Interprofessional Extracorporeal Membrane Oxygenation Cardiopulmonary Resuscitation Simulations Aimed at Decreasing Actual Cannulation Times: A Longitudinal Study.

BACKGROUND: Since 2013, the cardiac intensive care unit (CICU) at Children's National has conducted annual extracorporeal membrane oxygenation cardiopulmonary resuscitation (ECPR) simulations that focus on team dynamics, room setup, and high-quality CPR. In 2019 and 2020, the simulations were expanded to include the surgical and extracorporeal membrane oxygenation (ECMO) teams in an effort to better understand and improve this process. METHODS: During a 4-week period in 2019, 7 peripheral ECPR simulations were conducted, and through a 3-week period in 2020, 7 central ECPR simulations were conducted. Participants in each session included: 8 to 10 CICU nurses, 1 CICU attending, 1 to 2 ICU or cardiology fellows, 1 cardiovascular surgery fellow or attending, and 1 ECMO specialist. For each session, the scenario continued until the simulated patient was on full cardiopulmonary bypass. An ECMO trainer was used for peripheral simulations and a 3-dimensionally-printed heart was used for central cannulations. An ECMO checklist was used to objectively determine when the patient and room were fully prepared for surgical intervention, and simulated cannulation times were recorded for both groups. A retrospective chart review was conducted to compare actual cannulation times before and after the intervention period, and video was used to review the events and assist in dividing them into medical versus surgical phases. Control charts were used to trend the total ECPR times before and after the intervention period, and mean and P values were calculated for both ECPR times and for all other categorical data. RESULTS: Mean peripheral ECPR times decreased significantly from 71.7 to 45.1 minutes ( P = 0.036) after the intervention period, and this was reflected by a centerline shift. Although we could not describe a similar decrease in central ECPR times because there were only 6 postintervention events, the times for each of these events were shorter than the historical mean of 37.8 minutes. There was a trend in improved survival, which did not meet significance both among patients undergoing peripheral ECPR (15.4% ± 10% to 43.8% ± 12.4%, P = 0.10) and central ECPR (36.4% ± 8.4% to 50% ± 25%, P = 0.60). The percentage of time dedicated to the medical phases of the actual versus simulated procedures was very consistent among both peripheral (33.0% vs. 31.9%) and central (39.6% vs. 39.8%) cannulations. CONCLUSIONS: We observed a significant decrease in peripheral cannulation times at our institution after conducting interprofessional ECPR simulations taken to the establishment of full cardiopulmonary bypass. The use of an ECMO trainer and a 3-dimensionally-printed heart allowed for both the medical and surgical phases of the procedure to be studied in detail, providing opportunities to streamline and improve this complex process. Larger multisite studies will be needed in the future to assess the effect of efforts like these on patient survival.

Implementation of a Medical Clearance Algorithm for Psychiatric Emergency Patients.

BACKGROUND: Despite evidence demonstrating limited benefit, many clinicians continue to perform routine laboratory testing of well-appearing children to medically clear them before psychiatric admission. METHODS: We conducted a quality improvement project to reduce routine laboratory testing among pediatric patients requiring admission to our psychiatric unit. We convened key stakeholders whose input informed the modification of an existing pathway and the development of a medical clearance algorithm. Our outcome was a reduction in routine laboratory testing for children requiring psychiatric admission. Our balancing measure was the number of patients requiring transfer from the inpatient psychiatry unit to a medical service. We used run charts to evaluate nonrandom variation and demonstrate sustained change. RESULTS: Before the introduction of the new medical clearance algorithm, 93% (n = 547/589) of children with psychiatric emergencies received laboratory testing. After implementing the medical clearance algorithm, 19.6% (n = 158/807) of children with psychiatric emergencies received laboratory testing. Despite a decreased rate of routine testing, there were no transfers to the medical service. CONCLUSIONS: Implementing a medical clearance algorithm can decrease routine laboratory testing without increasing transfers to the medical service among children requiring psychiatric admission.

Measuring the impact of an empiric antibiotic algorithm for pulmonary exacerbation in children and young adults with cystic fibrosis.

