bluuebunny/crossref_metadata_2025 huggingface dataset:
Feasibility of Episode-Based Bundled Payment for a Pediatric Surgical Condition: Posterior Spinal Fusion
Authors: Shaughnessy Erin E. , Sturm Peter , Sitzman Thomas J.
Published: June 2019

Introduction:

Episode-based bundled payment (EBBP) is an alternative model of health-care payment that aims to align providers’ and hospitals’ incentives toward delivery of more coordinated, higher quality, and lower cost care. EBBP programs have been studied for numerous adult conditions over the past decade, yet there have been no studies exploring the use of EBBP in pediatric conditions.

Methods:

This article explores the feasibility of EBBP for a relatively common, costly, pediatric surgical procedure: spinal fusion for adolescent idiopathic scoliosis. We begin with a review of successful EBBP programs in the United States. We then apply American College of Surgeons criteria for bundled payment episode selection to identify benefits and challenges of using EBBP for this condition.

Results:

We identify several features of pediatric spinal fusion that make it an attractive EBBP target: high variability in costs with multiple distinct targets for cost reduction, high variability in quality across hospitals, and proven methods for improvement via application of standardized, evidence based pathways. We find that challenges to EBBP may arise due to the relatively low incidence of the procedure, which limits overall savings to the health-care community.

Conclusions:

Our results suggest that spinal fusion for adolescent idiopathic scoliosis is an attractive pediatric target for EBBP, with potential benefits to patients, providers, health systems, and payers if limitations in procedure volume and administrative expense are overcome. The framework presented may also be useful for analyzing feasibility of EBBP for other pediatric conditions.
Deployment of a Second Victim Peer Support Program: A Replication Study
Authors: Merandi Jenna , Liao Nancy , Lewe Dorcas , Morvay Shelly , Stewart Barb , Catt Charline , Scott Susan D.
Published: June 2019

Background:

The second victim phenomenon occurs when health-care providers experience significant professional distress (compassion dissatisfaction, burnout, secondary traumatic stress) and psychological distress (shame, anxiety, and depression) as a result of medical errors or adverse patient outcomes. Few hospitals have institution-wide systems in place to assist employees through the recovery process.

Methods:

At Nationwide Children’s Hospital (NCH), a peer-based support program called “YOU Matter” was executed and spread hospital-wide. The program emulated the framework and execution strategy designed by University of Missouri Health Care’s (MUHC) “forYOU” Team. Strategic elements of the program’s structure were reviewed and adapted for NCH with system-wide deployment and enhancement to include electronic peer support reporting. This article summarizes program implementation, management, and sustainment over the past 2 years.

Results:

By following University of Missouri Health Care’s model, we successfully deployed an institution-wide second victim program. Since the November 2013 initiation, we have documented 232 peer and 21 group encounters. High-risk clinical areas for second victimization at NCH included the emergency department (ED), pediatric intensive care unit (PICU), cardiothoracic intensive care unit (CTICU), and pharmacy department. Registered nurses (RNs) and licensed practical nurses (LPNs) have had the highest number of encounters necessitating second victim support (32%). Supported staff reported improved emotional state and improved return-to-work metrics.

Conclusions:

An organization’s culture of patient safety can be enhanced by ensuring staff psychological safety. Programs like “YOU Matter” and the “forYOU” Team are essential building blocks to improve the overall safety culture and quality of care. Implementation of “YOU Matter” at NCH validates the MUHC program and demonstrates its generalizability to other health-care institutions.
Emergency Department Asthma Medication Delivery Program: An Initiative to Provide Discharge Prescriptions and Education
Authors: Durkin Kayla , Montgomery Tricia , Lamberjack Kristen , Hafer Cindy C. , Naprawa James , Yarosz Shannon
Published: June 2019

Background:

Prescription fill rates for children being discharged from the emergency department (ED) after asthma exacerbations are low, placing the child at risk for additional ED visits or admissions for asthma. This article describes the implementation of an ED asthma prescription delivery service designed to improve pharmacy prescription capture and decrease ED revisit rates.

Methods:

A core group developed a service to provide asthma prescriptions and education to patients in their ED room before discharge. The project assessed the percent of ED asthma patients who filled ED asthma prescriptions at the hospital outpatient pharmacy, 7-, 14-, and 30-day ED revisit rates, and patient satisfaction.

Intervention:

Patients/families who chose to participate in the service received asthma prescriptions and education at the ED bedside. Within 1–3 days, ED outreach nurses obtained patient satisfaction survey responses via telephone.

Results:

There was a statistically significant increase in the number of patients who filled ED asthma prescriptions at the hospital outpatient pharmacy (22.2% versus 33.8%; P < 0.0001). The decrease in 7-, 14-, or 30-day ED revisit rates for patients who received the medication delivery service compared with standard of care was not statistically significant. Patients were satisfied to very satisfied with the service.

