bluuebunny/crossref_metadata_2025_split huggingface dataset:
Identification of Critical to Quality Elements for Intensive Care Rounds by Kano Analysis
Authors: Tripathi Sandeep , Henrekin Lamonica L. , Read Cynthia D. , Welke Karl F. 
Published: June 2019

Background:
Pediatric cardiac intensive care unit rounds require high levels of efficiency in data transfer and decision making to achieve optimal performance. Traditional survey methods do not discriminate and prioritize effectively the elements of rounds essential to a provider. In this study, we describe our experience with a novel survey method (Kano analysis) to assess customers’ (surgeons, intensivists, cardiologists, advanced practice nurses, and nurses) requirements from rounds.

Methods:
A 26-point survey divided into 3 domains (presentation, decision, and process elements) was conducted among Pediatric Intensive Care Unit (PICU) providers. Based on the survey, attractive, must be, performance, indifferent, and reverse categories were identified using methods described in the literature. Average satisfaction and dissatisfaction coefficients and percentages of attractive and mandatory elements in subgroups were compared. Results from the quantitative analysis were charted on a categorization plane.

Results:
The survey was returned by all providers with 96% valid responses. The highest satisfaction coefficient in the presentation domain was for “one line statement about the patient” (0.76), in the decision domain “rhythm/anti-arrhythmics” (0.54), and in the process domain “reformatting presentation script” (0.77). The highest dissatisfaction gradients were for “overnight events” (-0.91), “rhythm/anti-arrhythmics” (-0.71), and “asking families to join rounds” (-0.49). Among the 5 subgroups, surgeons required the largest percentage of items as mandatory or attractive and had the highest dissatisfaction coefficients in all 3 categories.

Conclusion:
Kano survey can provide rapid and precise actionable data to restructure a new process. Further research potentially also involving patients and families in the Kano survey may provide insight on patient-centered care models.
Effects of Skin-to-Skin Care on Late Preterm and Term Infants At-Risk for Neonatal Hypoglycemia
Authors: Chiruvolu Arpitha , Miklis Kimberly K. , Stanzo Karen C. , Petrey Barbara , Groves Chelsey G. , McCord Kari , Qin Huanying , Desai Sujata , Tolia Veeral N. 
Published: June 2019

Objective:
The objective of this study was to evaluate the effects of prolonged skin-to-skin care (SSC) during blood glucose monitoring (12–24 hours) in late preterm and term infants at-risk for neonatal hypoglycemia (NH).

Study design:
We conducted a retrospective pre- and postintervention study. We compared late preterm and term infants at-risk for NH born in a 1-year period before the SSC intervention, May 1, 2013, to April 30, 2014 (pre-SSC) to at-risk infants born in the year following the implementation of SSC intervention, May 1, 2014, to April 30, 2015 (post-SSC).

Results:
The number of hypoglycemia admissions to neonatal intensive care unit among at-risk infants for NH decreased significantly from 8.1% pre-SSC period to 3.5% post-SSC period (P = 0.018). The number of infants receiving intravenous dextrose bolus in the newborn nursery also decreased significantly from 5.9% to 2.1% (P = 0.02). Number of infants discharged exclusively breastfeeding increased from 36.4% to 45.7%, although not statistically significant (P = 0.074).

Conclusion:
This SSC intervention, as implemented in our hospital, was associated with a significant decrease in newborn hypoglycemia admissions to neonatal intensive care unit. The SSC intervention was safe and feasible with no adverse events.
Reducing Blood Testing in Pediatric Patients after Heart Surgery: Proving Sustainability
Authors: Bodily Stephanie A. , Delgado-Corcoran Claudia , Wolpert Katherine , Lucas Kathryn , Presson Angela P. , Bratton Susan L. 
Published: June 2019

Introduction:
Frequent blood testing increases risk of iatrogenic anemia, infection, and blood transfusion. This study describes 3 years of sustained blood testing reduction from a quality improvement (QI) initiative which began in 2011.