BACKGROUND: Antimicrobial stewardship is a systematic effort to change prescribing attitudes that can provide benefit in the provision of care to persons with cystic fibrosis (CF). Our objective was to decrease the unwarranted use of broad-spectrum antibiotics and assess the impact of an empiric antibiotic algorithm using quality improvement methodology. METHODS: We assembled a multidisciplinary team with expertise in CF. We assessed baseline antibiotic use for treatment of pulmonary exacerbation (PEx) and developed an algorithm to guide empiric antibiotic therapy. We included persons with CF admitted to Children's National Hospital for treatment of PEx between January 2017 and March 2020. Our primary outcome measure was reducing unnecessary broad-spectrum antibiotic use, measured by use consistent with the empiric antibiotic algorithm. The primary intervention was the initiation of the algorithm. Secondary outcomes included documentation of justification for broad-spectrum antibiotic use and use of infectious disease (ID) consult. RESULTS: Data were collected from 56 persons with CF who had a total of 226 PEx events. The mean age at first PEx was 12 (SD 6.7) years; 55% were female, 80% were white, and 29% were Hispanic. After initiation of the algorithm, the proportion of PEx with antibiotic use consistent with the algorithm increased from 46.2% to 79.5%. Documentation of justification for broad-spectrum antibiotics increased from 56% to 85%. Use of ID consults increased from 17% to 54%. CONCLUSION: Antimicrobial stewardship initiatives are beneficial in standardizing care and fostering positive working relationships between CF pulmonologists, ID physicians, and pharmacists.

A Multimodal Quality Improvement Curriculum for Pediatric GME Program Directors.

The 2016 Accreditation Council for Graduate Medical Education Clinical Learning Environment Review report identified knowledge gaps for quality in the clinical environment. It suggested quality improvement (QI) training is necessary to develop skills to improve health care quality. However, at the authors' institution, there is limited department-level QI mentorship and engagement, thus limiting QI experiences for residents and fellows. The authors developed pediatric graduate medical education program director (PD) proficiency in QI through a fellowship-focused QI project. PDs underwent an 18-month QI curriculum consisting of focused online QI education, a half-day workshop, additional QI didactic sessions, project presentations, and individual QI coaching. QI knowledge in 9 domains and participants' confidence were assessed. Participants' self-perceived confidence and skills increased by at least 20% in most domains. Overall, PDs felt prepared to help with their fellows' future QI projects. Fellowship-focused QI projects and individual coaching were key to course engagement.

Improving Point-of-Care Ultrasound Documentation and Billing Accuracy in a Pediatric Emergency Department.

OBJECTIVE: The performance and interpretation of point-of-care ultrasound (POCUS) should be documented appropriately in the electronic medical record (EMR) with correct billing codes assigned. We aimed to improve complete POCUS documentation from 62% to 80% and improve correct POCUS billing codes to 95% or higher through the implementation of a quality improvement initiative. METHODS: We collected POCUS documentation and billing data from the EMR. Interventions included: (1) staff education and feedback, (2) standardization of documentation and billing, and (3) changes to the EMR to support standardization. We used P charts to analyze our outcome measures between January 2017 and June 2018. RESULTS: Six hundred medical records of billed POCUS examinations were included. Complete POCUS documentation rate rose from 62% to 91%, and correct CPT code selection for billing increased from 92% to 95% after our interventions. CONCLUSIONS: The creation of a standardized documentation template incorporated into the EMR improved complete documentation compliance.

Improving Throughput for Mid-acuity Patients in the Pediatric Emergency Department.

PURPOSE: Visits to pediatric emergency departments (EDs) are increasing, leading to overcrowding, prolonged patient wait times, and negative patient experiences. In our system, these prolonged wait times and negative experiences notably impact mid-acuity patients. As such, we sought to decrease their time-to-first-provider from 92 to 60 minutes. METHODS: After identifying inefficiencies in patient arrival, triage, and assessment, we redesigned our physical space and implemented a new triage process. Further, we deployed a new multidisciplinary front-end team consisting of a physician, nurses, and ED tech specialists to create and implement an initial management plan. Time-to-first-provider for mid-acuity patients was the main outcome measure. We examined ED length of stay (LOS) as a balancing measure. Post hoc, we measured time-to-first-nursing assessment and the proportion of high-acuity patients seen within 20 minutes as additional measures of the impact of these interventions on our system. All analyses were measured using statistical process control charts. RESULTS: During high patient volumes, we decreased the time-to-first-provider to 70 minutes, but exceeded our goal during low patient volumes (41 minutes). We observed a 5% decrease in LOS during both high and low patient volumes (5% and 8%, respectively). There was a 60% increase in the time-to-first-nursing assessment. CONCLUSIONS: A new front-end process resulted in improved time-to-first-provider and LOS. The new process was associated with longer times for nursing assessments but did not negatively impact the rapid physician assessment of higher acuity patients.

Reducing Vancomycin Use in a Level IV NICU.

