOS减少50%以上，且不增加30天再入院率。
{"title":"Quality Report: Postoperative Guideline Implementation Reduces Length of Stay after Fontan Procedure","authors":"Virginia Cox, S. Hart, Diane Hersey, Jennifer Gauntt, S. Carrillo, P. McConnell, J. Simsic","doi":"10.1097/pq9.0000000000000661","DOIUrl":"https://doi.org/10.1097/pq9.0000000000000661","url":null,"abstract":"Introduction: Patients following the Fontan procedure have a physiology that results in prolonged pleural effusion, often delaying hospital discharge. The hospital length of stay (LOS) of patients following the Fontan procedure at our institution was significantly longer than the Society of Thoracic Surgery benchmark. This quality improvement project aimed to decrease hospital LOS in patients following the Fontan procedure from a baseline of 23 days to 7 days by January 1, 2021, and sustain indefinitely. Methods: We implemented standardized postoperative clinical practice guidelines in April 2020. We designed guidelines using previously published protocols. Key features included an ambulatory PleurX drain (BD, Franklin Lakes, N.J.), diuresis with fluid restriction, and pulmonary vasodilation with supplemental oxygen and sildenafil. All patients were discharged from the hospital with a PleurX drain in place. We compared clinical outcome variables before and after guideline implementation. As a balancing measure, we tracked 30-day readmissions. Results: One hundred seven patients underwent the Fontan procedure before guideline implementation from January 2015 to January 2020, with an average hospital LOS of 23 days. Postguideline implementation, 35 patients underwent the Fontan procedure from April 2020 to July 2022, with an average hospital LOS of 8 days in 2020, which further improved to an average hospital LOS of 7 days. There was no change in 30-day readmission after guideline implementation (24% pre versus 23% post; P = 0.86). Conclusion: Implementing clinical practice guidelines for patients following the Fontan procedure led to an over 50% reduction in hospital LOS without increasing 30-day readmission.","PeriodicalId":343243,"journal":{"name":"Pediatric Quality and Safety","volume":"6 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"131810705","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-05-01DOI: 10.1097/pq9.0000000000000655
David R. Karas, S. Upadhyayula, April Love, M. Bigham
Introduction: Cystitis and pyelonephritis are common bacterial infections in infants and children, and initial treatment is usually empirical. Antimicrobial stewardship advocates using narrow-spectrum antibiotics with consideration for local resistance patterns. Narrow-spectrum antibiotic use is critical in addressing the global issue of bacterial antimicrobial resistance, associated with approximately 5 million annual deaths. Methods: The antimicrobial stewardship committee developed a guideline for diagnosing and managing urinary tract infections and distributed it to all primary care providers. A standardized order set provided clinical decision support regarding appropriate first-line antibiotic therapy. A chief complaint of dysuria prompted the use of the order set. Prescription rates for the most common antimicrobials were tracked on a control chart. Results: From March 2018 through March 2020, there were 4,506 antibiotic prescriptions for urinary tract infections. Utilization of the recommended first-line therapy, cephalexin, increased from 27.5% to 74.8%. Over the same period, trimethoprim-sulfamethoxazole, no longer recommended due to high local resistance, decreased from 31.8% to 8.1%. Providers have maintained these prescribing patterns since the conclusion of the project. Conclusion: Using clinical decision support as a standardized order set can sustainably improve the use of first-line antimicrobials for treating pediatric urinary tract infections.