Conclusion:

Postimplementation of a medication delivery program within the ED, there was an increase in the percentage of patients who filled ED asthma medication prescriptions at the hospital outpatient pharmacy. There was no difference in ED revisit rates for patients who enrolled in the prescription delivery service versus standard of care.
Impact of a Successful Speaking Up Program on Health-Care Worker Hand Hygiene Behavior
Authors: Linam W. Matthew , Honeycutt Michele D. , Gilliam Craig H. , Wisdom Christy M. , Deshpande Jayant K.
Published: June 2019

Background:

Health-care worker (HCW) hand hygiene (HH) is the cornerstone of efforts to reduce hospital infections but remains low. Real-time mitigation of failures can increase process reliability to > 95% but has been challenging to implement for HH.

Objective:

To sustainably improve HCW HH to > 95%.

Methods:

A hospital-wide quality improvement initiative to improve HH was initiated in February 2012. HCW HH behavior was measured by covert direct observation utilizing multiple-trained HCW volunteers. HH compliance was defined as correct HH performed before and after contact with the patient or the patient’s care area. Interventions focusing on leadership support, HCW knowledge, supply availability, and culture change were implemented using quality improvement science methodology. In February 2014, the hospital began the Speaking Up for Safety Program, which trained all HCWs to identify and mitigate HH failures at the moment of occurrence and addressed known barriers to speaking up.

Results:

Between January 1, 2012, and January 31, 2016, there were 30,514 HH observations, averaging 627 observations per month (9% attending physicians, 12% resident physicians, 46% nurses, 33% other HCW types). HCW HH gradually increased from 75% to > 90% by December 2014. After the Speaking Up for Safety Program, HCW HH has been > 95% for 20 months. Physician HH compliance has been above 90% for over a year.

Conclusion:

Creating a specific process for staff to speak up and prevent HH failures, as part of a multimodal improvement effort, can sustainably increase HCW HH above 95%.
Implementation of the Asthma Control Test in a Large Primary Care Network
Authors: Sangvai Shilpa , Hersey Stephen J. , Snyder Dane A. , Allen Elizabeth D. , Hafer Cindy , Wickliffe Jeanne , Groner Judith A.
Published: June 2019

Introduction:

Achieving control in asthma is a primary goal of pediatric care, and assessing the degree of control is a principal step in management. The purpose of this quality improvement project was to implement the Asthma Control Test (ACT) and the Childhood Asthma Control Test (C-ACT) in a large primary care network as a means to reliably and consistently assess asthma control at all visit types.

Methods:

A prospective design was used to measure provider documentation of the ACT or C-ACT. Patients (or caregivers) 4 years of age or older with a known diagnosis of asthma were administered the ACT (ages 12 and older) or the C-ACT (ages, 4–11). The quality improvement project, which involved multiple interventions, took place at 11 centers of the Primary Care Network of Nationwide Children’s Hospital from November 2013 to December 2014. A goal was set for a 70% completion rate of the ACT/C-ACT at any visit type for patients 4 years of age or older with asthma.

Results:

Six months after the introduction of the questionnaires, the 70% completion rate was reached. Rates of ACT/C-ACT completion have consistently exceeded 70% through December 2016.

Conclusions:

We demonstrated that the ACT/C-ACT can be integrated into a busy primary care network. It is imperative to work toward better asthma care; consistent assessment of asthma control can be the critical first step.
Integrating a Geneticist in a Multidisciplinary Clinic for Down Syndrome Increases Commitment to Genetic Counseling
Authors: Santoro Stephanie L. , Jacobson Theodora , Lemle Stephanie , Bartman Thomas
Published: June 2019

Background:

Although most physicians and genetic professionals are familiar with Down syndrome, many families do not have experience with Down syndrome before having a child diagnosed. The American Academy of Pediatrics has specific recommendations for genetic counseling and chromosome analysis for Down syndrome.

Local Problem:

The literature indicates that adherence to completion of appropriately timed genetic counseling is low at 31%. This study was initiated to determine our adherence rates and to improve if needed.

Methods:

In the Down syndrome clinic at Nationwide Children’s Hospital, a subspecialty clinic in the Division of Developmental and Behavioral Pediatrics, a genetic counselor was on-call but did not routinely attend. The intervention consisted of multidisciplinary care with the presence of a clinical geneticist. Statistical Process Control Charts and Fisher’s exact test were used to determine the impact of the intervention.

Results:

Our baseline rate of adherence to genetic counseling was similar to previous publications. Direct genetics involvement in the Down syndrome clinic in place of an on-call genetic counselor led to significant improvement in adherence to genetic counseling recommendations over a 6-month period from 35% to 62%, P < 0.001 and sustained for 6 months. Postclinic adherence rates and subanalyses by age showed similar results. The final postvisit adherence rate of 89% in February 2017 demonstrates continued improvement. Geneticist involvement allowed chromosome reports uploading and karyotype listing in electronic medical records.

Implications and Lessons Learned:

Genetic counseling in newborns with Down syndrome is important, yet was often not received at Nationwide Children’s Hospital before this study. Integrating a geneticist resulted in improvement. Implementing similar models at other institutions can ensure that the correct genetic testing is completed, results documented and families counseled appropriately.
Improving Inpatient Asthma Management: The Implementation and Evaluation of a Pediatric Asthma Clinical Pathway
Authors: Magruder Teresa G. , Narayanan Sridaran , Walley Susan , Powers Tony , Whitlock Hollace , Harrington Kathleen , Wall Terry C.
Published: June 2019

Introduction:

Asthma exacerbations are a leading cause of pediatric hospitalizations. Despite national guidelines, variability exists in the use and dosing of bronchodilators, oxygen management, and respiratory assessments of patients. We aimed to implement an inpatient Asthma Clinical Pathway (Pathway) to standardize care and reduce length of stay (LOS).

