Pediatric quality & safety最新文献

Introduction: Congenital hypothyroidism (CH) is a common endocrine disorder that requires optimal management and intensive follow-up to prevent neurocognitive impairment, especially within the first 3 years of life.

Methods: We implemented a quality improvement (QI) initiative to standardize care and reduce loss to follow-up for children younger than 3 years with CH. The project was conducted in a pediatric endocrinology clinic at a large tertiary hospital in the Midwestern United States from January 2021 to December 2024. The primary aim was to increase the percentage of patients younger than 3 years with CH who achieved 2 or more normal thyroid-stimulating hormone (TSH) levels within a rolling 12-month period, from a baseline of 77% to a goal of greater than 95%. A multidisciplinary QI team-endocrinologists, nurses, social workers, administrative staff, a certified QI specialist, and care coordinators-used Plan-Do-Study-Act cycles to optimize care. Data were collected monthly from the electronic medical record to identify patients who did not meet TSH targets or missed clinic visits. Key interventions included case management, standardized caregiver education, and identification of high-risk patients. The monthly cohort consisted of 74-124 children younger than 3 years with CH.

Results: After 12 months of intervention, this initiative increased the percentage of unique patients younger than 3 years with CH who achieved 2 normal TSH values within a rolling 12-month period, from a baseline of 77%-94%-an improvement that has been sustained.

Conclusions: This QI initiative highlights the importance of interdisciplinary collaboration in improving the clinical care of pediatric patients with CH.

Introduction: Despite the American Academy of Pediatrics recommendations to use validated developmental screening tools, national adoption remains low. To address this, we launched a quality improvement project to implement the Survey of Well-being of Young Children (SWYC) in our residency clinic and assess its impact. Our primary aim was to achieve more than 50% screening coverage for early childhood well visits, with equitable implementation across both English-speaking and non-English primary speaking families. We also hypothesized that the implementation of SWYC would equitably increase early intervention (EI) referral rates across language groups.

Methods: We included children aged 8-33 months attending well-child visits. Interventions included staff education, daily huddles, and the SWYC integration into the electronic health record. Social work (SW) referrals, though not exclusive to EI, were used as an imperfect proxy, as a designated SW initiates EI referrals in our clinic. We compared referral rates before and after implementation using chi-square tests.

Results: SWYC usage reached 50% within 4 months of implementation. There was no significant difference in SWYC use between English and non-English primary speakers (P = 0.131). SW referral rates increased by 2.9 percentage points after implementation (P = 0.009), with no significant difference in SW referral rates between language groups (P = 0.922).

Conclusions: This quality improvement project highlighted the rapid adoption of a standardized developmental screening tool, resulting in increased SW referrals, which suggests improved identification of developmental concerns with language equity between English and non-English primary speaking families. Standardized screening is an important step in improving developmental outcomes and supporting care equity.

Introduction: As of March 30, 2022, the Food and Drug Administration recommended thyroid function testing for children less than 4 years of age within 3 weeks of receiving intravenous iodinated contrast due to an increased risk of thyroid dysfunction. Multifaceted solutions are needed to identify patients at risk of hypothyroidism, ensure timely testing, interpret results, and communicate information to primary care providers and caregivers. Our objective was to increase compliance with thyroid function test (TFT) completion or communication of the need for TFTs to 20% within 3 months and to 75% within 12 months.

Methods: We identified patients using the following inclusion criteria: age less than 4 years and receipt of intravenous iodinated contrast. Electronic medical record tools, including conditional and automated SmartText in radiology reports, discharge summaries, and after-visit summaries, were used to identify patients and improve cross-encounter communication.

Results: We identified 446 children who met the inclusion criteria. Of these, 42% (n = 189) had high-risk comorbidities. Compliance with communicating the need for TFTs to primary care providers through discharge summaries increased from a mean of 5% to 60% and with caregivers through after-visit summaries from a mean of 5% to 81% in 13 months. The percentage of TFTs completed increased from a mean of 10% to 22%, of which 22% (n = 22) were abnormal. Four patients received thyroid hormone supplementation.

Conclusions: This project has successfully achieved its aim. Although this recommendation is unique to a small cohort of patients, similar strategies could be used to identify patients and coordinate follow-up testing across encounters.

Introduction: Asthma is the most common chronic illness in pediatrics, placing a significant burden on patients and the healthcare system. The lack of standardization in screening, diagnosis, and treatment remains a key challenge in pediatric asthma management. This project used the Project BREATHE toolkit, supplied through the New York State Department of Health, to implement a care process for children with asthma receiving care at our institution. Our primary objective was to enhance asthma care through a quality improvement framework to optimize outcomes and reduce healthcare usage.