{"title":"Utilizing Clinical Decision Support in the Treatment of Urinary Tract Infection across a Large Pediatric Primary Care Network","authors":"David R. Karas, S. Upadhyayula, April Love, M. Bigham","doi":"10.1097/pq9.0000000000000655","DOIUrl":"https://doi.org/10.1097/pq9.0000000000000655","url":null,"abstract":"Introduction: Cystitis and pyelonephritis are common bacterial infections in infants and children, and initial treatment is usually empirical. Antimicrobial stewardship advocates using narrow-spectrum antibiotics with consideration for local resistance patterns. Narrow-spectrum antibiotic use is critical in addressing the global issue of bacterial antimicrobial resistance, associated with approximately 5 million annual deaths. Methods: The antimicrobial stewardship committee developed a guideline for diagnosing and managing urinary tract infections and distributed it to all primary care providers. A standardized order set provided clinical decision support regarding appropriate first-line antibiotic therapy. A chief complaint of dysuria prompted the use of the order set. Prescription rates for the most common antimicrobials were tracked on a control chart. Results: From March 2018 through March 2020, there were 4,506 antibiotic prescriptions for urinary tract infections. Utilization of the recommended first-line therapy, cephalexin, increased from 27.5% to 74.8%. Over the same period, trimethoprim-sulfamethoxazole, no longer recommended due to high local resistance, decreased from 31.8% to 8.1%. Providers have maintained these prescribing patterns since the conclusion of the project. Conclusion: Using clinical decision support as a standardized order set can sustainably improve the use of first-line antimicrobials for treating pediatric urinary tract infections.","PeriodicalId":343243,"journal":{"name":"Pediatric Quality and Safety","volume":"8 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"115848987","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-05-01DOI: 10.1097/pq9.0000000000000658
Michelle M. Gontasz, B. Chalk, Caroline Liang
Introduction: Despite the updated American Academy of Pediatrics recommendation for universal administration of the hepatitis B vaccine for newborns, delays in routine prophylaxis are common in the Neonatal Intensive Care Unit (NICU). Delayed immunization can increase perinatal acquisition risks and lead to subsequent delays in routine childhood immunization. This study aimed to increase the on-time administration of the birth dose of the hepatitis B vaccine from 46% to ≥70% at a level III and level IV NICU within the same health system. Methods: The stakeholder group developed project interventions using quality improvement methods, including implementing unit guidelines and a prompt in the progress note template. The outcome measure was the percent on-time administration of the initial hepatitis B vaccine for inborn NICU patients born to hepatitis B-negative mothers. The process measure was the percent on-time administration or a valid reason to delay immunization following the guidelines. Statistical process control P-charts graphically represented the measures to assess for change from January 2019 to May 2021. Results: In total, 2192 patients were included. The percent on-time administration improved from 48% to 57%. The percentage of on-time administration or valid reason to delay increased from 76% to 80%. Conclusions: Quality improvement methodology facilitated the identification of barriers to on-time hepatitis B prophylaxis in the NICU and the improvement of the timeliness of administration across 2 sites. Guidelines tailored to this population and changes to the progress note template successfully created and sustained change and may benefit other NICUs.
{"title":"Improving On-time Administration of the Initial Hepatitis B Vaccine in the NICU","authors":"Michelle M. Gontasz, B. Chalk, Caroline Liang","doi":"10.1097/pq9.0000000000000658","DOIUrl":"https://doi.org/10.1097/pq9.0000000000000658","url":null,"abstract":"Introduction: Despite the updated American Academy of Pediatrics recommendation for universal administration of the hepatitis B vaccine for newborns, delays in routine prophylaxis are common in the Neonatal Intensive Care Unit (NICU). Delayed immunization can increase perinatal acquisition risks and lead to subsequent delays in routine childhood immunization. This study aimed to increase the on-time administration of the birth dose of the hepatitis B vaccine from 46% to ≥70% at a level III and level IV NICU within the same health system. Methods: The stakeholder group developed project interventions using quality improvement methods, including implementing unit guidelines and a prompt in the progress note template. The outcome measure was the percent on-time administration of the initial hepatitis B vaccine for inborn NICU patients born to hepatitis B-negative mothers. The process measure was the percent on-time administration or a valid reason to delay immunization following the guidelines. Statistical process control P-charts graphically represented the measures to assess for change from January 2019 to May 2021. Results: In total, 2192 patients were included. The percent on-time administration improved from 48% to 57%. The percentage of on-time administration or valid reason to delay increased from 76% to 80%. Conclusions: Quality improvement methodology facilitated the identification of barriers to on-time hepatitis B prophylaxis in the NICU and the improvement of the timeliness of administration across 2 sites. Guidelines tailored to this population and changes to the progress note template successfully created and sustained change and may benefit other NICUs.","PeriodicalId":343243,"journal":{"name":"Pediatric Quality and Safety","volume":"37 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"126433076","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2022-10-18DOI: 10.1097/pq9.0000000000000609