Methods:

A respiratory therapy–driven Pathway was designed for inpatient asthma management. The Pathway included standardized respiratory therapy assessments, bronchodilator dosing, and protocols for progression and clinical worsening. We monitored key process measures. Patients admitted to the Pathway during pilot implementation (March to December 2011) were compared retrospectively with a “Usual Care” cohort admitted during the same period. We compared average LOS, average billed charges per hospitalization (charges), and 30-day readmissions between groups. Statistical process control charts were utilized to analyze LOS and charges for all asthma admissions following Pathway implementation (March 2011 to September 2016). Readmissions and Pathway removals were balancing measures.

Results:

During pilot, Pathway patients (n = 153) compared with “Usual Care” patients (n = 166) had shorter LOS (0.95 versus 1.86 days; P < 0.001) and lower charges ($7,413 versus $11,078; P < 0.001). Readmission rates were not significantly different between groups. LOS for all asthma admissions (n = 3,429) decreased from 2.30 to 1.44 days (P < 0.001) following Pathway implementation. Charges remained stable. The readmission rate (per 100 discharges) for all asthma was 2.42 and not significantly different between Pathway and non-Pathway groups.

Conclusions:

Pathway implementation reduced LOS and stabilized charges while not increasing readmission rates. The Pathway facilitated sustainable widely adopted improvements in asthma care.
A Quality Improvement Collaborative for Pediatric Sepsis: Lessons Learned
Authors: Paul Raina , Melendez Elliot , Wathen Beth , Larsen Gitte , Chapman Laura , Wheeler Derek S. , Wakefield Toni , Macias Charles G.
Published: June 2019

Background:

Sepsis is a leading cause of morbidity and mortality in children worldwide. Barriers exist for timely recognition and management in emergency care settings. This 1-year quality improvement collaborative sought to reduce mortality from sepsis.

Methods:

Fifteen hospitals participated initially. We included children with a spectrum of illness from sepsis to septic shock. The intervention bundle focused on recognition, escalation of care, and the first hour of resuscitation. We conducted monthly learning sessions and disseminated data reports of site-specific and aggregated metrics to drive rapid cycle improvement.

Results:

Seven sites contributed enough data to be analyzed. Of the 1,173 pediatric patients in the total cohort, 506 presented with severe sepsis/septic shock. Quarterly data demonstrated a mean improvement in initial clinical assessment from 46% to 60% (P < 0.001) and in adherence to the administration of first fluid bolus within 15 minutes from 38% to 46% (P < 0.015). There was no statistically significant improvement in other process metrics. There was no statistically significant improvement in mortality for the total cohort (sepsis to septic shock) or either of the subgroups in either 3- or 30-day mortality.

Conclusions:

A quality improvement collaborative focused on improving timely recognition and management of pediatric sepsis to septic shock led to some process improvements but did not show improvement in mortality. Future national efforts should standardize definitions and processes of care for sepsis to septic shock, including the identification of a “time zero” for measuring the timeliness of treatment.
Using a Quality Improvement Approach to Engage Families in Emergency Room Sepsis Huddles
Authors: Wiener Ethan , McGrath Meaghan N. , Schlucter Juliette , Pereira-Argenziano Lucy , Carr Amanda , Piasio Nicole , Levy Fiona H.
Published: June 2019

Background:

Interdisciplinary team huddles are a key component of the Sepsis Collaborative’s Recognition Bundle in the Emergency Department (ED). Family Engagement (FE) is essential to ensure best outcomes. Working with families as partners we co-produced a simulation-based training model including, clinical scenarios, family-centered competencies, and debriefs. This model engages family advisors who serve as coaches of standardized patients and interdisciplinary teams in an immersive learning experience.

Objective:

Apply our training model to standardize engagement of families during sepsis huddles in the ED.

Methods:

Using a quality improvement framework, we developed our key driver diagram (Fig. 1) and focused on development of standardized language as our first intervention to facilitate partnership with families during sepsis huddles. A succession of 6 improvement cycles were implemented (Fig. 2) with unique attending, nurse, and resident learner groups.

Results:

Based on family and clinician feedback (Fig. 3), the following standardized elements were developed: (1) explanation of sepsis huddle that invites families to partner and share concerns; (2) direct language to explain the term sepsis; (3) explanation of next steps, timeline, and confirmed point of contact. This language guided providers to engage more clearly and consistently.

