Pediatric quality & safety最新文献

Introduction: In the pediatric setting, overprescribing of antibiotics contributes to the rise of multidrug-resistant organisms. Antimicrobial stewardship programs (ASPs) are recommended to optimize antibiotic use and combat resistance. However, the implementation of ASPs in low- and middle-income countries faces several challenges. This study aimed to evaluate the implementation process of a multifaceted ASP in 2 pediatric hospitals in Argentina.

Methods: A qualitative study was conducted in two large public children's hospitals in Argentina, using semistructured interviews with 32 healthcare providers at the beginning and end of the ASP implementation. The study was guided by the normalization process theory.

Results: The intervention faced challenges, including limited understanding of its objectives, confusion with existing practices, and insufficient commitment from senior staff. Although junior staff were more receptive, communication barriers with external staff and workload concerns hindered broader adoption. Infectious disease specialists primarily led implementation, with limited involvement of other staff, particularly in training activities. Despite these challenges, participants reported improvements, such as the development of standardized antibiotic guidelines, better interdisciplinary collaboration, and improved communication. However, organizational support and resistance to new practices remained barriers.

Conclusions: This study highlights the importance of organizational context and staff commitment in ASP implementation. Tailored strategies that address the specific challenges of low- and middle-income countries are needed to effectively implement ASPs.

Introduction: Supracondylar fractures are among the most common injuries in the pediatric population. Recently, there has been increased interest in developing opioid-free anesthetic protocols that achieve these same goals without the risks associated with opioid use, such as postoperative nausea and vomiting (PONV), delayed discharges, and respiratory depression.

Methods: Seattle Children's Hospital implemented opioid-free anesthesia (OFA) for pediatric supracondylar fracture repairs in January 2021. This patient safety report compares the clinical outcomes of these patients to those who received intraoperative opioids. Clinical effectiveness was measured using the maximum pain scores in the postanesthesia care unit (PACU), postoperative opioid rescue rates in PACU and PONV rescue rate. PACU length of stay (LOS) was chosen as a clinical balancing measure.

Results: The opioid group (n = 464) had a mean maximum pain score of 3.39 compared with the OFA group (n = 816), which had a mean maximum of 3.70. The PACU IV opioid rescue rate for the opioid group was 38.82%, whereas the OFA group was 38.73%. The opioid group had a PONV rescue rate of 1.53%, compared with 0.23% in the OFA group. Mean LOS in the PACU was 79 minutes for the opioid group and 86 minutes for the OFA group.

Conclusions: The shift to OFA for intraoperative management of patients' supracondylar fracture repair resulted in similar postoperative analgesic outcomes when compared with an opioid-based approach, with a reduced PONV rate and minimal increase in LOS. Transitioning to OFA provided a safe and effective protocol for supracondylar repairs.

Introduction: Pediatric coronavirus disease 2019 (COVID-19) vaccination rates in the United States remain lower compared with adults. We aimed to (1) implement a quality improvement initiative to increase COVID-19 vaccination 2-fold in hospitalized patients 12-21 years of age from 4.7% during the baseline period (August 10, 2021-November 1, 2021) to 9.4% during the intervention phase (November 2, 2021-March 31, 2023) and (2) assess the importance of existing interventions and obtain feedback for future interventions to increase COVID-19 vaccination via a provider survey.

Methods: We conducted the quality improvement initiative in the inpatient units of a freestanding children's hospital. Interventions included provider education, electronic medical record best practice alerts, monthly competition, parental counseling to increase vaccine acceptance, and ensuring vaccine availability. The primary outcome measure was the percentage of hospitalized patients 12-21 years of age who received COVID-19 vaccine. Providers addressing COVID-19 vaccination with patients, as documented by COVID-19-specific problem lists, were a process measure. Length of stay was a balancing measure.

Results: Although COVID-19 vaccination increased 1.6-fold during the initial 5 months of interventions, the interrupted time series analysis did not show a significant impact of our interventions on vaccination. Documentation of COVID-19 vaccine-specific problem lists increased 1.9-fold during most of the intervention period. There was no significant (P = 0.61) difference in length of stay between children in the baseline and intervention groups.

Conclusions: Despite our best efforts, we could not increase the number of COVID-19 vaccinations in our patients. Lessons learned suggest that creating a nurse-driven COVID-19 vaccine screening/ordering protocol and integrating COVID-19/influenza vaccination annually during influenza season can potentially increase vaccination rates, but further research is required.

Introduction: Young adults with inflammatory bowel disease (IBD) are at the risk of poor outcomes when transferring to adult providers. We aimed to increase the percentage of patients with 14-17 years of age undergoing the transition of care and the percentage of patients 18-21 years of age initiating the transfer of care to 50% for 12 months. Our goal was also to improve patient satisfaction with the transfer process. Our balancing measure was not to increase the duration of IBD visits.