A. Dissanayake, A. MacLellan, Q. Doan, V. Sabhaney, P. Virk
Introduction: Hand hygiene is critical in preventing the spread of healthcare-associated infections. Routine hand hygiene surveillance and education are common for clinical staff in pediatric acute care settings. However, nonclinical staff, including research personnel, are often excluded from these programs and therefore represent a gap in ongoing infection control efforts. This project aimed to evaluate the impact of evidence-based interventions on improving hand hygiene adherence among research personnel in the pediatric emergency department to meet provincial targets set for clinical staff. Methods: We used a Plan-Do-Study-Act approach to carry out a peer-driven, multimodal hand hygiene improvement strategy involving education, surveillance, and feedback targeted to research assistants working in a pediatric emergency department. Two anonymous peer evaluators observed hand hygiene practices in several specific instances (eg, before/after patient interactions) and determined adherence a priori. Results: In an open sample of clinical research assistants (Ntotal = 22), hand hygiene adherence increased from 12.5% to 89.1% over 11 months. Increases in adherence were particularly notable before entering the patient environment compared to exiting. Conclusions: Hand hygiene interventions targeting research personnel show potential success in acute care. Further quality improvement initiatives in larger research personnel samples must robustly evaluate the framework’s effectiveness.
{"title":"Improving research personnel’s hand hygiene adherence in the pediatric acute care setting during the COVID-19 pandemic: a quality improvement initiative","authors":"A. Dissanayake, A. MacLellan, Q. Doan, V. Sabhaney, P. Virk","doi":"10.1097/pq9.0000000000000609","DOIUrl":"https://doi.org/10.1097/pq9.0000000000000609","url":null,"abstract":"Introduction: Hand hygiene is critical in preventing the spread of healthcare-associated infections. Routine hand hygiene surveillance and education are common for clinical staff in pediatric acute care settings. However, nonclinical staff, including research personnel, are often excluded from these programs and therefore represent a gap in ongoing infection control efforts. This project aimed to evaluate the impact of evidence-based interventions on improving hand hygiene adherence among research personnel in the pediatric emergency department to meet provincial targets set for clinical staff. Methods: We used a Plan-Do-Study-Act approach to carry out a peer-driven, multimodal hand hygiene improvement strategy involving education, surveillance, and feedback targeted to research assistants working in a pediatric emergency department. Two anonymous peer evaluators observed hand hygiene practices in several specific instances (eg, before/after patient interactions) and determined adherence a priori. Results: In an open sample of clinical research assistants (Ntotal = 22), hand hygiene adherence increased from 12.5% to 89.1% over 11 months. Increases in adherence were particularly notable before entering the patient environment compared to exiting. Conclusions: Hand hygiene interventions targeting research personnel show potential success in acute care. Further quality improvement initiatives in larger research personnel samples must robustly evaluate the framework’s effectiveness.","PeriodicalId":343243,"journal":{"name":"Pediatric Quality and Safety","volume":"111 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2022-10-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"114984367","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2022-10-18DOI: 10.1097/pq9.0000000000000613
Amy Poppy, S. Ziniel, D. Hyman
Introduction: Hospitals have no standard for measuring comparative rates of serious safety events (SSE). A pediatric hospital safety collaborative has used a common definition and measurement system to classify SSE and calculate a serious safety event rate. An opportunity exists to evaluate the use of this measurement system. Methods: A web-based survey utilizing 7 case vignettes was sent to 132 network hospitals to assess agreement in classifying the vignettes as SSEs. Respondents classified the vignettes according to the taxonomy used at their respective organizations for deviations and SSE classification. Results: Of the 82 respondents, 67 (82%) utilized the same SSE classification system. Respondents did not assess deviations for 2 of the 7 vignettes, which had clear deviations. Of the remaining 5 vignettes, 3 had a substantial agreement of deviation (>85%, Gwet’s AC ≥ 0.68), and 2 had fair agreement (<70%, Gwet’s AC ≤ 0.39). Four of the 7 vignettes had a substantial agreement on SSE classification (>80%; Gwet’s AC ≥ 0.80), and 3 had slight to moderate agreement (<70%, Gwet’s AC ≤ 0.78). Conclusions: Results demonstrated agreement and variability in determining deviation and SSE classification in the 7 vignettes. Although the SSE methodology and metric used by participant pediatric hospitals yields generally similar review results, one must be cautious in using the SSE rate to compare patient safety outcomes across different hospitals.