Methods:
The cohort consisted of postop children whose surgery had a Risk Adjustment for Congenital Heart Surgery (RACHS) classification consecutively admitted to a tertiary Cardiac Intensive Care Unit. Data were collected for a 2010 preintervention, 2011 intervention, and 2012–13 postintervention periods, tabulating common laboratory studies per patient (labs/pt) and adjusted for length of stay (labs/pt/d). The QI initiative eliminated standing laboratory orders and changed to testing based on individualized patient condition. Adverse outcomes data were collected including reintubation, central line–associated bloodstream infections and hospital mortality. Safety was measured by the number of abnormal laboratory studies, electrolyte replacements, code blue events, and arrhythmias.

Results:
A total of 1169 patients were enrolled (303 preintervention, 315 intervention, and 551 postintervention periods). The number of labs/pt after the QI intervention was sustained (38 vs. 23 vs. 23) and labs/pt/d (15 vs. 11 vs. 10). The postintervention group had greater surgical complexity (P = 0.002), were significantly younger (P = 0.002) and smaller (P = 0.008). Children with RACHS 3–4 classification in the postintervention phase had significant increased risk of reintubation and arrhythmias.

Conclusions:
After the implementation of a QI initiative, blood testing was reduced and sustained in young, complex children after heart surgery. This may or may not have contributed to greater reintubation and arrhythmias among patients with RACHS 3–4 category procedures.
A Quality Initiative for Optimal Therapeutic Hypothermia during Transport for Neonates with Neonatal Encephalopathy
Authors: Bourque Stephanie L. , Meier Stephanie A. , Palmer Claire , Melara Diane L. , Grover Theresa R. , Delaney Cassidy A. 
Published: June 2019

Introduction:
Neuroprotection with therapeutic hypothermia (TH) is standard of care for neonatal encephalopathy (NE) and decreases death and neurodevelopmental disability. TH initiated shortly after birth insult results in greater neuroprotection compared with delayed initiation.

Methods:
Quality improvement methodology was used to improve temperature control during transport to a level IV neonatal intensive care unit. We included neonates with NE transported to a single institution for TH from 2010 to 2016. The quality improvement interventions were 2-fold. Review of the Transport Body Cooling Protocol revealed a suboptimal temperature goal of 34–35°C; this protocol was revised to 33–34°C. The second intervention was the implementation of an active cooling protocol. Clinical characteristics were compared using 2-sample t tests for continuous variables and Fisher’s exact tests for categorical variables; statistical process control chart was used to monitor admission temperatures.

Results:
We obtained baseline data for 78 neonates admitted from 2010 to 2014. These data were compared with postintervention data for 26 patients admitted between 2015 and 2016. Distance transported, NE severity, and seizures were similar between the 2 groups. The use of active cooling increased from 8% preimplementation to 31% postimplementation (P < 0.01). After implementation of the 2 interventions, more infants were admitted within the goal temperature of 33–34°C, 58% versus 22% (P < 0.01), and the average neonatal intensive care unit admission temperature improved from 34.4 ± 0.8°C to 33.8 ± 0.8°C (P < 0.01).

Conclusion:
Increased utilization of active cooling during transport for TH improves the percentage of neonates admitted within the target temperature range. However, 42% of neonates remained outside the target temperature range, supporting the need for additional tools to improve admission temperatures.
Decision Tree Model for Hematology/Oncology Patients with Severe and Nonsevere Sepsis
Authors: Munger Jessica A. , Lavin Stephanie M. , Hurt Clint J. , Bullock Erin K. , Gelvez Javier 
Published: June 2019

Background:
Hematology/oncology (H/O) patients have been screened for sepsis since 2013 at a pediatric hospital. Using sepsis screening (Ss) tool, results, and addition of organ dysfunction screening (ODs), decision tree (DT) was designed (Fig. 1) for nurses to identify sepsis and intervene.

Objectives:
Positive Ss require multiple assessments by nurses and H/O physicians creating sepsis alert fatigue. By implementing DT, calls to H/O physicians for sepsis alerts could be reduced 24% without increasing misses of patients with sepsis.

Methods:
Patients with Ss < 4 considered negative; Ss > 4 positive. ODs < 2 considered negative, = 2 at risk, > 2 positive for sepsis. In 2016, Ss were performed on H/O patients upon admission, status change, or nurse concern. May 2017, DT was implemented on H/O. From 5/5/17 to 8/30/17 Ss and ODs were conducted every 12 hours or with status change (Fig. 2).

