Pediatric quality & safety最新文献

Introduction: Disparities exist in access to coronavirus disease 2019 (COVID-19)-related health information. We aimed to close a gap in online traffic between English and Spanish COVID-19-related health information on our institution's publicly-facing website by 50% within ten months.

Methods: We used A3 improvement methodology. Outcome measures were the mean monthly difference between English and Spanish COVID-19 online traffic vis-a-vis (1) total webpage views and (2) unique webpage visits. Process measures were stratification of outcome measures by language. Plan-Do-Study-Act cycles included: Recurring advertisements on a local Spanish television station disseminating up-to-date COVID-19 information, including our institution's Spanish COVID-19 online resources, incorporation of QR codes into clinic discharge paperwork linking to institutional Spanish COVID-19 resources, and leveraging social media to expand reach. Control charts assessed impact over time.

Results: There were 1,226,196 total webpage views (369,983 Spanish; 856,213 English) and 1,065,536 unique webpage visits (350,518 Spanish; 715,018 English). Both outcome measures displayed sustained, special cause improvement from a mean monthly difference of 25,397 to 11,321 webpage views (55.4% reduction, June 2021) and 25,066 to 7080 unique webpage visits (71.8% reduction, February 2021) corresponding to special cause improvements in process measures. Improvements were not temporally associated with an intervention but coincided with emergency use approval of the COVID-19 vaccine for children aged 12-15 years (May 2021).

Conclusions: Although our interventions did not directly show improvements in our measures, we noted increased page views of Spanish COVID-19-related health information on our institution's publicly-facing website in times of high demand for linguistically appropriate services, including pediatric vaccine roll-out.

Background: An increasing proportion of the population in the United States have limited English proficiency (LEP). Hospitals that receive federal funding must offer interpreter services. However, access is often lacking for patients. Patients with LEP are at higher risk for adverse events, and the Emergency Department is a particularly high-risk environment for these events.

Methods: This quality improvement initiative took place from April 2021 to August 2022 in an urban, tertiary care Pediatric Emergency Department. A driver diagram informed four Plan-Do-Study-Act cycles, and data were collected through medical record review, patient surveys, and staff surveys. We tracked outcomes using run and control chart data.

Results: During the study period, the proportion of patients with LEP reporting "always" having an interpreter was unchanged (no centerline shift-control chart rules). Documentation of interpreter use for encounters with patients with LEP improved. Preferred language documentation and documentation of the need for an interpreter in the electronic medical record showed no change. Process measure data for staff-reported use of professional interpreters significantly increased, and the use of ad hoc interpreters decreased significantly. Length of stay did not change for English or LEP patients.

Conclusions: This quality improvement initiative improved appropriate documentation of LEP and decreased use of nonqualified interpreters, although no change occurred in the proportion of patients who reported always having an interpreter. Patient satisfaction was unaffected.

Introduction: Adherence to the American Academy of Pediatrics clinical practice guidelines for screening and managing high blood pressure (BP) is low. This team sought to improve recognition and documentation of relevant diagnoses in patients aged 13-20 years who presented to general pediatric clinics.

Methods: The primary outcome measure was the proportion of office visits for patients ages 13-20 with a BP ≥ 120/80 with a visit or problem list diagnosis of hypertension or elevated BP. Secondary measures included (1) the proportion of patients who had their BP measured in the right arm, (2) the proportion of patients who had a mid-arm circumference measurement recorded, and (3) the proportion of patients who had a second BP reading measured at the visit. Interventions addressed key drivers for evidence-based high BP screening: standard BP measurement, electronic health record clinical decision support, and clinical pathway adoption. Data were collected over a twenty-seven-month period and plotted using the Laney p' chart.

Results: Provider documentation of elevated BP or hypertension improved from a baseline mean of 24% in April 2020 through January 2022 to 41% in February 2021 through June 2022. All secondary outcome measures also demonstrated significant improvement.

Conclusions: This project demonstrates the feasibility of improving adherence to best practices of BP measurement in primary care clinics through education, acquisition of resources, and implementation of electronic health record flags for abnormal values.

Introduction: Adolescents with elevated body mass index are at increased risk for comorbidities such as dyslipidemia, diabetes mellitus, and metabolic dysfunction-associated steatotic liver disease. Guideline-based screening can identify impacted patients early, allowing for lifestyle modifications and other treatments to improve long-term health. Unfortunately, only 20% of pediatric patients with obesity receive recommended screening.