{"title":"Variability in Serious Safety Event Classification among Children’s Hospitals: A Measure for Comparison?","authors":"Amy Poppy, S. Ziniel, D. Hyman","doi":"10.1097/pq9.0000000000000613","DOIUrl":"https://doi.org/10.1097/pq9.0000000000000613","url":null,"abstract":"Introduction: Hospitals have no standard for measuring comparative rates of serious safety events (SSE). A pediatric hospital safety collaborative has used a common definition and measurement system to classify SSE and calculate a serious safety event rate. An opportunity exists to evaluate the use of this measurement system. Methods: A web-based survey utilizing 7 case vignettes was sent to 132 network hospitals to assess agreement in classifying the vignettes as SSEs. Respondents classified the vignettes according to the taxonomy used at their respective organizations for deviations and SSE classification. Results: Of the 82 respondents, 67 (82%) utilized the same SSE classification system. Respondents did not assess deviations for 2 of the 7 vignettes, which had clear deviations. Of the remaining 5 vignettes, 3 had a substantial agreement of deviation (>85%, Gwet’s AC ≥ 0.68), and 2 had fair agreement (<70%, Gwet’s AC ≤ 0.39). Four of the 7 vignettes had a substantial agreement on SSE classification (>80%; Gwet’s AC ≥ 0.80), and 3 had slight to moderate agreement (<70%, Gwet’s AC ≤ 0.78). Conclusions: Results demonstrated agreement and variability in determining deviation and SSE classification in the 7 vignettes. Although the SSE methodology and metric used by participant pediatric hospitals yields generally similar review results, one must be cautious in using the SSE rate to compare patient safety outcomes across different hospitals.","PeriodicalId":343243,"journal":{"name":"Pediatric Quality and Safety","volume":"56 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2022-10-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"129366269","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2022-09-01DOI: 10.1097/pq9.0000000000000596
K. Raghavan, Jonathan D. Burlison, Edward M. Sanders II, M. Rossi
Introduction: Significant adverse drug events (ADEs) due to anesthesia infusion pump programming errors were reported at our institution. We incorporated independent two-provider infusion pump programming verification, an evidence-supported intervention, into our anesthesia medication infusion process with a goal of reducing associated ADEs to zero in 2 years. Methods: Using the model for improvement, we developed key drivers and interventions and utilized plan-do-study-act (PDSA) cycles. Drivers included education and training, verification process, visual aids, information technology, and safety culture. Interventions included anesthesia provider training, information dissemination, independent two-provider verification process of smart pump programming, verification documentation capability, verification compliance tracking, and visual aids. Our outcome measures were relevant ADEs and near-miss events. Process and balancing measures were the percentage of smart pump programs with independent second verification and delayed case starts due to second provider verification, respectively. Results: During the project period, only one related grade E ADE occurred, and the root cause was not conducting an independent pump programming verification. Thirteen grade B near-miss events were prevented due to independent second verification. Second verification adherence reached 85% and was sustained, and no delayed case starts occurred. Conclusions: With structured quality improvement methods, the process of independent two-provider verification of infusion pump programming during anesthesia can be successfully implemented, and errors in a high-volume setting reduced without negatively affecting case start times. The cultural and organizational factors we report may aid other institutions in gaining project buy-in and sustainment.