Results:
Design period: 1,457 Ss (n = 1,393); 200 Ss positive (n = 180); 8 Ss, ODs < 2 (n = 44); 152 Ss, ODs = 2 (n = 139); and 0 Ss, ODs > 2. Implementation period: 6,502 Ss (n = 512); 1,647 Ss positive (n = 292); 293 Ss, ODs < 2 (n = 72); 1,351 Ss, ODs = 2 (n = 265); and 30 Ss, ODs > 2 (n = 14). See Figure 3 for pediatric intensive care unit (PICU) transfers during design/implementation periods.

Conclusions/Implications:
During implementation, calls were reduced to H/O physicians by 17.5% (ODs < 2). Most patients were ODs = 2. Recommendations included calling physician only if nurse was concerned of patient’s status with OD = 2. DT with addition of ODs has increased awareness of sepsis and communication between transferring providers. We have not found an increase in sepsis misses requiring transfer to PICU.
Improving Wait Time for Patients in a Pediatric Echocardiography Laboratory - a Quality Improvement Project
Authors: Parthiban Anitha , Warta Ashley , Marshall Jennifer A. , Reid Kimberly J. , Mann Keith , Shirali Girish , Swanson Tara 
Published: June 2019

Background:
Prolonged wait times for echocardiograms in the outpatient pediatric cardiology clinic led to patient and provider dissatisfaction at our institution. The aims of this project were to measure our baseline performance with regard to echocardiogram wait time (EWT), to implement a formal quality improvement (QI) program to improve EWT, and to measure the impact of QI on EWT.

Methods:
A QI team was formed comprising of cardiologists (A.P., T.S.), sonographer (A.W.), and QI mentor (J.M.). EWT was defined as time in minutes from initiation of the order in the electronic medical record to start of the echocardiogram. Goal EWT was set as ≤ 20 minutes for 90% patients. Flowcharts were created after process observation to identify sources of potential delay contributing to EWT. QI methodology such as driver diagrams were utilized to identify interventions, which were then implemented and studied as Plan-Do-Study-Act cycles.

Results:
Sequential interventions included early start time, huddles involving clinic and echo laboratory staff, patient tracking system, and repurposing of a clinic room for echo. EWT was tracked for 840 patients. Mean EWT was 22.5 ± 17.5 minutes at baseline and decreased to 15.3 ± 7.8 minutes postintervention (P < 0.001). Postintervention, 81% of the patients waited < 20 minutes for their echo, and 98% patients waited < 30 minutes, compared with baseline numbers of 62% and 76%, respectively (P < 0.001).

Conclusions:
We were able to utilize QI methodology to derive interventions and track changes, resulting in quantifiable improvement in EWT in a busy pediatric echo laboratory.
A Saturated Approach to the Four-Phase, Brain-Based Simulation Framework for TeamSTEPPS® in a Pediatric Medicine Unit
Authors: Clapper Timothy C. , Ching Kevin , Mauer Elizabeth , Gerber Linda M. , Lee Joanna G. , Sobin Brittany , Ciraolo KerriAnn , Osorio Snezana Nena , DiPace Jennifer I. 
Published: June 2019

Introduction:
Although many organizations have reported successful outcomes as a result of Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS), implementation can be challenging, with its share of administrative obstacles and lack of research that shows observable change in practice.

Methods:
This quantitative, pretest/posttest design pilot research used a combination of classroom simulation-based instruction and in situ simulation in a Pediatrics department in an urban academic center. All personnel with direct patient care responsibilities (n = 547) were trained in TeamSTEPPS in an 8-week period. TeamSTEPPS course knowledge scores were compared pretraining to posttraining using the Wilcoxon rank-sum test. The performance of two-day and overnight shift teams, pre- and postintervention was assessed using the TeamSTEPPS Team Performance Observation Tool.

Results:
TeamSTEPPS course knowledge improved from the beginning of the course to completion with median scores of 16 and 19, respectively (P < 0.001). Both day and evening postintervention groups demonstrated greater team performance scores than their control counterparts. Specifically, postintervention day shift team showed the greatest improvement and demonstrated more TeamSTEPPS behaviors.

