Pediatric quality & safety最新文献

Background: Children and youth in foster care (CYFC) are a population with special healthcare needs, and the American Academy of Pediatrics has healthcare standards to care for this population, but implementation challenges include identifying clinic patients in foster care (FC). Documentation of FC status in the Electronic Health Record (EHR) can support the identification of CYFC to tailor care delivery. Therefore, we aimed to improve the percentage of CYFC with problem list (PL) documentation of FC status from 20% to 60% within 12 months.

Methods: This study used a five-cycle plan-do-study-act quality improvement model in two co-located primary care teaching clinics. The primary outcome was the weekly percentage of patients with FC status on EHR PL. Ishikawa cause and effect analysis and resident survey identified barriers and informed interventions: education, patient list distribution, documentation training, email reminders, and clinic champion. We constructed statistical process control charts of the primary outcome to assess for improvement.

Results: Mean weekly percentage of patients with FC status on PL improved from 19.8% to 60.2%. The most extensive improvements occurred after designating a clinic champion and providing email reminders with enhanced patient lists. The sustainability of PL documentation (mean = 71.7%) was demonstrated 3-4 years after the completion of plan-do-study-act cycle interventions.

Conclusions: Educating providers, collaborating with child welfare to provide patient lists to providers, standardizing documentation, and designating clinic champions are promising methods of improving EHR documentation of FC status. Identifying and documenting FC status are important initial steps to optimizing care for this vulnerable population in primary care.

Background: Bronchiolitis is a leading cause of pediatric hospitalizations. A high-flow nasal cannula (HFNC) does not significantly improve clinical outcomes and is associated with increased costs and intensive care unit (ICU) utilization. Despite this, hospitals continue to overuse HFNC in children with bronchiolitis. We aimed to reduce HFNC initiation in children hospitalized with bronchiolitis by 20 percentage points within 6 months.

Methods: This study included patients aged 1 month to 2 years diagnosed with bronchiolitis, excluding patients with prematurity less than 32 weeks or preexisting cardiopulmonary, genetic, congenital, or neuromuscular abnormalities. Measures included HFNC utilization, length of stay, length of oxygen supplementation (LOOS), ICU transfers, and emergency department (ED) revisits and readmissions. For our primary intervention, we implemented a HFNC initiation protocol incorporating a respiratory scoring system, a multidisciplinary care-team huddle, and an emphasis on supportive care. Staff education, electronic health record integration, and audit and feedback were used to support implementation. Statistical process control charts were used to track metrics.

Results: We analyzed 325 hospitalizations (126 baseline and 199 postintervention). The proportion of children hospitalized with bronchiolitis who received HFNC decreased from a mean of 82% to 60% within 1 month of implementation. Length of stay decreased from a median of 54 to 42 hours, and length of oxygen supplementation decreased from 50 to 38 hours. There were no significant changes in ICU transfers, 7-day ED revisits, or readmissions.

Conclusions: Implementing a HFNC initiation protocol can safely reduce the overutilization of HFNC in children hospitalized with bronchiolitis.

Background: Neonates exposed to painful procedures require pain assessment and reassessment using nonverbal scales. Nurses perform initial assessments routinely, but reassessment is variable. The goal was to increase pain reassessments in neonates with a previous score of 4 or higher within 60 minutes from 50% to 75% within 12 months.

Methods: After identifying key drivers, we tested several interventions using the IHI's Model for Improvement. The outcome measure was the rate of reassessments within 1 hour after scoring ≥4 on the Neonatal Pain Agitation and Sedation Scale (N-PASS). Duration of time between scoring and intervention was documented. Interventions included electronic health record (EHR) changes, direct communication with bedside nurses through text messages and emails, in-person education, and a yearly competency module. The process measure was the number of messages/emails to staff. Sedation scores were the balancing measure.

Results: Baseline compliance was 50% with significant variability. A centerline shift occurred after the first intervention. After the first four interventions in the following 3 months, a 29% total increase occurred. Overall time-lapse between reassessments decreased from 102 to 90 minutes. Overall sedation scores decreased from -2.5 during the baseline to -1.7 during the sustain period. The goal of 75% pain reassessments was achieved and sustained for two years.