{"title":"Independent Double-check of Infusion Pump Programming: An Anesthesia Improvement Effort to Reduce harm.","authors":"K. Raghavan, Jonathan D. Burlison, Edward M. Sanders II, M. Rossi","doi":"10.1097/pq9.0000000000000596","DOIUrl":"https://doi.org/10.1097/pq9.0000000000000596","url":null,"abstract":"Introduction: Significant adverse drug events (ADEs) due to anesthesia infusion pump programming errors were reported at our institution. We incorporated independent two-provider infusion pump programming verification, an evidence-supported intervention, into our anesthesia medication infusion process with a goal of reducing associated ADEs to zero in 2 years. Methods: Using the model for improvement, we developed key drivers and interventions and utilized plan-do-study-act (PDSA) cycles. Drivers included education and training, verification process, visual aids, information technology, and safety culture. Interventions included anesthesia provider training, information dissemination, independent two-provider verification process of smart pump programming, verification documentation capability, verification compliance tracking, and visual aids. Our outcome measures were relevant ADEs and near-miss events. Process and balancing measures were the percentage of smart pump programs with independent second verification and delayed case starts due to second provider verification, respectively. Results: During the project period, only one related grade E ADE occurred, and the root cause was not conducting an independent pump programming verification. Thirteen grade B near-miss events were prevented due to independent second verification. Second verification adherence reached 85% and was sustained, and no delayed case starts occurred. Conclusions: With structured quality improvement methods, the process of independent two-provider verification of infusion pump programming during anesthesia can be successfully implemented, and errors in a high-volume setting reduced without negatively affecting case start times. The cultural and organizational factors we report may aid other institutions in gaining project buy-in and sustainment.","PeriodicalId":343243,"journal":{"name":"Pediatric Quality and Safety","volume":"14 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2022-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"127718934","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2022-09-01DOI: 10.1097/pq9.0000000000000590
K. Wolpert, Rebecca Kestle, Nicholas Weaver, Kelly Huynh, M. Yoo, R. Nelson, R. Lane
Introduction: Anaphylaxis is a life-threatening condition necessitating emergent management. However, the benefits of prolonged observation and indications for hospitalization are not well established. Through the implementation of a disposition-focused clinical decision support tool (CDST), this quality improvement initiative aimed to reduce hospitalization for low-risk patients presenting to the pediatric emergency department (PED) with anaphylaxis from 49% to ≤12% within 12 months of implementation. Methods: The intervention included patients 18 years and younger of age presenting with anaphylaxis to the PED. A multidisciplinary team identified a 2006 evidence-based guideline as a significant contributor to hospitalization. The updated guideline incorporated a disposition-focused CDST that stratified patients as low-risk or high-risk and recommended discharge of low-risk patients after a 4-hour observation period. The primary outcome measure was the percentage of low-risk patients hospitalized. Balancing measures included low-risk patient 72-hour return rate and PED length of stay for all comers. Secondary outcomes included a focused cost analysis. Results: Fifty-three children preintervention and 43 children postintervention presenting with anaphylaxis met low-risk criteria. Postimplementation, hospitalization of low-risk patients decreased from 49% to 7% (P < 0.0001). No low-risk patients returned in 72 hours for an anaphylaxis-related concern (P = 0.83). The median PED length of stay increased from 189 to 193 minutes (P < 0.0001). The median cost per low-risk encounter decreased by $377 (P = 0.013). Conclusions: After implementing an evidence-based disposition-focused CDST, hospitalization of low-risk patients presenting to the PED with anaphylaxis significantly decreased without an increase in 72-hour returns. In addition, patient encounters demonstrated cost savings.