Methods: Following identifying key drivers contributing to suboptimal asthma care in our region, our transdisciplinary team developed a standardized asthma care process. From July 2020 to June 2021, the process was systematically applied to all patients admitted with a diagnosis of asthma. Control charts were reviewed monthly to assess adherence and uptake of care process components, facilitating continuous quality improvement and data-driven modifications.

Results: Following implementation, inhaled corticosteroid prescriptions increased from 50% to 81%, whereas subspecialist consults rose from 8.3% to 77%. The proportion of patients receiving asthma severity assessments ranged from 71% to 90%, and the rates of asthma education fluctuated from 50% to 89%. Additionally, the rate of emergency department visits declined from 5.2% to 4.7% and hospitalizations from 12.7% to 10.1% following implementation.

Conclusions: Implementing a transdisciplinary asthma care process resulted in sustained improvements in asthma management and reduced asthma-related emergency department visits and hospitalizations. These findings highlight the effectiveness of a structured, team-based approach in optimizing pediatric asthma care.

Introduction: Partnering with and educating families in the neonatal intensive care unit (NICU) is critical for infant neurodevelopment, parent wellness, and family support. Early family integration in care improves both short-term and long-term outcomes. This quality improvement project has 2 specific aims: (1) increase the percentage of small babies (born at <28 wk of gestation or <1000 g) whose families participated in a multidisciplinary family-centered care conference (FCCC) from 0% to 50%, and (2) increase family attendance at the first NICU follow-up clinic from 74% to 90%.

Methods: Using the model for improvement, we conducted plan-do-study-act cycles with iterative interventions to achieve our aims. The FCCCs focused on promoting family involvement at the bedside, infant neurodevelopment, skin-to-skin care, family support, and transitions within the NICU and after discharge. Outcome, process, and balancing measures were tracked and analyzed for special cause variation using statistical process control charts.

Results: Within 18 months, the percentage of infants whose families participated in an FCCC increased from 0% to 39% (48/123). Based on the post-FCCC survey, families found the FCCC helpful in providing information on how they can be involved in their infant's care. They recommended the FCCC to other families, and they expressed interest in a second FCCC focused on preparing for the transition home.

Conclusions: Family participation in a multidisciplinary FCCC increased over time but has not yet achieved the stated goal. We anticipate that further plan-do-study-act cycles will improve adherence to a robust FCCC program by integrating families into their infants' care during critical developmental stages.

Introduction: Penicillins are first-line treatments for many childhood infections, but providers avoid them when patients report a penicillin allergy, although approximately 94% of these patients may tolerate penicillin. Patients with penicillin allergy labels often receive second-line antibiotics, which increases the risk of treatment failure and adverse events. To address this, programs to implement penicillin allergy de-labeling have increased; however, strategies to accomplish de-labeling most efficiently through guideline dissemination have not been well-studied.

Methods: A multidisciplinary team created an evidence-based screening algorithm and standard protocol to screen eligible pediatric inpatients and de-label documented penicillin allergies. Plan-do-study-act cycles identified opportunities for improvement to the standard protocol.

Results: We developed a screening tool to assess the risk of penicillin allergy and integrated it into the electronic health record for administration by clinical nurses. Follow-up actions, including de-labeling or further testing, are automatically communicated to the provider. Nurse-initiated screening increased from 3.8% to 28.1% after adding an electronic "worklist task" reminder. Allergy de-labeling demonstrated special cause variation following the dissemination of a standardized amoxicillin challenge order set and then again after a brief period of audit and feedback; however, the increases were not sustained.

Conclusions: A nurse-administered screening questionnaire and protocolized follow-up actions can help achieve safe de-labeling at hospitals without a dedicated penicillin allergy service.

Introduction: Earlier therapeutic hypothermia (TH) is associated with improved neurodevelopmental outcomes in infants with hypoxic-ischemic encephalopathy (HIE). We aimed to increase the percentage of inborn infants with TH initiation before 3 hours from 25% to 75% within 12 months.

Methods: This project took place at 2 academically affiliated Level III NICUs. We included infants inborn with moderate or severe HIE who met standard criteria for TH. The team developed a driver diagram and process map, which informed interventions. We compared data using descriptive statistics and Statistical Process Control charts.