Conclusion:
This pilot study involving 1 department in an urban hospital showed that TeamSTEPPS knowledge and performance could be improved to increase patient safety and reduce medical errors. However, teams need to be trained within a shorter period so they can apply a shared-model of teamwork and communication. Leaders and educators throughout the department must also reinforce the behaviors and include them in every education intervention.
A Quality Improvement Initiative to Decrease Time to Antibiotics for Children with Intestinal Failure, Fever, and a Central Line
Authors: Hariharan Selena , Mezoff Ethan A. , Dandoy Christopher E. , Zhang Yue , Chiarenzelli Janis , Troutt Misty L. , Simpkins Jean , Dewald Mary , Klotz Kim , Mezoff Adam G. , Cole Conrad R. 
Published: June 2019

Introduction:
Pediatric intestinal failure (IF) patients experience significant morbidity, including sepsis related to central line–associated bloodstream infections. Adult studies of sepsis demonstrate an association between time to antibiotic administration (TTA) and mortality. To overcome challenges in treating pediatric IF patients in an emergency department (ED), we appropriated an existing, reliable system for febrile immunocompromised oncology/bone marrow transplant children. We describe the translation of this process to febrile IF patients in the ED and steps toward sustained improvement.

Methods:
We formed a multidisciplinary team and used the Model for Improvement to define aims and identify key drivers. The goal was to use an existing improvement process to increase the percentage of patients with IF who receive antibiotics within 60 minutes of arrival to the ED from 46% to 90%. Key drivers included pre- and postarrival processes, staff and family engagement, and a preoccupation with failure. We performed Plan-Do-Study-Act cycles targeting family engagement, prearrival efficiency, and postarrival consistency.

Results:
Two hundred seventy-six encounters involving febrile IF patients between November 2012 and March 2017 were evaluated. There was a sustained reduction in the median time from arrival to antibiotic administration (71–45 minutes). We decreased TTA to less than 60 minutes for 77% of febrile IF patients.

Conclusions:
The basic tenets of process improvement for 1 high-risk population can be translated to another high-risk population but must be adjusted for variability in characteristics.
Reducing Time to Pain Medication Administration for Pediatric Patients with Long Bone Fractures in the Emergency Department
Authors: Schuman Sarah S. , Regen Rebecca B. , Stuart Lindsay H. , Harrell Camden , Jones Tamekia L. , Stewart Barbara M. , Berg Allyson M. , Longjohn Mindy , Kink Rudy J. 
Published: June 2019

Introduction:
Pain management is a critical aspect of effective long bone fracture treatment. Pediatric patients frequently report suboptimal pain management, which is an area of growing public concern. The purpose of this quality improvement project was to develop a protocol with the goal to administer pain medication to children presenting with suspected long bone fractures ≤47 minutes of emergency department arrival.

Methods:
A multidisciplinary team developed a standardized protocol for pain management of patients presenting with musculoskeletal pain utilizing acetaminophen as the first-line agent under a nurse-initiated order. Following education and implementation, weekly reports generated using the International Classification of Diseases codes of fractures were reviewed to assess compliance with the protocol. This study evaluates the frequency of a second pain medication administration and reduction in vital signs and pain scores.

Results:
Implementation of a pain management protocol reduced median time to pain medication administration to 26 minutes. Overall, 63% (n = 638) of patients required a second pain medication. Of these, 66.5% (348/523) who initially received acetaminophen and 59.7% (286/479) who initially received an opioid required a second pain medication. No significant changes in pre and posttreatment vital signs were found between groups. Patients who initially received opioids experienced a greater reduction in posttreatment pain scores.

Conclusions:
Using a standardized pain management protocol in combination with comprehensive education effectively reduces median time to pain medication administration in pediatric patients with long bone fractures. Acetaminophen is a rapid and effective first-line agent for managing pain in this population.
Improving Low-acuity Patient Flow in a Pediatric Emergency Department: A System Redesign.
Authors: Berkowitz Deena A. , Brown Kathleen , Morrison Sephora , Payne Asha , Pettinichi Jeannie , Schultz Theresa Ryan , Thomas Anthony , Chamberlain James M. 
Published: June 2019

Background:
Children’s National Health Systems pediatric emergency department (ED), is a level 1 trauma center in Washington, DC, which treats over 90 000 patients annually. Approximately 50% of arriving patients are triaged as low acuity, Emergency Severity Index level 4 or 5. With limited space and resources, these patients are treated inefficiently, with average delays from arrival to provider time of 1.3 hours and length of stays (LOS) close to 2.5 hours.