{"title":"Reducing Admission for Anaphylaxis in a Pediatric Emergency Department Using a Clinical Decision Support Tool","authors":"K. Wolpert, Rebecca Kestle, Nicholas Weaver, Kelly Huynh, M. Yoo, R. Nelson, R. Lane","doi":"10.1097/pq9.0000000000000590","DOIUrl":"https://doi.org/10.1097/pq9.0000000000000590","url":null,"abstract":"Introduction: Anaphylaxis is a life-threatening condition necessitating emergent management. However, the benefits of prolonged observation and indications for hospitalization are not well established. Through the implementation of a disposition-focused clinical decision support tool (CDST), this quality improvement initiative aimed to reduce hospitalization for low-risk patients presenting to the pediatric emergency department (PED) with anaphylaxis from 49% to ≤12% within 12 months of implementation. Methods: The intervention included patients 18 years and younger of age presenting with anaphylaxis to the PED. A multidisciplinary team identified a 2006 evidence-based guideline as a significant contributor to hospitalization. The updated guideline incorporated a disposition-focused CDST that stratified patients as low-risk or high-risk and recommended discharge of low-risk patients after a 4-hour observation period. The primary outcome measure was the percentage of low-risk patients hospitalized. Balancing measures included low-risk patient 72-hour return rate and PED length of stay for all comers. Secondary outcomes included a focused cost analysis. Results: Fifty-three children preintervention and 43 children postintervention presenting with anaphylaxis met low-risk criteria. Postimplementation, hospitalization of low-risk patients decreased from 49% to 7% (P < 0.0001). No low-risk patients returned in 72 hours for an anaphylaxis-related concern (P = 0.83). The median PED length of stay increased from 189 to 193 minutes (P < 0.0001). The median cost per low-risk encounter decreased by $377 (P = 0.013). Conclusions: After implementing an evidence-based disposition-focused CDST, hospitalization of low-risk patients presenting to the PED with anaphylaxis significantly decreased without an increase in 72-hour returns. In addition, patient encounters demonstrated cost savings.","PeriodicalId":343243,"journal":{"name":"Pediatric Quality and Safety","volume":"54 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2022-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"128026346","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2022-09-01DOI: 10.1097/pq9.0000000000000589
Chisom Agbim, Marci J. Fornari, Emily Willner, Sarah C. Isbey, D. Berkowitz, Katura Palacious, G. Badolato, M. McIver
Introduction: Anaphylaxis is a potentially fatal systemic reaction that requires prompt recognition and targeted treatment. Despite international consensus and national guidelines, there is often incomplete care for pediatric patients discharged from the emergency department (ED) with a diagnosis of anaphylaxis. Our institution experienced wide variability in discharge planning for patients with anaphylaxis. The goal of our study was to improve care at ED discharge for pediatric patients with anaphylaxis using a quality improvement framework. The specific aims were to increase the frequency of patients diagnosed with anaphylaxis who receive an anaphylaxis action plan at ED discharge from 0% to 60% and to increase referrals to an allergy clinic from a baseline of 61%–80% between October 2020 and April 2021. Methods: Targeted interventions included revisions to the electronic health record system, forging interdisciplinary partnerships and emphasizing provider education. Outcome measures were the proportion of patients receiving an anaphylaxis action plan and an allergy clinic follow-up. The balancing measure was the ED length of stay. Results: The study showed an increase in anaphylaxis action plans from 0% to 34%. Allergy clinic referral rates improved from 61% to 82% within the same period. The average length of stay of 347 minutes remained unchanged. Conclusions: Revising the discharge instructions to include an anaphylaxis action plan and reinforcing provider behaviors with educational interventions led to an overall improvement in discharge care for patients with anaphylaxis. Future work will focus on electronic health record changes to continue progress in additional clinical settings.