Conclusions:

Our co-produced training approach resulted in the development of standardized language as 1 component to support Family Engagement in ED sepsis huddles. Clinicians shared that family feedback was essential in the creation of succinct, meaningful, and mutually engaging language. Though not measured in this intervention, clinicians shared the perception that this training improved efficiency and priority to engage families in huddles.
Electronic Screening Tool and Shock Huddle Process for Children at Risk for Sepsis
Authors: Stinson Hannah R. , Stevens Erica , Koetter Paige , Setlik Jennifer , Viteri Shirley , Frizzola Meg
Published: June 2019

Background:

Nemours created an electronic screening tool for severe sepsis/septic shock (SS/SS) called the Shock Score (Table 1). At a threshold score, a Shock Huddle (SH) is initiated, and the patient is assessed by the Shock RN (pediatric intensive care unit nurse with enhanced training on sepsis) with the primary team (Fig. 1).

Objectives:

We sought to describe the characteristics of the score and the demographics of patients who underwent an SH.

Methods:

One thousand seven hundred forty-eight admissions were screened over 109 days. Cases of SS/SS were identified by chart review of patients with an elevated score, transfers to the intensive care unit via the medical emergency team, and patients with International Classification of Disease-10 codes of R65.20/R65.21. A subset (1,323 admissions) was used to evaluate the score characteristics.

Results:

There were 58 cases of SS/SS. Five cases were missed by the score due to a missed high risk condition or delay in documentation. One hundred twenty SH were completed on 51 unique patients. Seventy-three percent had a high risk condition. Nearly 40% of SHs involved diagnostic or therapeutic intervention (Table 2). The score had an area under the receiver operating characteristic curve (AUROC) 0.8, sensitivity 0.9 (0.72–0.97), specificity 0.44 (0.35–0.54), negative predictive value 0.95 (0.84–0.99), and positive predictive value 0.28 (0.19–0.38).

Conclusions/Implications:

The score demonstrates acceptable characteristics as a screening tool to identify children at risk for sepsis. Nearly 40% of SHs included a diagnostic or therapeutic intervention. Misses of the score were related to high risk conditions that were not scored by the electronic medical record and delays in documentation.
Escalation Huddles: Facilitating Sepsis Activations Using Hospital-wide Escalation Processes
Authors: Lockwood Justin , Wathen Beth , Rolison Elise , Reese Jennifer , Bajaj Lalit , Swanson Angela , Carpenter Todd
Published: June 2019

Background:

Bedside huddles can be valuable parts of hospital sepsis responses. These huddles, however, risk duplication of effort with existing care escalation systems, and they may also be of value in settings other than sepsis. Streamlining care escalation processes may present an opportunity to improve sepsis responses.

Objectives:

To facilitate team-based discussion of patients with suspected sepsis as a step toward reducing time to first antibiotic administration.

Methods:

Existing care escalation frameworks were amended (Figs. 1, 2) and incorporated into rapid cycle process improvement initiatives on non-ICU units. New sepsis response resources were created to facilitate team communication, intravenous (IV) access, and timely antibiotic delivery (Fig. 3).

Results:

An Escalation Huddle system was created to bring local care teams together early during clinical deterioration, including cases of suspected sepsis. Rapid Response Team activation is available but not mandated. An Urgent IV & Blood Draw algorithm was created to facilitate IV access using a protocolized progression through existing hospital resources. An Inpatient Suspected Sepsis order set was created with antibiotic decision support and recommendations for evaluation of organ dysfunction. These processes have been improved through 3 “Plan, Do, Study, Act” cycles.

Conclusions:

Rather than create a separate sepsis response system, we chose to enhance existing hospital-wide escalation processes by formalizing an Escalation Huddle system and developing new tools to enhance sepsis responses within that system. We anticipate this approach will facilitate discussion of suspected sepsis cases and improve sepsis responses while avoiding inefficient or duplicative escalation actions by care team members.
De-escalation of Care Through Pediatric Intensive Care Unit Liberation Rounds and a Daily Checklist
Authors: Kawai Yu , Rohlik Gina M. , Neu Lori L. , Mujic Anna J. , Duncan Julie M. , Feigal Scott A. , Rowekamp Debra J. , Fetterly Britt M. , Fryer Karen R. , Conlon Patricia M. , Huskins W. Charles , Schiltz Brenda M. , Ouellette Yves , Nemergut Michael E. , Kahoud Robert J. , Arteaga Grace M.
Published: June 2019

Introduction:

Pediatric intensive care unit (PICU) Liberation Bundle
1
was implemented to standardize weaning of ICU support after clinical stabilization and to prevent iatrogenicity by timely assessment of pain, extubation readiness, sedation, delirium, withdrawal, early mobilization, and family engagement. By implementing a PICU Liberation bedside rounding process and a de-escalation daily rounding checklist, we hypothesized that the PICU Liberation Bundle compliance will improve and the risk for iatrogenic conditions can be minimized.

Methods:

The “old” rounding process used a nursing script organized by organ systems while the “new” process (Fig. 1) focused on PICU Liberation Bundle elements and the addition of a physician-completed checklist (Fig. 2). Independent observers collected data during rounds. All checklists completed over the first 50 days after deployment were analyzed.

Results:

There was an increase in frequency of PICU Liberation Bundle elements discussed during the “new” process with similar rounding time compared with the “old” process (Table 1). The overall compliance with the checklist was 90.4% (322 of 356 total patient-days). The medical plan was modified 62 times in 14.0% (45 of 322) of the checklists completed. The 5 most frequently modified tasks were converting intravenous to per os meds (13), initiating bowel regimen (11), initiating GI prophylaxis (9), consulting physical therapy/occupational therapy/physical medicine and rehabilitation services (9), and initiating sleep enhancement protocol (6) accounting for 77.4% (48/62) of all amendments made.