Methods: A multidisciplinary quality improvement team designed and implemented a project to improve comorbidity screening utilizing the Model for Improvement. Provider education and incentive, clinical decision support, and regular performance feedback were chosen as interventions. Screening rates were tracked on a statistical process control chart.

Results: From March through December of 2022, 9547 pediatric patients aged 10 years and up with body mass index greater than or equal to the 95^th percentile were seen for preventive care visits. Screening rates for comorbidities increased from a baseline of 19.5%-58% and were sustained for over 3 months. Numerous patients at risk for chronic disease were identified.

Conclusions: Evidence-based clinical decision support, along with provider education and engagement, can effectively increase screening rates for comorbidities in pediatric patients with obesity.

Introduction: Multidisciplinary clinics aim to coordinate care between multiple specialties for children with medical complexity yet may result in information overload for caregivers. The after-visit summary (AVS) patient instruction section offers a solution by summarizing visit details and recommendations. No known studies address patient instruction optimization and integration within a multidisciplinary clinic setting. This project aimed to improve the quality of patient instructions to support better postvisit communication between caregivers and providers in a multidisciplinary pediatric neuromuscular program.

Methods: A multidisciplinary stakeholder team created a key driver diagram to improve postvisit communication between caregivers and providers in the clinic. The first specific aim was to achieve an 80% completion rate of AVS patient instructions within 6 months. To do so, a standardized electronic medical record "text shortcut" was created for consistent information in each patient's instructions. Feedback on AVS from caregivers was obtained using the Family Experiences with Coordination of Care survey and open-ended interviews. This feedback informed the next specific aim: to reduce medical jargon within patient instructions by 25% over 3 months. Completion rates and jargon use were reviewed using control charts.

Results: AVS patient instruction completion rates increased from a mean of 39.4%-85.0%. Provider education reduced mean jargon usage in patient instructions, from 8.2 to 3.9 jargon terms.

Conclusions: Provider education and caregiver feedback helped improve patient communication by enhancing AVS compliance and diminishing medical jargon. Interventions to improve AVS patient instructions may enhance patient communication strategies for complex medical visits.

Background: This project aimed to introduce substance use screening, using the CRAFFT (Car, Relax, Alone, Forget, Family/Friends, Trouble) screening tool, into the routine care of adolescents using quality improvement strategies and tools.

Methods: We expanded a single-site project showing the successful introduction of CRAFFT screening into adolescent care to include the entire 34-site primary care network of a children's hospital in Northeastern Ohio. We deployed quality improvement methodology to facilitate the acceptance and use of the screener. Data showing the percentage of eligible adolescents screened were collected and shared monthly with network providers.

Results: The single-site phase increased the screening rate from 3.5% to 72%. The percentage screened for the network phase rose from 0% to >90% in the first 2 months of the project and remained at that level. Of those screened, 85% were low risk, 3% were medium risk, and 2% were high risk. Ten percent of the results were not recorded in a way that allowed for post hoc risk assessment. During the network phase, 35,750 of 38,427 (93%) eligible patients completed the screening form.

Conclusions: This project resulted in the highly reliable use of the CRAFFT screener in a large primary care network.

Introduction: The United States faces a growing burden of neonatal opioid withdrawal syndrome in rural hospitals. Traditional treatments often extend hospital stays and medication use. The Eat, Sleep, and Console (ESC) approach offers a new management strategy but is challenging in resource-limited settings. This study aimed to apply ESC in rural hospitals to reduce neonatal intensive care unit admissions, decrease length of stay (LOS) to under 7 days, and lower medication use by more than 80% within a year.

Methods: Our quality improvement initiative at rural hospitals implemented a multimodal approach for in utero opioid-exposed infants, involving staff education, electronic medical record updates, and nonpharmacological care strategies. Data from January 2020 to December 2023 assessed treatment impact, including pharmacotherapy need and hospital stay lengths, using statistical process control for analysis.

Results: After ESC implementation, the percentage of opioid-exposed infants receiving pharmacological treatment significantly decreased from 60.7% to 7.9%. The average LOS was reduced from 14.5 days to 5.25 days. These improvements persisted for 24 months, with no readmissions within 30 days of discharge. This approach also reduced hospital charges by over $5 million, demonstrating its clinical and financial effectiveness.

Conclusions: The multidisciplinary approach successfully implemented ESC in a resource-limited setting, significantly reducing both the LOS and medication exposure for opioid-exposed infants while also saving significant healthcare costs. This successful model has been adopted by at least four regional rural hospitals, thus broadening the program's impact.