{"title":"Improving Care at Emergency Department Discharge for Pediatric Patients with Anaphylaxis Using a Quality Improvement Framework","authors":"Chisom Agbim, Marci J. Fornari, Emily Willner, Sarah C. Isbey, D. Berkowitz, Katura Palacious, G. Badolato, M. McIver","doi":"10.1097/pq9.0000000000000589","DOIUrl":"https://doi.org/10.1097/pq9.0000000000000589","url":null,"abstract":"Introduction: Anaphylaxis is a potentially fatal systemic reaction that requires prompt recognition and targeted treatment. Despite international consensus and national guidelines, there is often incomplete care for pediatric patients discharged from the emergency department (ED) with a diagnosis of anaphylaxis. Our institution experienced wide variability in discharge planning for patients with anaphylaxis. The goal of our study was to improve care at ED discharge for pediatric patients with anaphylaxis using a quality improvement framework. The specific aims were to increase the frequency of patients diagnosed with anaphylaxis who receive an anaphylaxis action plan at ED discharge from 0% to 60% and to increase referrals to an allergy clinic from a baseline of 61%–80% between October 2020 and April 2021. Methods: Targeted interventions included revisions to the electronic health record system, forging interdisciplinary partnerships and emphasizing provider education. Outcome measures were the proportion of patients receiving an anaphylaxis action plan and an allergy clinic follow-up. The balancing measure was the ED length of stay. Results: The study showed an increase in anaphylaxis action plans from 0% to 34%. Allergy clinic referral rates improved from 61% to 82% within the same period. The average length of stay of 347 minutes remained unchanged. Conclusions: Revising the discharge instructions to include an anaphylaxis action plan and reinforcing provider behaviors with educational interventions led to an overall improvement in discharge care for patients with anaphylaxis. Future work will focus on electronic health record changes to continue progress in additional clinical settings.","PeriodicalId":343243,"journal":{"name":"Pediatric Quality and Safety","volume":"37 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2022-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"127475754","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2022-09-01DOI: 10.1097/pq9.0000000000000601
Judson A. Moore, Lindsay Eilers, Amanda J Willis, Michael D. Chance, Julie A. La Salle, Ellen H. Delgado, Katie M. Bien, Jordana R. Goldman, S. Sheth
Introduction: Patient transfers pose a potential risk during hospitalizations. Structured communication practices are necessary to ensure effective handoffs, but occur amidst competing priorities and constraints. We sought to design and implement a multidisciplinary process to enhance communication between pediatric cardiovascular intensive care unit and cardiology floor teams with a comprehensive approach evaluating efficiency, safety, and culture. Methods: We conducted a prospective quality improvement study to enact a bed-availability triggered bedside handoff process. The primary aim was to reduce the time between handoff and unit transfer. Secondary metrics captured the impact on safety (reported safety events, overnight transfers, bounce backs, and I-PASS utilization), efficiency (transfer latency, unnecessary patient handoffs, and cumulative time providers were engaged in handoffs), and culture (team members perceptions of satisfaction, collaboration, and handoff efficiency via survey data). Results: Eighty-two preimplementation surveys, 26 stakeholder interviews, and 95 transfers were completed during the preintervention period. During the postintervention period, 145 handoffs were audited. We observed significant reductions in transfer latency, unnecessary handoffs, and cumulative provider handoff time. Overnight transfers decreased, and no negative impact was observed in reported safety events or bouncebacks. Survey results showed a positive impact on collaboration, efficiency, and satisfaction among team members. Conclusions: Developing safer handoff practices require a collaborative, structured, and stepwise approach. Advances are attainable in high-volume centers, and comprehensive measurement of change is necessary to ensure a positive impact on the overall patient and provider environment.
{"title":"Comprehensive Improvement of Cardiology Inpatient Transfers: A Bed-availability Triggered Approach","authors":"Judson A. Moore, Lindsay Eilers, Amanda J Willis, Michael D. Chance, Julie A. La Salle, Ellen H. Delgado, Katie M. Bien, Jordana R. Goldman, S. Sheth","doi":"10.1097/pq9.0000000000000601","DOIUrl":"https://doi.org/10.1097/pq9.0000000000000601","url":null,"abstract":"Introduction: Patient transfers pose a potential risk during hospitalizations. Structured communication practices are necessary to ensure effective handoffs, but occur amidst competing priorities and constraints. We sought to design and implement a multidisciplinary process to enhance communication between pediatric cardiovascular intensive care unit and cardiology floor teams with a comprehensive approach evaluating efficiency, safety, and culture. Methods: We conducted a prospective quality improvement study to enact a bed-availability triggered bedside handoff process. The primary aim was to reduce the time between handoff and unit transfer. Secondary metrics captured the impact on safety (reported safety events, overnight transfers, bounce backs, and I-PASS utilization), efficiency (transfer latency, unnecessary patient handoffs, and cumulative time