Conclusions:

PICU Liberation rounding process improved adherence with the PICU Liberation Bundle elements, and the checklist caught numerous missed opportunities, thereby increasing the frequency of timely de-escalation of care and minimizing the risk of iatrogenic conditions without lengthening rounding time.
Optimizing Performance: Revolutionizing the Sepsis Team with a Fresh Start
Authors: Acevedo Mina , Wilson Michele
Published: June 2019

Introduction:

Improving Pediatric Sepsis Outcomes (IPSO) is an extensive project that requires commitment over several years. The seventh key driver of IPSO, Optimizing Performance, is a vital section to ensure progress is sustained over time. Initially, the sepsis team at Loma Linda University Children’s Hospital was motivated, but over time enthusiasm dwindled and physicians disengaged.

Methods:

To optimize performance, quality improvement methods of the Shewhart cycle were utilized to examine the team, foster engagement, and ultimately stimulate progress.
1
Strategies were built on the concept of “make a C2ASE for the team,” where Clarity & Consistency, Accountability, Support, and Empowerment (C2ASE) is the formula for success. The mission was highlighted, and a charter was created. Team members were held accountable, and decisions were made at biweekly meetings. Support was obtained through Children’s Hospital Association webinars, office calls, and coaching sessions. The team was empowered through appreciation, recognition, and celebrations of milestones together.

Results:

Following revitalization efforts, physician attendance at committee meetings improved from 17% to 45% as shown in Figure 1. Subsequently, in a 5-month period, the following sepsis processes were established: screening, huddle, order set, video, screensavers, webpage, dashboard, a launch in 1 care setting, and over 300 submitted data files.

Conclusion:

A disengaged sepsis team was revolutionized by making a C2ASE, via Clarity of the mission, Consistency in expectations, Accountability for actions, seeking Support and Empowering the team. The results of the revitalized commitment rejuvenated morale and stimulated progress to fight pediatric sepsis at Loma Linda University Children’s Hospital.
Automation of a Paper-based Screening Tool for Early Sepsis Risk Detection in the Emergency Department
Authors: Lloyd Julia K. , Ahrens Erin A. , Clark Donnie , Nuss Kathryn E.
Published: June 2019

Background:

Presentation of sepsis is dependent on synthesis of varied clinical information, making identification of septic patients challenging. Common practice is to identify sepsis through a manual screening tool, which may miss opportunities for early sepsis detection. Electronic screening efforts requiring additional documentation by providers may not integrate easily into provider workflow.

Objectives:

To develop an automated sepsis risk screening tool in the electronic health record that would accurately identify patients at risk for sepsis without requiring additional documentation.

Methods:

Criteria in the manual screening tool were mapped to standard documentation routinely entered in the electronic health record (Epic Systems, Corp.). Data elements were scored electronically at arrival and every 15 minutes during their encounter from the medical history, medication record, vital signs, and physical assessment (Fig. 1). Scores that exceeded a predefined sepsis risk threshold triggered a Best Practice Advisory, which alerted bedside staff to perform sepsis huddles and consider appropriate interventions. Statistical comparison of the automated tool to the manual process was completed by two-tail paired t test.

Results:

In an 8-week testing period, the automated sepsis risk screening tool identified 100% of patients flagged by the manual process (N = 29) (Table 1). The electronic tool identified sepsis patients, on average, 68 minutes earlier. This was statistically significant (P < 0.001).

Conclusions/Implications:

The automated sepsis risk screening tool is as accurate as a validated manual process and alerted bedside clinicians earlier. Deployment has potential to improve timely sepsis detection and management of patients without requiring additional documentation by provider.
10,000 Good Catches: Increasing Safety Event Reporting In A Pediatric Health Care System
Authors: Crandall Kristen M. , Almuhanna Ahmed , Cady Rebecca , Fahey Lisbeth , Floyd Tara Taylor , Freiburg Debbie , Hilliard Mary Anne , Kalburgi Sonal , Khan Nafis I. , Patrick DiAnthia , Pavuluri Padmaja , Potter Kelvin , Scafidi Lisa , Sigman Laura , Shah Rahul K.
Published: June 2019

Background:

In 2014, Children’s National Health System’s executive leadership team challenged the organization to double the number of voluntary safety event reports submitted over a 3-year period; the intent was to increase reliability and promote our safety culture by hardwiring employee event reporting.

Methods:

Following a Donabedian quality improvement framework of structure, process, and outcomes, a multidisciplinary team was formed and areas for improvement were identified. The multidisciplinary team focused on 3 major areas: the perceived ease of reporting (ie, how difficult is it to report an event?); the perceived safety of reporting (ie, will I get in trouble for reporting?); and the perceived impact of reporting (ie, does my report make a difference?) technology, making it safe to report, and how reporting makes a difference. The team developed a key driver diagram and implemented interventions designed to impact the key drivers and to increase reporting.

