Pediatric quality & safety最新文献

Introduction: Inflammatory bowel disease (IBD), including ulcerative colitis and Crohn disease (CD), presents significant challenges in management, particularly regarding standardized endoscopic scoring. This study aimed to assess and improve procedural documentation practices among endoscopists managing newly diagnosed pediatric IBD (PIBD).

Methods: This quality improvement project involved a preintervention review of records for newly diagnosed patients with PIBD from January 2022 to December 2022 and a postintervention review of records from March 2023 to March 2024. We evaluated procedural documentation practices pre- and postintervention using control charts. We conducted an educational session on standardized procedural documentation for endoscopists in March 2023. Standardized procedural documentation was defined as the Mayo endoscopic score for ulcerative colitis and the simple endoscopic score for CD. We displayed a reminder flow diagram on the computer used by endoscopists for their procedural documentation.

Results: In the preintervention period (n = 29), endoscopists used standardized documentation in 21% of cases (6/29). Postintervention (n = 43), standardized documentation use increased to 72% (31/43), demonstrating a 51% improvement. Subgroup analysis revealed variable adoption rates, with 100% for IBD-undetermined and 0% for patients with very early onset IBD. Control p-chart revealed a downward trend in the defect rate in the later months, suggesting improved adherence.

Conclusions: Our initiative significantly enhanced the utilization of standardized endoscopic documentation among endoscopists for newly diagnosed patients with PIBD. This improvement underscores the effectiveness of structured educational strategies in promoting adherence to best practices. Future efforts should focus on sustaining these gains and addressing subgroup-specific challenges to optimize patient care in IBD management.

Introduction: The 2022 American Academy of Pediatrics Clinical Practice Guideline revision for newborn hyperbilirubinemia raised thresholds for phototherapy initiation. Our global aim was to align care across 2 partner hospitals with the revised clinical practice guideline. Our aim was to decrease readmissions for phototherapy by 20% in 12 months.

Methods: Using the model for improvement, a stakeholder team conducted this quality improvement initiative at our state's largest birthing hospital and partner pediatric hospital. We collected baseline data from January to August 2022 and implementation data from September 2022 to February 2024. We included newborns 14 days or younger readmitted to the pediatric hospital general ward for phototherapy. Interventions included provider education, local clinical guidelines, and electronic medical record updates. Outcome measures of count and rate of monthly readmissions were tracked on a C chart and U chart, respectively. The process measure of time between occurrence of subthreshold phototherapy initiation was tracked on a t-chart. The balancing measure of the length of stay was analyzed on an XbarS chart. We assessed special cause variation using established statistical process control chart rules.

Results: A total of 10,620 deliveries occurred, with 104 readmissions for hyperbilirubinemia. The mean count of monthly readmissions decreased from 5.8 to 2.4 from the baseline to the implementation period; the rate of monthly readmissions decreased from 1.4% to 0.6%. Mean days between the occurrence of subthreshold phototherapy initiation increased from 15.5 to 62.5 days. The average length of stay remained at 21.5 hours.

Conclusions: This partner hospital initiative significantly decreased newborn hyperbilirubinemia readmissions.

Introduction: During a nationwide surge in asthma exacerbations in the fall of 2022, there was a critical shortage of albuterol nebulizer solution, requiring our institution to explore ways to conserve nebulized albuterol. The metered-dose inhaler (MDI) and vibrating mesh nebulizer (VMN) offer more efficient methods of albuterol administration. We aimed to incorporate alternative albuterol administration methods within our emergency department (ED) to decrease the amount of nebulized albuterol solution administered for asthma exacerbations.

Methods: We assessed the average cumulative albuterol dose per patient encounter 28 months before our interventions. Our multidisciplinary team developed interventions using QI methods, modifying the ED asthma clinical practice guideline and associated electronic order set to incorporate the MDI and VMN. The primary outcome was decreasing the average cumulative dose of nebulized albuterol per patient encounter. Balancing measures include ED length of stay (LOS), hospital admissions, and revisit rates within 24 hours.

Results: This project began in May 2023, with 2,781 patients included in the subsequent 16 months postproject implementation. We identified special cause variation in the average dose of albuterol nebulization decreasing from 17.42 to 11.57 mg per encounter, which was sustained postintervention. Although we saw decreased ED LOS for discharged patients, there were no changes in overall ED LOS, admissions, or revisit rates.

Conclusions: Changes to the clinical practice guidelines and order set incorporating alternative albuterol administration methods led to a sustained decrease in the average dose of nebulized albuterol used per patient encounter.

Introduction: High reliability organization principles are an established approach to reducing risk in highly complex environments. Our hospital recognized an opportunity to integrate these principles during the disruption of the COVID-19 pandemic.

