Pediatric quality & safety最新文献

Introduction: Using plan-do-study-act cycles, our team aimed to increase mean provider adherence to the Lead Exposure Protocol at the Boston Medical Center Pediatric Primary Care Clinic from 16% (baseline global mean provider adherence) to 80% from April 1, 2021, to February 1, 2023, thereby curbing the secondary effects of lead exposure.

Methods: Our team performed a chart review of patients 6 months to 5 years of age with blood lead levels (BLLs) ≥2 µg/dL (n = 853) to track provider adherence to Boston Medical Center's Lead Exposure Protocol. We created p charts to track the efficacy of interventions to improve adherence. Interventions included (1) electronic medical record SmartPhrases, (2) provider education, (3) provider feedback, (4) implementation of a follow-up nursing workflow, and (5) simplification of nursing workflow.

Results: For BLL 2-4 µg/dL (n = 783), a centerline shift in provider adherence was observed, with >8 points above the preintervention mean after intervention (2) and an increase in mean adherence from 14.1% to 50%. For BLL 5-9 µg/dL (n = 58), no centerline shift was observed, with only 6 points above the upper control limit after intervention (4). The 2-4 µg/dL range changes indicate special cause variance and system change. Global mean provider adherence increased by 3.3 times to 53%.

Conclusions: Simple, low-cost process changes improved adherence to complex guidelines for managing lead-exposed children in the primary care setting. Similar interventions could be implemented on a broader scale to standardize the management of other routine pediatric screens.

Introduction: A reported penicillin allergy reduces the likelihood that the patient will receive first-line surgical antibiotic prophylaxis (SAP), which can increase the risk of developing a surgical site infection (SSI). This project aimed to increase the use of first-line SAP agents in orthopedic and pediatric surgery patients with a reported penicillin allergy.

Methods: The Institute for Healthcare Improvement quality improvement methodology was followed. Key drivers included patient and family awareness of true penicillin allergies, standardization for ordering antibiotics, staff buy-in, electronic medical record utilization, and staff comfort with ordering first-line SAP. Initial plan-do-study-act cycles focused on provider education. Subsequent plan-do-study-act cycles focused on the antibiotic delivery process, antibiotic selection, screening tool development for severe delayed hypersensitivity reactions, education, and data transparency. The outcome measure was the percentage of orthopedic and pediatric surgery patients with a reported penicillin allergy that received first-line SAP per month.

Results: Since the start of the project in December 2022, there were 2 statistically significant changes in the outcome measure's mean, shifting the mean from 25% to 84% in orthopedic and pediatric surgery patients with a reported penicillin allergy who received first-line SAP. There were no adverse medication reactions and no statistically significant change in SSIs.

Conclusions: The mean has been at 84% for 9 months showing a sustainable process and culture change regarding first-line SAP usage for orthopedic and pediatric surgery patients. This was achieved through targeting the antibiotic delivery processes without relying on hard stops within the medical record.

Introduction: Standardization is crucial in improving healthcare outcomes, equity and quality. Clinical decision support tools are key to achieving this goal. At our organization, Epic serves as our electronic health record, and SmartSets are Epic's version of outpatient standardized order sets with embedded clinical decision support tools. In 2022, the utilization of SmartSets in our hospital's gastrointestinal division was only 1.9%, far below our organizational target of 50%.

Methods: Our group formed a quality improvement (QI) team and chose the model for improvement methodology. The interventions focused on education, buy-in, feedback performance monitoring, and the enhancement and development of new SmartSets. Our primary aim was to increase the utilization rate of SmartSets by gastrointestinal providers from 1.9% to 20%, and our secondary aim was to reduce the time spent by providers on orders by 10% from 3.3 to 2.8 minutes per encounter. Our balancing measure was monitoring safety reports during the study period.

Results: SmartSet utilization improved to greater than 20% within 7 months of the project initiation. Three months after implementing SmartSet updates and introducing new SmartSets into production, time spent on orders during clinical encounters decreased from a median of 3.3 to 2.4 minutes per encounter. We appreciated that there was no change in safety reporting during the project timeline.

Conclusions: We achieved our goal of improving utilization rates of standardized SmartSets and reducing time spent on orders using a QI methodology. Our achievements underscore the effectiveness of QI methods in enhancing SmartSet utilization and streamlining order processes.

Background: Among hospitalized children, episodes of aggressive patient behavior place healthcare staff at risk for serious injuries. By implementing a behavioral response team at a children's hospital, we aimed to reduce monthly employee injuries related to aggressive patient behavior from 3.4 to 2.4 per 1,000 acute care visits during 12 months.