Results:

Children’s National increased the number of safety event reports from 4,668 in fiscal year 2014 to 10,971 safety event reports in fiscal year 2017. Median event report submission time was decreased by nearly 30%, anonymous reporting decreased by 69%, the number of submitting departments increased by 94%, and the number of reports submitted as “other” decreased from a baseline of 6% to 2%.

Conclusions:

Children’s National Health System’s focus on increasing safety event reporting resulted in increased organizational engagement and attention. This initiative served as a tangible step to improve organizational reliability and the culture of safety and is readily generalizable to other hospitals.
Improving Screening for Sepsis in the Pediatric Emergency Department
Authors: Rutman Lori , Beardsley Elaine , Fenstermacher Sara , Geiger Julie , Zahradnik Nancy
Published: June 2019

Introduction:

Early recognition of sepsis is critical to providing efficient and effective care for a potentially life-threatening condition. When automated sepsis screening is not available, front-line ED providers, often bedside nurses, must incorporate screening into their busy workflow. The aim of this project was to increase the completion of an ED-based sepsis screening tool in at-risk patients from a baseline of 5–15% to > 50% in 3 months.

Methods:

A key driver diagram was developed (Fig. 1). We used statistical process control to evaluate changes in sepsis screening over time.

Results:

At baseline, 15% of ED patients with fever were screened using the electronic, nurse-initiated tool. We noted a single point outside the upper control limit (special cause variation) in October 2015 concurrent with implementation of a clinical pathway for septic shock, but this improvement was not sustained over time. Special cause was again noted with a shift of 8 points above the centerline in June 2016 following an educational push and reminders for ED nurses, increasing overall screening to 30%. Further improvement (special cause) was noted after significant modifications were made to the screening tool in June 2017 (Fig. 2).

Conclusion:

Quality improvement methodologies (development of a SMART aim, key driver diagram, and multiple plan-do-study-act cycles) led to improvement in screening at-risk patients for sepsis.
Assessing Barriers to Uveitis Screening in Patients with Juvenile Idiopathic Arthritis Through Semi-Structured Interviews
Authors: Ballenger Laura R. , Ardoin Stacy P. , Driest Kyla D.
Published: June 2019

Introduction:

Uveitis is a significant complication in patients with juvenile idiopathic arthritis (JIA) and can be asymptomatic until vision loss develops. Published guidelines recommend uveitis screening eye examinations every 3–12 months depending on multiple factors, but no literature evaluates adherence with and barriers to obtaining these screening eye examinations. This study assesses barriers in nonadherent patients to establish key drivers for future interventions.

Methods:

We identified patients with JIA who were nonadherent with uveitis screening guidelines through the electronic medical record (EMR). A rheumatologist conducted semistructured interviews with the patients or guardians regarding the patients’ most recent eye examinations, knowledge of the screening frequency, and barriers to completing the eye examinations. The results were qualitatively analyzed to determine any categorical variables present.

Results:

Ninety-two patients were identified as nonadherent, and the rheumatologist interviewed 45 patients or guardians. Categories identified following the interviews were system problems, access to care issues, and knowledge deficits. The largest category identified was system problems that included most recent eye examination not being in the EMR, the wrong eye provider identified in the EMR or difficulty with scheduling eye appointments.

Conclusions:

This qualitative study identified categories of barriers to obtaining screening eye examinations in patients with JIA. Identification of these barriers will facilitate the development of a specific aim and key driver diagram to guide future quality improvement interventions.
A Retrospective Review of a Bed-mounted Projection System for Managing Pediatric Preoperative Anxiety
Authors: Caruso Thomas J. , Tsui Jeremy H. , Wang Ellen , Scheinker David , Sharek Paul J. , Cunningham Christine , Rodriguez Samuel T.
Published: June 2019

Introduction:

Most children undergoing anesthesia experience significant preoperative anxiety. We developed a bedside entertainment and relaxation theater (BERT) as an alternative to midazolam for appropriate patients undergoing anesthesia. The primary aim of this study was to determine if BERT was as effective as midazolam in producing cooperative patients at anesthesia induction. Secondary aims reviewed patient emotion and timeliness of BERT utilization.

Methods:

We conducted a retrospective cohort study of pediatric patients undergoing anesthesia at Lucile Packard Children’s Hospital Stanford between February 1, 2016, and October 1, 2016. Logistic regression compared induction cooperation between groups. Multinomial logistic regression compared patients’ emotion at induction. Ordinary least squares regression compared preoperative time.

Results:

Of the 686 eligible patients, 163 were in the BERT group and 150 in the midazolam. Ninety-three percentage of study patients (290/313) were cooperative at induction, and the BERT group were less likely to be cooperative (P = 0.04). The BERT group was more likely to be “playful” compared with “sedated” (P < 0.001). There was a reduction of 14.7 minutes in preoperative patient readiness associated with BERT (P = 0.001).