Methods: We implemented 3 interventions through iterative plan-do-study-act cycles. To understand the impact of the interventions for 12 months, we used statistical process control charts. The duration of IBD visits was used as a balancing measure. We administered an anonymous satisfaction survey through the electronic health record.

Results: Total transition discussions increased to a mean of 38% (n = 68). Transition discussions with patients 14-17 years of age increased from baseline, though not consistently. Patients 18-21 years of age initiating transfer of care increased to a mean of 5% (n = 1) following the first intervention and to a mean of 30% (n = 13) following our second and third interventions with special cause variation. There was no significant difference in the duration of IBD visits before and after the intervention period (P = 0.54). No patients were dissatisfied following our interventions.

Conclusions: We saw improved transition discussions and transfer initiation rates by implementing the first steps of a new process to transition young adults with IBD.

Introduction: Lipid screening identifies at-risk patients to facilitate cardiovascular risk reduction. National pediatric guidelines recommend universal lipid screening between 9-11 and 17-21 years of age. We aimed to improve adherence to lipid screening for all age-appropriate outpatient pediatric cardiology visits from a baseline of 35% to 90% between November 2021 and July 2023.

Methods: All outpatient visits for patients 9-11 and 17-21 years were included. Chart review and an Epic electronic health record report identified patients screened, lipid test results, and need for further testing. A P-chart was generated. After establishing a baseline for 8 weeks, interventions, including an Epic dot phrase, group and individual feedback, and Epic best practice alert (BPA), were incorporated via plan-do-study-act cycles. Balancing measures included anonymous provider surveys on visit length and experience.

Results: More than 1,700 patient visits were included. At baseline, 35% of all age-appropriate patients were screened. The Epic dot phrase prompted a positive shift with a new mean of 59% screened. Another change occurred after the BPA alert, with an increase in screening to 84%. Lipid screening prompted by this initiative found that 38% of those with testing results in Epic had abnormal results requiring follow-up. Providers did not report a significant change in visit length due to screening.

Conclusions: Quality improvement interventions improved adherence to universal lipid screening guidelines. The Epic dot phrase and BPA facilitated positive shifts. These simple interventions can be spread to other practices to improve adherence to lipid screening and other guidelines.

Introduction: Many children require sedation for imaging. We aimed to reduce sedation for thoracic (chest and cardiac) computed tomography (CT) scans in children 0-4 years old from 65% to 20% by December 2018 and to sustain.

Methods: We counted baseline, intervention, and a follow-up period thoracic CT scans performed with sedation in children 0-4 years old. We developed a new volumetric target-mode electrocardiogram-gated CT imaging protocol to reduce scan time and control for factors that decrease image quality. Additional interventions included technologist training, communication to radiologists and clinicians, and eliminating a default request for sedation accompanying the electronic order for most thoracic CT scans. A statistical process control chart tracked data to study process changes over time.

Results: During the baseline and intervention periods, 232 of 357 and 217 of 794 scans required sedation. Interventions created 2 centerline shifts. Overall, thoracic CT scans in children 0-4 years old requiring sedation decreased from 65% to 24% and was sustained 5 years later. No patients during the baseline period, one (1 of 794, 0.1%) during the intervention period and 2 (2 of 480, 0.4%) during the audit period 5 years later, initially had nondiagnostic nonsedated scans that required an additional scan with sedation.

Conclusions: We developed a volumetric target-mode electrocardiogram-gated CT protocol, eliminated default sedation ordering, and trained and educated staff to reduce sedation in young children undergoing thoracic CT scans. The frequency of sedation for thoracic CT in children 0-4 years old decreased from 65% to 24% and was sustained after revising imaging parameters and eliminating a default sedation order.

Introduction: Although associated with respiratory morbidity, elective endotracheal intubation (ETI) for laser photocoagulation for retinopathy of prematurity (ROP) is the standard practice at our institution, with 100% of patients undergoing preoperation ETI. To mitigate this risk, we strove to reduce the percentage of infants intubated for laser photocoagulation by 30% by June 2022.

Methods: We assembled a multidisciplinary team and implemented a deep sedation guideline utilizing dexmedetomidine, fentanyl, and midazolam with noninvasive ventilation support for laser photocoagulation in January 2020. Outcome, process, and balancing measures tracked the efficacy and safety of the quality improvement project.

Results: We reduced the percentage of infants requiring intubation for laser photocoagulation from 100% (8/8) to 10% (1/10). We reduced the average time to return to baseline respiratory status from 224.1 to 33.8 hours (9.3d to1.4 d). Cardiorespiratory index scores slightly increased (1 to 1.2), and pain scores remained unchanged after interventions.