Methods: At a children's hospital, a multidisciplinary team used quality improvement methodology to implement a behavioral response team that provided proactive and reactive support to staff caring for children at risk for aggressive behavior. Full-scale implementation occurred in July 2022. We measured days between Occupational Health and Safety Administration (OSHA)-recordable employee injuries related to aggressive patient behavior and total monthly employee injuries related to aggressive patient behavior per 1,000 acute care visits (emergency department visits and/or hospitalizations) by patients 3 years of age or older.

Results: In the year after full-scale implementation, an average of 101 BRT rounds and 17 reactive responses occurred per month. The maximum number of days between OHSA-recordable employee injuries related to aggressive patient behavior increased from 163 days in the year before full-scale implementation to 271 days in the following year. Monthly employee injuries related to aggressive patient behavior decreased from 3.4 to 1.7 injuries per 1,000 acute care visits by patients 3 years of age or older.

Conclusions: The BRT model, which provides proactive and reactive support to hospital staff caring for children at risk for aggressive behavior, should be considered a strategy to reduce employee injuries and promote workplace safety.

Introduction: Weight is vital for tracking fluid status and nutrition and assuring patients have accurate dosing weights in the pediatric intensive care unit (PICU). Challenges in acquiring weights in critically ill patients include clinical instability, limited equipment, and lack of appropriate orders in the electronic medical record (EMR).

Methods: We implemented interventions that targeted EMR weight orders and actual collection of weights in the 42-bed PICU of a children's hospital. Preintervention data were collected from February to March 2023 for all patients admitted to the PICU with a length of stay (LOS) ≥3 days. We surveyed PICU nurses to identify barriers to collecting weights. Interventions included a multidisciplinary team approach, safety checklist, nursing education, and automatization of weight orders. The study team monitored the number of patients with weight orders and weights obtained as ordered twice weekly from March 2023 to April 2024 using statistical process control charts.

Results: There were 1728 patient instances of LOS ≥3 days. Preintervention data showed 70.4% of patients with appropriate weight orders and 35.5% with weights obtained. Implementing a safety checklist, nursing education, EMR changes, and automatizing weight orders, the centerline for weight orders shifted to 94.3% and for weights obtained to 69.5%. Reminder emails to all ICU providers and nursing check-ins maintained the centerline. No increase in unplanned extubations occurred.

Conclusions: Through interventions involving rounding providers, nurses, and the EMR, the frequency of weights ordered and obtained in a busy PICU sustainably increased.

Introduction: Developmental disorders (DDs) affect approximately 1 in 6 children in the United States. Early identification and treatment improve developmental outcomes and child and family functioning. Disparities exist in the diagnosis of DD that leads to inequitable access to developmental services during important periods of neuroplasticity. Improve access to the developmental and behavioral pediatrics (DBP) clinic for developmental evaluation when developmental delays occur among children 3-5 years of age by increasing the percentage of children scheduled for and completing an initial visit in 90 days from 20% to 40%.

Methods: We used the Institute of Health Improvement model, executed mapping failure modes, created a key driver diagram and conducted plan-do-study-act cycles. We plotted data over time in a statistical control chart. The key intervention was an expedited, collaborative referral and scheduling process developed, tested, and implemented by the general pediatric clinic and DBP stakeholders. Additional interventions included reminder notifications and calls to patients who missed appointments.

Results: The percentage of patients referred to DBP who scheduled and completed their initial visit in DBP within 90 days increased from 20% to 40%. DBP clinicians suspecting that patients had global developmental delay and/or autism spectrum disorder at the initial DBP visit referred them for more extensive developmental testing with psychology and speech-language providers.

Conclusions: Access to developmental evaluation for preschool-aged children at risk for delayed diagnosis and treatment was improved using quality improvement methodology focused on flexible and creative priority scheduling practices from within the medical home.

Introduction: Pediatric seizures account for approximately 1% of emergency department (ED) presentations. Laboratory evaluation and emergent electroencephalogram (EEG) are not indicated in patients with a new-onset, unprovoked, afebrile seizure with a normal physical examination. This study aimed to reduce unnecessary ED resource utilization.

Methods: Through plan-do-study-act cycles from March 2021 to July 2023, a multidisciplinary team implemented change concepts, including creating a clinical pathway and supporting order sets, scheduling outpatient EEGs from the ED, and automating messages to the neurology team to ensure patient follow-up. The primary outcome measure was the percentage of qualified patients who received an EEG in the ED. Secondary outcome measures were the percentage of patients who had ED complete blood counts or neurology consults, the room-to-discharge time in minutes, and healthcare cost per patient. The balancing measure was the 30-day ED bounce-back rate.