Conclusions:

Although most patients were cooperative for induction in both groups, the midazolam group was more cooperative. The BERT reduced the preinduction time and was associated with an increase in patients feeling “playful.”
Quality Initiative to Improve time to Antibiotics for Febrile Pediatric Patients with Potential Neutropenia
Authors: Monroe Kathy , Cohen Clay T. , Whelan Kimberly , King Amber , Maloney Lisa , Deason Janet , Nichols John Charles , Friedman Gregory K. , Kutny Matthew , Hayes Leslie
Published: June 2019

Introduction:

In patients who are immunocompromised, fever may indicate a life-threatening infection. Prompt time to antibiotic administration in febrile patients at risk for neutropenia has been identified by national and international panels as a key benchmark of quality care in emergent situations. A quality improvement initiative to improve health care provided in a pediatric emergency department (ED) is described.

Methods:

A clinical pathway was previously initiated in a pediatric ED with a goal of improving time to antibiotics for febrile neutropenia patients. An agreed upon pathway and order set being initiated. Improvements were seen but not to the desired level. This project involved an improvement cycle that focused on nonvalue added time in the workflow.

Results:

Percent of patients receiving antibiotics within the goal time of 1 hour increased from 40% to 80% with the intervention. Process measures including arrival to ED bed time, ED bed to antibiotic order time and antibiotic order time to delivery time were followed.

Conclusion:

Clinical guidelines, order sets and detailed understanding of the actual workflow at the point of care delivery can be instrumental in achieving the goals of reducing time to antibiotics.
Applying Lessons from an Inaugural Clinical Pathway to Establish a Clinical Effectiveness Program
Authors: Algaze Claudia A. , Shin Andrew Y. , Nather Chealsea , Elgin Krisa H. , Ramamoorthy Chandra , Kamra Komal , Kipps Alaina K. , Yarlagadda Vamsi V. , Mafla Monica M. , Vashist Tanushree , Krawczeski Catherine D. , Sharek Paul J.
Published: June 2019

Introduction:

Clinical effectiveness (CE) programs promote standardization to reduce unnecessary variation and improve healthcare value. Best practices for successful and sustainable CE programs remain in question. We developed and implemented our inaugural clinical pathway with the aim of incorporating lessons learned in the build of a CE program at our academic children’s hospital.

Methods:

The Lucile Packard Children’s Hospital Stanford Heart Center and Center for Quality and Clinical Effectiveness partnered to develop and implement an inaugural clinical pathway. Project phases included team assembly, pathway development, implementation, monitoring and evaluation, and improvement. We ascertained Critical CE program elements by focus group discussion among a multidisciplinary panel of experts and key affected groups. Pre and postintervention compared outcomes included mechanical ventilation duration, cardiovascular intensive care unit, and total postoperative length of stay.

Results:

Twenty-seven of the 30 enrolled patients (90%) completed the pathway. There was a reduction in ventilator days (mean 1.0 + 0.5 versus 1.9 + 1.3 days; P < 0.001), cardiovascular intensive care unit (mean 2.3 + 1.1 versus 4.6 + 2.1 days; P < 0.001) and postoperative length of stay (mean 5.9 + 1.6 versus 7.9 + 2.7 days; P < 0.001) compared with the preintervention period. Elements deemed critical included (1) project prioritization for maximal return on investment; (2) multidisciplinary involvement; (3) pathway focus on best practices, critical outcomes, and rate-limiting steps; (4) active and flexible implementation; and (5) continuous data-driven and transparent pathway iteration.

Conclusions:

We identified multiple elements of successful pathway implementation, that we believe to be critical foundational elements of our CE program.
A Longitudinal and Sustainability Assessment of Pediatric Interfacility Transport Handover Standardization
Authors: Sochet Anthony A. , Ryan Kelsey S. , Miller Walter , Bartlett Jennifer L. , Nakagawa Thomas A. , Bingham Ladonna
Published: June 2019

Introduction:

Standardization of interfacility transport handover is associated with improved shared mental model development, efficiency, and teaming. We sought to build upon previously published data by evaluating 1-year follow-up data, assessing face-validity, and describing sustainability.

Methods:

We performed a pre-post, retrospective cohort study in a stand-alone, tertiary, pediatric referral center for children 0–18 years of age transported to our pediatric intensive care unit, neonatal intensive care unit, or emergency department from October 2016 to November 2017. Handover was standardized using multidisciplinary checklists, didactics, and simulation. Data were collected for three 8-week periods (preintervention, postintervention, and 1-year follow-up). Outcomes included shared mental model index (shared mental model congruence expressed as an index, percent congruence regarding healthcare data), teaming data (efficiency, attendance, interruptions, interdependence), and face validity (5-point, Likert scale questionnaires). Statistics included 1-way analysis of variance, Kruskal-Wallis, chi-square, and descriptive statistics.

Results:

One hundred forty-eight handovers (50 preintervention, 50 postintervention, and 48 at 1-year) were observed in the emergency department (41%), pediatric intensive care unit (45%), and neonatal intensive care unit (14%). No differences were noted in demographics, diagnoses, PIM-3-ROM, length of stay, mortality, ventilation, or vasoactive use. Sustained improvements were observed in shared mental model congruence expressed as an index (38% to 82%), physician attendance (76% to 92%), punctuality (91.5% to 97.5%), interruptions (40% to 10%), provision of anticipatory guidance (42% to 85%), and handover summarization (42% to 85%, all P < 0.01). Efficiency was maintained throughout (mean duration 4.5 ± 2.1 minutes). Face validity data revealed handover satisfaction, effective communication, and perceived professionalism.