Conclusions: A multidisciplinary team approach using a deep sedation guideline and noninvasive ventilation can safely reduce the requirement for intubation during laser photocoagulation with a faster return to baseline respiratory status.

Introduction: Endotracheal intubation is frequent in the neonatal intensive care unit (NICU) but may result in neonatal distress and instability. Premedication reduces adverse effects, such as hypoxia, bradycardia, and pain. The Specific, Measurable, Achievable, Relevant and Time-Bound aim for this project was to increase premedication use for nonemergent neonatal intubation in a specific NICU from 22% to 80% from March 2021 to May 2023.

Methods: We use quality improvement methodology to explain our theory for improvement. Our key driver diagram depicts this initiative's aims, key drivers, and interventions to increase premedication use for neonatal intubation. We defined exclusion criteria and medications, and one author collected demographic data retrospectively after the procedure. The stakeholders summarized the baseline data, performed plan-do-study-act cycles, and showed outcome measures in a statistical process control chart. Statistical analysis used Fisher's exact test to compare categorical variables.

Results: Between 2021 and 2023, 333 infants underwent endotracheal intubation; 130 infants were included. The most common indication for intubation was hypoxemic respiratory failure-52% (68/130). Premedication use increased from 22% to 52%. Among the exclusion criteria, the most common indication for nonpremedication was intubation in the delivery room, 38.4% (78/203). In the premedication group, intubation on the first attempt occurred in 77.6% (52/67) of the cases, versus the nonpremedication group, 66.7% (32/48) (P = 0.3).

Conclusions: Premedication for neonatal intubation increased by 30%, although we did not reach the desired 80% goal. Establishing a premedication bundle, alongside a unit-specific protocol and effective teamwork, marks the initial stride toward enhancing analgesia/sedation practices in the NICU.

Introduction: Education and management of children with new-onset or established diabetes mellitus (DM) requiring insulin initiation do not always require hospitalization. We developed a pathway for outpatient day treatment of select patients after initial evaluation in the emergency department (ED) at a pediatric, tertiary care academic medical center.

Methods: A multidisciplinary team identified key initial eligibility criteria for outpatient day treatment for insulin initiation, including absence of diabetic ketoacidosis, age ≥3 years, and plasma beta-hydroxybutyrate (BOHB) <1 mmol/L. Electronic medical record reviews and surveys administered to endocrine providers determined exclusions or reasons for nonparticipation. Refinement of the pathway occurred through iterative plan-do-study-act cycles. Statistical process control evaluated the uptake among eligible patients.

Results: We launched the pathway in September 2020. Of 534 patients presenting to the ED with new-onset or established DM requiring insulin initiation in the first 2.5 years, 198 were potentially eligible for day treatment. Of these, 65 children (33%) completed the pathway. One additional patient was hospitalized following Day 1 of education due to newly identified psychosocial stressors. The increase of BOHB cutoff to 1.5 mmol/L and the option of rapid-acting insulin bolus for borderline BOHB resulted in a significant shift in utilization from a mean of 24.4% to 41.1%. Persistent barriers to participation include limited appointment availability, weekend presentation, and patient/family concerns.

Conclusions: Outpatient day treatment was successful for select pediatric patients with new-onset or established DM requiring insulin initiation. However, this approach necessitates flexible resources and supportive patient messaging.

Background: High volumes and competing priorities delay care initiation for neonatal hyperbilirubinemia within the pediatric emergency department (ED). Our freestanding children's hospital developed a quality improvement project to implement a nurse-initiated neonatal hyperbilirubinemia clinical pathway (CP) intended to decrease treatment initiation and intravenous fluid (IVF) rates.

Methods: A multidisciplinary team used the model for improvement to delineate and address key drivers of treatment delays. The team established a nurse-driven CP and enhanced the electronic health record to support and enforce new workflows, which included capillary specimen collection and phototherapy initiation before the first provider assessment. IVF criteria and laboratory evaluation were standardized. The primary aim was to decrease the time to initiation of phototherapy from a mean of 136 to 60 minutes after ED arrival for 6 months. The secondary aim was to decrease the proportion of patients obtaining IVF from 31% to 15% for the same time frame.

Results: ED arrival to phototherapy initiation decreased from 136 to 49 minutes. The IVF rate decreased from 31% to 12%. ED length of stay decreased from 185 to 122 minutes. Hospital length of stay remained unchanged.

Conclusions: A nurse-initiated CP for neonates with hyperbilirubinemia improved time-to-care initiation and ED throughput while decreasing unnecessary IVF administration.