Methods: This work took place at our quaternary pediatric hospital. Interventions fell within 3 categories: optimizing structure for success, measurement and transparency, and assigning accountability and empowering all. Our outcome measures of interest were several significant safety events meeting predefined definitions per month, and our process metric was the total number of events reported in our safety event reporting system.

Results: Following multiple cycles of interventions, the U chart of high-impact safety events per month demonstrated a centerline shift from 5.6 to 8.5 events per 10,000 adjusted patient days in April 2021 and a subsequent shift down to 5.9 events per 10,000 adjusted patient days in March 2023. A U chart of safety reports showed a decrease from 47.2 to 29.9 events per 1,000 adjusted patient days in April 2020, subsequently increasing to 39.9 events per 1,000 adjusted patient days in March 2022.

Conclusions: Through interventions focused on high reliability organization principles, our hospital successfully increased the detection of high-impact safety events and then decreased the number of these serious events. We implemented these interventions despite the disruptions of the COVID-19 pandemic, and they have served as a protective mechanism during subsequent system stressors.

Introduction: Appendicitis is the most common pediatric surgical emergency, and computed tomography (CT) remains an overused diagnostic test for appendicitis. Our institutional rate of CT utilization for suspected appendicitis was higher than in peer children's hospitals, so we aimed to reduce CT utilization during the evaluation of pediatric appendicitis from 31.3% to 15% within 12 months.

Methods: From September 2021 to October 2022, we conducted a multidisciplinary quality improvement initiative among patients evaluated for appendicitis in the pediatric emergency department (PED). Interventions included standardizing evaluation with a clinical practice guideline, an order set in the electronic medical record for clinical decision support, and radiologist use of an ultrasound report template. The primary measure was the percentage of patients undergoing evaluation for appendicitis who received an abdominal CT scan. Process measures were the timing of surgical consultation and ultrasound report template use. Balancing measures included negative pathology appendectomies and PED return visits within 72 hours with subsequent appendicitis diagnosis. We analyzed data using statistical process control charts and Nelson rules to detect special cause variation.

Results: We evaluated a total of 2,010 patients for acute appendicitis, with 624 representing baseline encounters with a CT rate of 31.3%. Quality improvement interventions reduced the CT rate to 12.1% sustained for 10 months without impacting the rate of negative pathology appendectomy or PED return visits within 72 hours.

Conclusions: Quality improvement methodology led to a sustained reduction in CT utilization for patients undergoing evaluation for appendicitis in a PED.

Introduction: Timely outpatient follow-up after hospitalization for asthma exacerbation is essential for ongoing management and preventing future episodes. We identified significant variability in scheduling postdischarge pulmonology follow-up, leading to inconsistent care. This quality improvement initiative aimed to ensure at least 90% of patients admitted for an acute asthma exacerbation who had been seen by the pulmonology team scheduled for an outpatient pulmonary follow-up with an 80% attendance rate within 45 days of hospital discharge.

Methods: A multidisciplinary team developed 3 key drivers. Key interventions included developing standardized asthma care guidelines and ensuring timely pulmonary consultation for all patients admitted to the pediatric intensive care unit with asthma exacerbation. The pulmonary team was also notified of patients previously seen by the department who were admitted to the floor for asthma exacerbation. The outcome measures included the percentage of patients admitted with asthma exacerbation scheduled for pediatric pulmonology follow-up appointments within 45 days and the percentage attending those appointments.

Results: The percentage of scheduled appointments increased from 58.7% to 97.3%, and the appointment attendance rate improved from 45.3% to 85.2%. A retrospective review 3 years after the project's implementation showed sustained improvement, with 93% of appointments scheduled and 82.7% attended.

Conclusions: Scheduling pulmonary follow-up appointments before discharge and using active reminders with immediate rescheduling of cancelations improved outpatient visit attendance. Further research is needed to confirm whether timely follow-up enhances asthma control and reduces readmissions.

Introduction: Adolescents and young adults (AYAs) account for approximately half of all new diagnoses of sexually transmitted infections (STIs) in the United States. Screening AYA men is imperative to stopping the spread of infection as well as preventing long-term sequelae. Although our AYA medical practice has consistently screened AYA women at rates more than 80% annually, the baseline screening rate for men was less than 70%.

Methods: Between May 2021 and October 2023, we conducted a quality improvement initiative among male primary care patients older than 15 years who had an annual physical within the past 3 years. Interventions included adding a bathroom sign clearly stating urine would not be used for drug testing and creating and implementing a chlamydia and gonorrhea (GC/CT) testing alert in the electronic health record for all male medical visits. Our primary outcome was the percentage of patients who received GC/CT screening.