Objectives:
In July 2016, Children’s National Health Systems ED initiated a focused approach to improve both patient flow and experience for these low-acuity patients.

Methods:
We assembled a multidisciplinary ED-based task force. The quality improvement initiative began in January 2017 and consisted of 4 steps: (1) front-end space redesign; (2) implementation of a new front-end patient triage and assessment process; (3) increased doctor and nurse staffing; and (4) dissemination of data updates to reinforce awareness and adherence to workflow. Our process outcomes were arrival-to-provider time and LOS for low-acuity patients. Our balancing measures were the rate of return to the ED within 72 hours and arrival to provider times for high-acuity patients. We used statistical process control methodology to measure the effects of our interventions over time. We performed a secondary analysis to measure the response of wait times to total daily volume comparing preintervention to postintervention.

Results:
We decreased the LOS by 11 minutes (9%) and arrival to MD times 21 minutes (35%) for the same period 1 year apart.
Pediatric Surgeon Perceptions of Participation in External Patient Safety Programs: impact on Patient Safety
Authors: Berman Loren , Rangel Shawn , Tsao KuoJen ,   for the APSA Quality and Safety Committee
Published: June 2019

Introduction:
Surgeons play a crucial role in preventing harm and contributing to the safety culture of their institutions. External safety data programs are designed to review adverse events and provide performance benchmarks to ameliorate future adverse events. The extent to which pediatric surgeons are aware of these programs, utilize data from these programs, and believe that they improve patient safety, is unknown.

Methods:
A cross-sectional survey of the American Pediatric Surgical Association membership was conducted to evaluate participation in and attitudes toward national safety benchmark programs (eg, National Surgical Quality Improvement Program). Surgeons’ perceptions of these activities, including barriers to participation and utilization of safety data, were measured. We performed standard frequency analyses and tests of associations between surgeon characteristics and the likelihood of utilizing safety data.

Results:
The response rate was 38% (353/928). Seventy-two percentage of respondents reported institutional participation in external safety benchmark programs. Of those, only 68% utilized data to improve or monitor patient safety. Surgeon-reported barriers to this process included lack of knowledge, time, and institutional resources.

Conclusions:
Many pediatric surgeons are aware of institutional participation in external safety data programs, but only a portion are involved in the utilization of these data. We have identified several barriers to participation and data utilization. These findings can help direct educational efforts to optimize our ability to learn from adverse event benchmarking and improve pediatric surgical care.
Audit-and-Feedback and Workflow Changes Improve Emergency Department Care of Critically Ill Children
Authors: Spencer Sandra P. , Karsies Todd 
Published: June 2019

Introduction:
Children with severe infection have improved outcomes when they received antibiotics promptly. Positive cultures help guide physicians in antibiotic selection. In 2011, 30% of children intubated in the emergency department received antibiotics and had respiratory culture collected within 60 minutes of intubation. Knowing the risk of delaying appropriate antibiotics, we charted a quality improvement team to improve compliance with 80% of intubated patients receiving both.

Methods:
The team evaluated all children intubated with concern for infection in the emergency department. Using a multidisciplinary team and employing quality improvement methods, we implemented multiple plan-do-study-act cycles to improve time to antibiotics and respiratory cultures. The team continued to implement successful interventions and restarted interventions directly affecting improvement.

Results:
While multiple interventions had small effects on the baseline of 30% compliance, 2 interventions appeared more influential than others. Workflow changes and audit-and-feedback created the largest, persistent positive changes. The importance of audit-and-feedback became very obvious when the project entered sustain mode. An abrupt decrease in compliance occurred when audit-and-feedback stopped. Complete recovery in compliance to greater than 80% occurred with the resumption of the audit-and-feedback intervention.

Conclusions:
Workflow changes and audit-and-feedback interventions resulted in large improvements. Loss of compliance with cessation of the audit-and-feedback and resumption demonstrated the importance of this intervention. Recovery to >80% compliance with the renewal of the audit-and-feedback program indicates its strength as a positive intervention.