Conclusions: Automated tools such as the trigger report provided data that increased noncompliance visibility. Real-time and personalized reminders and education improved awareness and set the tone for culture change. Electronic health record reminders for reassessments and standardized annual education helped in sustaining change.

Introduction: Failure to recognize and mitigate critical patient deterioration remains a source of serious preventable harm to hospitalized pediatric cardiac patients. Emergency transfers (ETs) occur 10-20 times more often than code events outside the intensive care unit (ICU) and are associated with morbidity and mortality. This quality improvement project aimed to increase days between ETs and code events on an acute care cardiology unit (ACCU) from a baseline median of 17 and 32 days to ≥70 and 90 days within 12 months.

Methods: Institutional leaders, cardiology-trained physicians and nurses, and trainees convened, utilizing the Institution for Healthcare Improvement model to achieve the project aims. Interventions implemented focused on improving situational awareness (SA), including a "Must Call List," evening rounds, a visual management board, and daily huddles. Outcome measures included calendar days between ETs and code events in the ACCU. Process measures tracked the utilization of interventions, and cardiac ICU length of stay was a balancing measure. Statistical process control chart methodology was utilized to analyze the impact of interventions.

Results: Within the study period, we observed a centerline shift in primary outcome measures with an increase from 17 to 56 days between ETs and 32 to 62 days between code events in the ACCU, with sustained improvement. Intervention utilization ranged from 87% to 100%, and there was no observed special cause variation in our balancing measure.

Conclusions: Interventions focused on improving SA in a particularly vulnerable patient population led to sustained improvement with reduced ETs and code events outside the ICU.

Background: Firearm injuries are a leading cause of morbidity and mortality for US youth. Secure storage is protective against firearm injuries in children. Despite this evidence and national recommendations, rates of firearm safety screening among pediatric providers are low, particularly in the inpatient setting. Therefore, we aimed to increase the frequency of firearm safety screening among patients admitted to the Pediatric Hospital Medicine service.

Methods: This project occurred in a tertiary pediatric hospital with a medium-sized pediatric residency program. The initial intervention was a firearm safety screening tool embedded into the electronic health record history and physical note template. Subsequent interventions included nursing education, monthly reminder emails, and gun violence discussions during intern orientation. Patients who screened positive were provided with educational materials and a free gun lock. Data collection occurred by chart review to determine the frequency of screening documentation in the H&P. A survey was also conducted among pediatric residents to identify persistent barriers to screening.

Results: The percentage of inpatient firearm safety screening increased from 0.01% to 39% over 25 months, with a centerline shift noted after 2 months. Residents cited a lack of time with the patient and a belief that it was not the appropriate time to screen as persistent barriers to screening.

Conclusions: This study identified an effective approach to improving firearm safety screening in an academic pediatric hospital. Hospitalization represents a unique opportunity for firearm safety screening and counseling, and inpatient providers should feel empowered to intervene in this setting.

A newborn male child with prenatally identified aortic arch hypoplasia presented to our facility for cardiac management. He had been started on prostaglandins at the delivery facility and was subsequently placed on a high-flow nasal cannula due to associated apnea. On the day of life three, the patient underwent cardiac computed tomography scan for delineation of his anatomy. The patient remained intubated after his imaging study in anticipation of surgical intervention, which took place at the age of 5 days. The patient required a peritoneal dialysis catheter placement 2 days after his procedure due to oliguria. He progressed into renal failure requiring continuous renal replacement therapy. This patient was subsequently discussed at our departmental morbidity and mortality conference. The short time frame between contrast administration for the computed tomography and surgical intervention was thought to have contributed to his renal failure. We discussed the adequacy of transverse aortic arch imaging by echocardiogram and the utility of advanced imaging in the fragile neonatal period. This discussion resulted in our department asking, "Is transthoracic echocardiography accurate when diagnosing and characterizing aortic coarctation at our institution? Are advanced imaging studies necessary in instances of simple coarctation?"