Results: Statistical process control p-chart analysis showed special cause variation with improved GC/CT screening rates among AYA men in primary care, including a significant increase in the mean screening rate from 73.5% to 83.5% following our second intervention, demonstrating a mean shift from previous results.

Conclusions: Clinic-level interventions-bathroom signage indicating urine would not be used for drug testing did not improve STI screening rates, whereas an electronic health record prompt for clinic staff regarding the need for STI testing-improved GC/CT screening rates among AYA men in primary care.

Introduction: Late-onset sepsis (LOS) is a common cause of neonatal morbidity and mortality. Professional organizations recommend avoiding empiric vancomycin use in neonates without risk factors for methicillin-resistant Staphylococcus aureus infection. We aimed to reduce the mean vancomycin antibiotic utilization rate (AUR) by 30% for 12 months in our neonatal intensive care unit (NICU).

Methods: We included neonates admitted to our level-3 NICU from March 15, 2023, to February 29, 2024, with suspected LOS in the intervention period. A multidisciplinary team used the Model for Improvement. Interventions tested using plan-do-study-act cycles included provider education, clinical practice guideline (CPG) implementation, and prospective audit with feedback (PAF). The outcome measure was the mean vancomycin AUR measured in days of therapy per 1,000 patients days, plotted monthly and analyzed for special cause variation. The process measure was CPG adherence. We tracked balancing measures related to morbidity and mortality.

Results: During the intervention period, 50 neonates underwent LOS evaluations. The mean vancomycin AUR decreased by 37.1%, from 27 to 17 days of therapy per 1,000 patient days, and was sustained postintervention. CPG adherence was 96%. Three neonates required changing from oxacillin to vancomycin for coagulase-negative staphylococci bacteremia (n = 2) and urinary tract infection (n = 1). There were no drug-related morbidity or sepsis-related mortality events.

Conclusions: This quality improvement project allowed a safe, rapid and sustained reduction of NICU-wide vancomycin use. Provider education, CPG implementation, and PAF were critical to optimizing empiric antibiotic management.

Introduction: Fluid overload, the pathologic state of positive fluid balance, is common in the pediatric intensive care unit (PICU) and is independently associated with poor outcomes. Quality improvement-based processes to measure and assess fluid balance in critically ill children are lacking.

Methods: The primary aim was to develop and implement a fluid management strategy that includes the standardized measurement and assessment of fluid balance, which is adhered to in at least 50% of all PICU patients. The 4 components of the strategy include (1) creating a fluid balance dashboard that tracks percent cumulative fluid balance over time, (2) documentation of daily weights, (3) fluid balance reporting and discussion incorporated into standardized rounds, and (4) active total intravenous (IV) fluid order.

Results: We reviewed 280 patient encounters between May 2023 and April 2024 and achieved the primary aim of at least 50% compliance with the fluid management strategy and maintained this success over time. Achieving the primary aim coincides with implementing daily weights and total IV fluid orders into PICU admission order sets.

Conclusions: In this quality improvement project, we develop, implement, and maintain compliance with a fluid management strategy. Future work will involve daily utilization of the fluid balance dashboard and monitoring compliance with total IV fluid orders. Implementing a quality improvement-based fluid management strategy may lead to improved awareness of the fluid status of patients and the prescription of fluid therapy to mitigate the harmful effects of fluid overload.

Introduction: This study examined a standardized event review approach, assessing hot and cold debriefs in pediatric in-hospital cardiac arrest (IHCA) to demonstrate their distinct but synergistic values.

Methods: This retrospective mixed-methods analysis was conducted for 2 years in a large, single-center pediatric intensive care unit (PICU) at a quaternary care, free-standing children's hospital. Following the standardization of debriefing processes, both hot and cold debriefs were systematically performed after PICU IHCA events where chest compressions lasted longer than 1 minute, utilizing standardized debrief forms. Event-level data were collected for each IHCA, with the possibility of patients being represented multiple times.

Results: There were 37 recorded PICU IHCAs during the study period from March 2020 to April 2022. Hot debriefs were performed in 84% (31/37) of events, and cold debriefs in 100% (37/37). Qualitative analysis of hot debriefs found that issues with communication and personnel (25%), cardiopulmonary resuscitation quality (25%), and medication preparation/administration (23.7%) were most cited. Analysis of cold debrief comments revealed that patient care (42.2%), environment and compliance (28.9%), and communication (20%) were the 3 most cited areas of potential improvement.

Conclusions: Hot and cold debriefs following pediatric IHCA are both feasible and clinically valuable. The combined use of these debriefing tools provided more comprehensive insights, with each format uniquely contributing to identifying distinct areas for improvement. Additionally, our findings highlight the importance of a carefully crafted and standardized approach to debriefing that aligns with the intended outcomes.