providers were engaged in handoffs), and culture (team members perceptions of satisfaction, collaboration, and handoff efficiency via survey data). Results: Eighty-two preimplementation surveys, 26 stakeholder interviews, and 95 transfers were completed during the preintervention period. During the postintervention period, 145 handoffs were audited. We observed significant reductions in transfer latency, unnecessary handoffs, and cumulative provider handoff time. Overnight transfers decreased, and no negative impact was observed in reported safety events or bouncebacks. Survey results showed a positive impact on collaboration, efficiency, and satisfaction among team members. Conclusions: Developing safer handoff practices require a collaborative, structured, and stepwise approach. Advances are attainable in high-volume centers, and comprehensive measurement of change is necessary to ensure a positive impact on the overall patient and provider environment.","PeriodicalId":343243,"journal":{"name":"Pediatric Quality and Safety","volume":"1 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2022-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"129856750","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2022-09-01DOI: 10.1097/pq9.0000000000000591
Rachel Feldman, Daniel Low, Irina Gorbounova, L. Ambartsumyan, Lynn D Martin
Introduction: In the current healthcare climate, the financial strain created by COVID-19, limited resources, and case backlogs highlight the need to optimize operating and procedure room efficiency and maximize capacity. At Seattle Children’s, a clinical multidisciplinary team developed and implemented a data-driven protocol to improve efficiency in a high-volume gastrointestinal (GI) suite. Methods: Key process measures, including all case on-time starts and postanesthesia care unit length of stay, were extracted from the electronic medical record and presented as Statistical Process Control (SPC) charts. Clinicians’ performance was stratified by rational subgrouping to better understand variation in the system. We defined an expert clinician as one who performs beyond 3-sigma limits on funnel plot analyses. We developed clinical protocols based on expert clinician clinical practices. We gave clinicians dynamic, daily feedback on this family of measures through continuously updated SPC charts. This real-world data drove system and individual-level plan-do-check-act improvement cycles. Results: Despite significant external challenges over 2 years, procedure volume increased by approximately 25%, on-time starts improved by 36%, turnover time decreased by 34%, and postanesthesia care unit length of stay decreased by 15%. GI laboratory revenue increased by approximately 25% (independent of increased charges per procedure), representing the potential for a $2 million increase in annual revenue. Conclusions: A multidisciplinary clinical team improved efficiency metrics in a busy pediatric GI suite. Access to real-world data through continuously updated SPC charts enabled plan-do-check-act cycles that led to measurable improvement. This data access also served to sustain team motivation and engagement.
{"title":"Leveraging Real-world Data to Increase Procedure Room Capacity: A Multidisciplinary Quality Improvement Project","authors":"Rachel Feldman, Daniel Low, Irina Gorbounova, L. Ambartsumyan, Lynn D Martin","doi":"10.1097/pq9.0000000000000591","DOIUrl":"https://doi.org/10.1097/pq9.0000000000000591","url":null,"abstract":"Introduction: In the current healthcare climate, the financial strain created by COVID-19, limited resources, and case backlogs highlight the need to optimize operating and procedure room efficiency and maximize capacity. At Seattle Children’s, a clinical multidisciplinary team developed and implemented a data-driven protocol to improve efficiency in a high-volume gastrointestinal (GI) suite. Methods: Key process measures, including all case on-time starts and postanesthesia care unit length of stay, were extracted from the electronic medical record and presented as Statistical Process Control (SPC) charts. Clinicians’ performance was stratified by rational subgrouping to better understand variation in the system. We defined an expert clinician as one who performs beyond 3-sigma limits on funnel plot analyses. We developed clinical protocols based on expert clinician clinical practices. We gave clinicians dynamic, daily feedback on this family of measures through continuously updated SPC charts. This real-world data drove system and individual-level plan-do-check-act improvement cycles. Results: Despite significant external challenges over 2 years, procedure volume increased by approximately 25%, on-time starts improved by 36%, turnover time decreased by 34%, and postanesthesia care unit length of stay decreased by 15%. GI laboratory revenue increased by approximately 25% (independent of increased charges per procedure), representing the potential for a $2 million increase in annual revenue. Conclusions: A multidisciplinary clinical team improved efficiency metrics in a busy pediatric GI suite. Access to real-world data through continuously updated SPC charts enabled plan-do-check-act cycles that led to measurable improvement. This data access also served to sustain team motivation and engagement.","PeriodicalId":343243,"journal":{"name":"Pediatric Quality and Safety","volume":"1 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2022-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"117096323","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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