Introduction: Asthma exacerbations are common presentations to pediatric emergency departments. Standard treatment for moderate-to-severe exacerbations includes administration of oral corticosteroids concurrently with bronchodilators. Early administration of corticosteroids has been shown to decrease emergency department length of stay (LOS) and hospitalizations. Our SMART aim was to reduce the time from arrival to oral corticosteroids (dexamethasone) administration in pediatric patients ≥2 years of age with an initial Pediatric Asthma Severity Score >6 from 60 to 30 minutes within 6 months.

Methods: We used the model for improvement with collaboration between ED physicians, nursing, pharmacy, and respiratory therapists. Interventions included nursing education, dosage rounding in the electronic medical record, supplying triage with 1-mg tablets and a pill crusher, updates to an asthma nursing order set and pertinent chief complaints triggering nurses to document a Pediatric Asthma Severity Score in the electronic medical record and use the order set. Our primary outcome measure was the time from arrival to dexamethasone administration. Secondary outcome measures included ED LOS for discharged patients and admission rate. We used statistical process control to analyze changes in measures over time.

Results: From October 2021 to March 2022, the average time for dexamethasone administration decreased from 59 to 38 minutes. ED LOS for discharged asthma exacerbation patients rose with overall ED LOS for all patients during the study period. There was no change in the admission rate.

Conclusions: Using quality improvement methodology, we successfully decreased the time from ED arrival to administration of dexamethasone in asthma exacerbation patients from 59 to 38 minutes over 10 months.

Introduction: Emerging evidence supports the use of alternative dosing weights for medications in patients with obesity. Pediatric obesity presents a particular challenge because most medications are dosed based on patient weight. Additionally, building system-wide pediatric obesity safeguards is difficult due to pediatric obesity definitions of body mass index-percentile-for-age via the Center for Disease Control growth charts. We describe a quality initiative to increase appropriate medication dosing in inpatients with obesity. The specific aim was to increase appropriate dosing for 7 high-risk medications in inpatients with obesity ≥2 years old from 37% to >74% and to sustain for 1 year.

Methods: The Institute for Healthcare Improvement model for improvement was used to plan interventions and track outcomes progress. Interventions included a literature review to establish internal dosing guidance, electronic health record (EHR) functionality to identify pediatric patients with obesity, a default selection for medication weight with an opt-out, and obtaining patient heights in the emergency department.

Results: Appropriate dosing weight use in medication ordered for patients with obesity increased from 37% to 83.4% and was sustained above the goal of 74% for 12 months.

Conclusions: Implementation of EHR-based clinical decision support has increased appropriate evidence-based dosing of medications in pediatric and adult inpatients with obesity. Future studies should investigate the clinical and safety implications of using alternative dosing weights in pediatric patients.

Introduction: Pediatric cardiac surgery is complex and has significant risk, requiring interprofessional teamwork for optimal outcomes. Unhealthy work environments have been linked to poor patient outcomes, staff dissatisfaction, and intention to leave. We describe the interprofessional health of pediatric cardiovascular operating room (CVOR) work environments in the United States and the establishment of a healthy work environment (HWE) benchmark score.

Methods: Utilizing the American Association of Critical Care Nurses Healthy Work Environments Assessment Tool (HWEAT), interprofessional staff from 11 pediatric CVORs were surveyed. Responses were aggregated, summarized, and stratified by role to examine differences. The following phase used an e-Delphi approach to obtain expert consensus on a benchmark target.

Results: Across 11 centers, 179 (60%) completed surveys were reviewed. The interprofessional mean HWEAT score was 3.55 (2.65-4.34). Mean scores for each standard were within the "good" range. Participants reported the highest scores for effective decision-making, with a mean of 3.69 (3.00-4.20). Meaningful recognition scored lowest, mean 3.26 (2.33-4.07). When stratified, surgeons reported higher overall HWE scores (M = 3.79, SD = 0.13) than nurses (M = 3.41, SD = 0.19; P = 0.02, two-tailed). The proposed benchmark was 3.50.

Conclusions: This is the first time the American Association of Critical Care Nurses HWEAT has been used to describe the interprofessional health of work environments in pediatric CVORs in the United States. The targeted benchmark can support pediatric CVOR improvement strategies. Creating and sustaining an HWE is an interprofessional opportunity to support high-quality patient outcomes and clinical excellence.