Conclusions:

Enhancements in teaming, shared mental model development, and face validity were achieved and sustained 1-year following handover standardization with only minimal reeducation during the study period.
Standardization of Radiologic Procedures for Pediatric Videofluoroscopic Swallow Studies: A Service-based Quality Improvement Initiative
Authors: Thompson Benjamin , Lundine Jennifer P. , Madhoun Lauren , Hu Houchun , Holliman-Wade Dominic , Bates D. Gregory
Published: June 2019

Introduction:

The videofluoroscopic swallow study (VFSS) remains the primary method to evaluate swallowing function in infants and children. However, limited standards exist to guide the image acquisition during pediatric VFSSs, leading to inadequate images, variable assessment quality, and potential for suboptimal diagnostic accuracy. The goal of this quality improvement project was to standardize the radiological procedure for radiologists at our institution.

Methods:

A multidisciplinary team of project leaders established 3 imaging standards to target (magnification, the field of view, and pulse repetition rate), based on the best available evidence. The team used the Institute for Healthcare Improvement’s Model for Improvement to guide the project, identified key drivers, and implemented specific interventions. Project leaders observed a total of 170 VFSS examinations, performed by radiology faculty, fellows, and residents over 24 months. The primary outcome for this project was physician compliance with 3 established imaging standards: field of view, magnification, and pulse repetition rate. Project leaders collected data without the radiologists’ knowledge, and also recorded average radiation exposure as a balancing measure during this process.

Results:

At baseline, compliance with all 3 criteria was 20%. Following interventions designed to improve radiologist performance with the 3 identified standards, the compliance rate reached 100% for the last 50 recorded VFSSs. During this same time, there was no meaningful increase in average radiation exposure compared with the 6 months before the implementation of this project.

Conclusions:

Compliance with standardized image acquisition of VFSSs can be accomplished using a systematic quality improvement protocol targeting simple, inexpensive interventions.
Trigger Criteria to Increase Appropriate Palliative Care Consultation in the Neonatal Intensive Care Unit
Authors: Humphrey Lisa , Schlegel Amy , Seabrook Ruth , McClead Richard
Published: June 2019

Introduction:

Pediatric palliative care (PPC) seeks longitudinal relationships with patients facing life-threatening conditions. The majority of pediatric deaths occur within the first year of life, especially neonatal intensive care unit (NICU); however, the consultation by PPC in the NICU is not routine. This project sought to improve the PPC’s presence within 1 NICU for patients facing life-limiting conditions through quality improvement techniques.

Methods:

A trigger list of severe, life-threatening conditions impacting neonates was created and implemented to increase PPC consultation within the NICU. Interventions to improve compliance with the trigger list included the collaborative creation of the trigger list, education, modification of PPC staff modeling, and expansion of the perinatal palliative care program.

Results:

Over the 2 years that the project occurred, 31 prenatal and postnatal patients were eligible for PPC consultation based on the trigger list. Of these, 24 received PPC consultation. The primary outcome measure of the project was to increase PPC consultations for those NICU infants identified on a severe diagnosis “trigger” list from 25% to 80% and to maintain this increase for 6 months. This project achieved 100% compliance within 12 months.

Conclusions:

Utilization of quality improvement methodology to address PPC underutilization within an NICU successfully led to the implementation of a trigger list for patients with severe diagnoses to receive PPC services. Such modeling could be used in other health systems to improve palliative care referrals.
Decreasing Door-to-Door Times for Infliximab Infusions in a Children's Hospital Observation Unit
Authors: Sandberg Kelly C. , Lucien Janet N. , Stoll Denise , Yanney Erica , Mezoff Adam
Published: June 2019

Introduction:

Children with inflammatory bowel disease (IBD) often require infliximab infusions to manage their disease. Infusions administered in the hospital setting require the patient and their families to devote many hours away from home. Changing to a rapid infusion protocol has been shown in the literature to be safe and has the potential to decrease time spent in the hospital receiving infusions.

Methods:

We describe stepwise changes made over a 4-month period to improve infliximab infusion efficiency and lessen the time spent in the hospital by IBD patients and their families. These changes included the implementation of a standardized order set, defaulting to rapid infusions for eligible patients, eliminating the post-infusion observation window, and improving the pharmacy's efficiency in preparing infusion medications. We utilized several established quality improvement tools, including a smart aim, key driver diagram, plan-do-study-act cycles, and statistical process control charts to measure these interventions.

Results:

Within three months of starting, the average door-to-door time patients spent in the hospital decreased by 128 minutes (2 hours 8 minutes). This improvement amounts to 768 minutes (12 hours 48 minutes) per year of time returned for normal childhood activities outside of the hospital. There were no infusion reactions during the period monitored.

Conclusions:

Implementation of a rapid infliximab infusion protocol made an impressive impact on freed family time without sacrificing patient safety. The changes we implemented could be helpful to other centers interested in decreasing in-hospital time for patients with IBD and their families.