Results: Thirty-four and 99 patients met the inclusion criteria for the baseline and implementation phases, respectively. ED EEGs decreased from 59% to 1%. Complete blood counts and neurology consults decreased from 50% to 16% and 90% to 31%, respectively. Room-to-disposition time decreased from 308 to 203.5 minutes. Preliminary healthcare cost per patient decreased by $630. The 30-day bounce-back rate increased from 0% to 8%.

Conclusions: Implementing a new-onset seizure pathway decreased ED resource utilization, shortened room-to-discharge time, and lowered healthcare costs.

Introduction: This project aimed to decrease surgical site wound infections (SSIs) to less than 1 per 100 cases in pediatric patients after cardiothoracic surgery.

Methods: A multidisciplinary workgroup was established to identify perioperative risk factors, and educational gaps and create a bedside quality improvement (QI) rounding group to monitor wounds. SSIs were defined according to the Centers for Disease Control National Healthcare Safety Network guidelines. Infection preventionists adjudicated infections as SSIs after an SSI huddle evaluated the case. A QI bundle was developed more than 2 eras: 2015 criteria included an enhanced hygiene bundle, scripted discharge telephone calls about wound care, and 2019 criteria identified SSI risk factors, developed an SSI-QI rounding team, created additional wound care education, and standardized wound care. Data were collected from January 2014 to December 2022 to assess SSI rates per 100 surgical cases, as well as clinically relevant short- and long-term outcomes.

Results: From December 2014 to December 2022, there were 5,610 surgical cases evaluated in SSI-QI rounds. Compared with the preintervention cohort, SSI rates decreased significantly during the intervention (SSI per 100 cases 2.82; 95% confidence interval, 1.94-4.09) and postintervention (SSI per 100 cases 0.55; 95% confidence interval, 0.24-1.26). There were no increases in reoperations, postoperative major complications, or discharge mortality throughout the study.

Conclusions: SSI rates decreased below the goal of 1 per 100 surgical cases. Standardized wound dressings, improving hygiene compliance including bath compliance from 80% to 96.1%, multidisciplinary collaboration, bedside rounds, and postdischarge procedures contributed to lowering and sustaining low SSI rates.

Introduction: Mobilization protocols are safe and feasible for critically ill pediatric patients in the intensive care unit (ICU), but barriers exist to sustainability. This study described a focused early mobility protocol, sustained over 5 years, which is on time for therapy consults and patient mobilization at a single institution.

Methods: A formal ICU mobility protocol was implemented as part of a unit-wide ICU liberation bundle. As part of the ongoing program assessment, over a specific 3-month timeframe annually from 2017 to 2023, the number of physical and occupational therapy (PT/OT) consults, mobilization rate, and time to PT/OT consult were analyzed. In addition, in 2023, we assessed specific barriers to early PT/OT consultation.

Results: Annually, for each study timeframe, there was a sustained decrease in time to therapy consult from a mean of 3.8 days for PT and 7 days for OT in 2017 to 1.9 and 1.6 days, respectively, in 2023. Similarly, the mobilization rate increased from 20.3 sessions per 100 patient days in 2017 to 48.2 in 2023. There was a trend toward missed or delayed therapy consults at times of higher ICU census. No adverse events were associated with mobilization.

Conclusions: An ICU early mobility protocol leads to a sustained decrease in the time to therapy consultation, an increase in the number of therapy consults, and an increase in the mobilization rate. Future interventions should focus on mitigating barriers to timely consultation, specifically at times of higher ICU census.

Introduction: First-case on-time starts (FCOTS) is an established metric of perioperative efficiency, impacting global perioperative throughput. Late-arriving surgeons are a common cause of late operating room (OR) starts. This project reflects a quality improvement effort to reduce late surgeon arrivals by 30% for 24 months and improve FCOTS.

Methods: A multidisciplinary perioperative leadership team developed clear expectations, including tracking, roles, review processes, and consequences. These were broadly communicated among stakeholders, and feedback was incorporated. A new same-day surgeon-to-surgeon feedback mechanism was instituted for late surgeon arrivals, allowing for surgeon feedback and reiteration of expectations. Results were prospectively tracked for 24 months before and following implementation.

Results: Late surgeon arrivals decreased by 45%, from 23.6 to 13 per month for 24 months before and following implementation, respectively (P < 0.001). Balancing measures did not see increases for the same periods. FCOTS increased from 66% to 72% postimplementation (P < 0.001). Statistical process control P-charts demonstrated centerline shifts for both metrics.

Conclusions: Development and communication of a clear framework of expectations, review, and consequences, with ongoing monitoring, clear performance expectations, and timely feedback, can reduce late surgeon arrival and improve FCOTS. Direct and timely communication provided immediate feedback to late surgeons and indicated reporting errors, providing more accurate data on late starts. Consistent policy enforcement is critical for credibility.