Results: Of the 70 included infants, 13 were in the baseline period, and 57 were in the implementation and sustainment period. There was a special cause variation that increased the centerline from 25% to 72%. The most common cause of initiation of TH after 3 hours of life was progression from mild to moderate HIE (39%). When infants with progression of encephalopathy were excluded, the central line further increased to 79%. In this refined cohort, the mean percentage of infants with TH initiated before 3 hours was 31%, 76%, and 80% in the baseline, implementation, and sustainment periods, respectively.

Conclusions: Quality improvement methodology can reduce the time to TH initiation in inborn infants, which is associated with improved neurodevelopmental outcomes. A common reason for delayed TH initiation is progression from mild to moderate encephalopathy.

Introduction: Discharging patients with new nasogastric tubes (NGTs) for enteral nutrition at home is complex and requires intricate care coordination and education from a multidisciplinary team. We designed a quality improvement (QI) initiative to improve efficiency and decrease variation in care coordination for patients discharged with a new NGT. Our objective was to reduce mean modified hospital length of stay (mLOS) by 10% from baseline within 6 months and sustain improvement for 12 months.

Methods: Applying the Model for Improvement, we used plan-do-study-act cycles to improve NGT discharge care coordination using a multidisciplinary team. Primary interventions rooted in Lean methodology included creating a standardized discharge algorithm, utilizing nurse practitioners as care coordination champions, routine consultation of an enteral tube service (ETS), and implementing a formula substitution guide. The primary outcome measure was mean mLOS. The process measure was the time from NGT placement to ETS consult. Balancing measures were ETS consult volume and 30-day healthcare reutilization. Statistical process control charts measured the impact of interventions.

Results: Baseline mLOS decreased from 8.2 to 7.4 days with a sustained reduction in process variability over time. Time from NGT placement to ETS consult decreased from 4.1 to 3.0 days. There were no changes in 30-day healthcare reutilization or ETS consult volume over time.

Conclusions: A multidisciplinary quality improvement initiative effectively improved complex NGT transitional care planning and was sustained over time.

Introduction: Asthma pathways reduce hospital length of stay (LOS), and respiratory therapists (RTs) can optimize care. This study aimed to use quality improvement methods to implement an asthma-specific RT role and RT-driven asthma pathway. The SMART aim was to reduce LOS for pediatric patients admitted for asthma to the general inpatient units by 20% within 22 months.

Methods: We included children 2-17 years of age who were admitted to a general inpatient unit for asthma. We excluded patients transferred from another hospital, initially admitted to the pediatric intensive care unit, or with comorbidities predisposed to severe respiratory illnesses. We used the Model for Improvement to design and study interventions. Key drivers focused on standardizing care, leveraging provider expertise, and supporting providers with education and technology. The outcome measure was LOS. The main process measure was the early transition to an albuterol metered-dose inhaler. Balancing measures were hospital reutilization rates and escalation of care. We used statistical process control charts and run charts to analyze the data.

Results: The study included 743 patients, with 339 in the intervention period. The intervention group had a younger median age (4 [3, 7] versus 6 [3, 10] years, P < 0.001) and more publicly insured patients (84% versus 68%, P < 0.001). LOS decreased from 39.4 to 30.7 hours, achieving our SMART aim without adversely affecting the balancing measures.

Conclusions: Quality improvement methodology aids in implementing an RT-driven asthma pathway on the pediatric floors to decrease LOS without adversely influencing hospital reutilization rates or transfers for escalation of care.

Introduction: Pain episodes are the most common emergency department (ED) presentation for patients with sickle cell disease (SCD). Prompt pain medication and frequent pain assessments are recommended. Our SMART aim was to reduce the time from ED rooming to first analgesia administration for children presenting with SCD pain from 50 to less than 30 minutes by June 2024.

Methods: Children presenting to the ED with a diagnosis of SCD requiring opioids for pain were included. The primary outcome was time from rooming to analgesia. A key driver diagram, developed by a multidisciplinary team, informed our interventions and then implemented through plan-do-study-act cycles. Statistical process control charts were used to analyze data with Nelson rules to detect special cause variation. Secondary measures included frequency of pain assessments in the first 2 hours and ED length of stay.

Results: From July 2020 to June 2024, there were 447 eligible encounters. Baseline data (n = 143) revealed an average time from ED rooming to analgesia of 50 minutes. Following interventions, including order set implementation, multidisciplinary collaboration, and incorporating the home action plan in the ED, special cause variation was detected with a centerline shift to 32 minutes. The median number of pain assessments in the first 2 hours of arrival improved from 2.2 to 2.7 with order set utilization. ED length of stay remained unchanged.

Conclusions: Standardizing care with an order set increased the number of pain assessments. Incorporation of the SCD home pain action plan into the ED treatment pathway decreased the time to analgesia.