Background: In 2013, Nationwide Children's Hospital's (NCH) Quality Tool School (QTS) was created as an initial Quality Improvement educational series, composed of three separate classes, totaling 5.5 hours of hands-on QI training. QTS complemented the NCH 40-hour Quality Improvement Essentials course.

Methods: Over 10 years, the series went through three phases of aims: Phase 1: develop and implement three core courses (Project Tools, Excel, and Control Charts); Phase 2: have participants complete the entire series of all three classes; Phase 3: have participants who complete the entire series of all three classes demonstrate the application of learning through involvement in a quality improvement project.

Results: Since initiation, QTS has provided an educational entry point for 1428 NCH employees to participate in QI projects and teams. QTS has shown statistically significant improvement in 2 of the 3 principal aims. The Phase 1 metric of average monthly one-class participation completion percentage showed a statistically significant centerline shift from 9 to 16 students in October 2018. The Phase 3 metric Percentage of QTS participants completing the QTS series of classes and then participating in a QI team began in 2016 with a baseline of 42%. A centerline shift from 42% to 63% occurred in Q4 2018.

Conclusions: QTS can provide QI education to healthcare system employees using limited resources. Organizations that strategically integrate a culture of QI into core beliefs can realize substantial improvement gains.

Background: Bowel management for children with chronic constipation may include repeated single-view abdomen radiographs (AXR) to monitor treatment success. Only one image of the abdomen is needed to include most of the colon, but technologists often make a second (or even third) exposure to be sure they have imaged the entire abdomen. Our quality improvement project aimed to reduce radiation exposure by decreasing the frequency of >1 exposure performed for AXR orders in children with chronic constipation from 27% to <10% by December 2022 and sustain.

Methods: We counted baseline (01/2020-11/2020) and intervention (12/2020-5/2023) examinations with >1 exposure. Initial interventions were a structured communication to technologists and an article in the monthly department newsletter and later, a technologist education module. Additional interventions included communication to radiologists, project updates and encouragement to all technologists, and individual technologist feedback. A statistical process control chart tracked data to study process changes over time.

Results: During the baseline and intervention periods, 525/1944 and 1329/8334 examinations, respectively, had >1 exposure performed for AXR orders. Interventions created 2 centerline shifts. Overall, examinations with >1 exposure decreased from 27% to 13.5%.

Conclusions: Frequency of >1 exposure performed for AXR orders in children with chronic constipation decreased from 27% to 13.5% through education and communication. This was sustained. We plan to assign training modules for all new technologists, policy reminders (annual training in odd years) for all technologists, and continue individualized learning opportunities.

Direct admissions (DAs) are a routine hospital entry portal with few guidelines to assess patient safety during this process. This study assessed the effectiveness of an institutional screen for patients presenting as DA. It investigated patient variables that may predict appropriateness for DA and those at high risk for deterioration.

Methods: The study includes patients who received the institutional screen between June 1, 2019, and May 31, 2020. We placed charts into three groups: group 1 (stable), group 2 (unstable), and group 3 (stable then transferred to pediatric intensive care unit within 6 hours). We assessed effectiveness by calculating sensitivity, specificity, and predictive values. We used comparative analysis between groups to identify patients safe for DA and those at high risk for deterioration.

Results: The screen was 80% sensitive and 100% specific, predicting 97.7% of stable patients. Of the 652 charts reviewed, 384 met the inclusion criteria. Group 1 (31.60, 26.45%, 5.23%) had lower respiratory rate, respiratory diagnosis, and oxygen requirement compared to group 2 (45.00, 78.13%, 15.63%) and group 3 (44.50, 75.00%, 50.00%). For SpO₂, group 1 (98.70) was higher than group 2 (96.03). For the Pediatric Early Warning Score, group 2 (1.72) was higher than group 1 (0.31) and group 3 (0.63).

Conclusions: The institutional screen is an effective tool to identify patients presenting as DA needing immediate emergency department intervention and/or pediatric intensive care unit care. The screen benefits patients with a respiratory diagnosis, oxygen requirement, high respiratory rate or low SpO₂.