BACKGROUND AND OBJECTIVES: Vancomycin remains one of the most commonly prescribed antibiotics in NICUs despite recommendations to limit its use for known resistant infections. Baseline data revealing substantially higher vancomycin use in our NICU compared to peer institutions informed our quality improvement initiative. Our aim was to reduce the vancomycin prescribing rate in neonates hospitalized in our NICU by 50% within 1 year and sustain for 1 year. METHODS: In the 60-bed level IV NICU of an academic referral center, we used a quality improvement framework to develop key drivers and interventions including (1) physician education with benchmarking antibiotic prescribing rates; (2) pharmacy-initiated 48-hour antibiotic time-outs on rounds; (3) development of clinical pathways to standardize empirical antibiotic choices for early-onset sepsis, late-onset sepsis, and necrotizing enterocolitis; coupled with (4) daily prospective audit with feedback from the antimicrobial stewardship program. RESULTS: We used statistical process u-charts to show vancomycin use declined from 112 to 38 days of therapy per 1000 patient-days. After education, pharmacy-initiated 48-hour time-outs, and development of clinical pathways, vancomycin use declined by 29%, and by an additional 52% after implementation of prospective audit with feedback. Vancomycin-associated acute kidney injury also declined from 1.4 to 0.1 events per 1000 patient-days. CONCLUSIONS: Through a sequential implementation approach of education, standardization of care with clinical pathways, pharmacist-initiated 48-hour time-outs, and prospective audit with feedback, vancomycin days of therapy declined by 66% over a 1-year period and has been sustained for 1 year.

Improvement science is a partner in basic and clinical research.

A breadth of time, effort, and resources are put into research. Improvement science is an applied science emphasizing rapid-cycle testing to learn about change and produce improvement. Its foundations lie in understanding your system, its parts and their relationships, and the psychology of change, yet the framework of improvement science is analogous to basic research. In basic research you first ask a question, then form a hypothesis based on background research. After testing this hypothesis, a researcher then draws conclusions and shares the results. In improvement science, researchers start the same, with asking a question, and then defining what is considered an improvement. Rapid-cycle tests of change are guided by subject matter experts and the people and processes involved. The data provided from these tests of change allow researchers to show improvement and share results. The success of improvement science is showcased through statistical process control charts, which inform when significant change has occurred. Improvement science can be applied across all fields of medicine; is a natural partner to basic and clinical research, as it plays a vital role in the implementation and adoption of the best evidence.

Decreasing Blood Culture Contaminants in a Pediatric Emergency Department: An Interrupted Time Series Analysis.

INTRODUCTION: High peripheral blood culture contamination rates (BCCR) in the emergency department (ED) contribute to overuse and harm. This study describes 2 years of quality improvement (QI) interventions that aimed to decrease a high BCCR in a pediatric ED. METHODS: The QI team created a Key Driver Diagram with multiple Plan-Do-Study-Act (PDSA) cycles. PDSA interventions included a venipuncture sterility checklist (PDSA1), phlebotomist feedback system (PDSA2), and physician ordering guidelines (PDSA3). The specific aim was to decrease the BCCR by 50% within 24 months. The secondary aim was to decrease the peripheral blood culture ordering rate (BCOR) by 10% within 24 months. The balancing measure was the proportion of pathogenic bacteremia cases at ED return visits before and after PDSA3 implementation. A financial measure estimated the savings in charges between the observed and expected contaminants in PDSA3. An interrupted time series design applied statistical process control methodology to detect special cause variations. RESULTS: The BCCR in the baseline, PDSA1, PDSA2, and PDSA3 periods were 3.02%, 2.30%, 1.58%, and 1.17%, respectively. The BCOR in the baseline, PDSA1, PDSA2, and PDSA3 periods was 4.80%, 4.26%, 3.82%, and 3.49%, respectively. Special cause variations occurred after PDSA cycle implementations for both BCCR and BCOR. There was no change in the balancing measure. The interventions were associated with an annual prevention of 95 contaminants and savings of $300,070. CONCLUSIONS: Interventions that focused on improving venipuncture technique and limiting unnecessary blood cultures were associated with fewer contaminants and the achievement of the QI team's project aims.

Improving Low-acuity Patient Flow in a Pediatric Emergency Department: A System Redesign.

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.

Conserved steroid hormone homology converges on nuclear factor κB to modulate inflammation in asthma.

Asthma is a complex, multifactorial disease comprising multiple different subtypes, rather than a single disease entity, yet it has a consistent clinical phenotype: recurring episodes of chest tightness, wheezing, and difficulty breathing (Pediatr Pulmonol Suppl. 1997;15:9-12). Despite the complex pathogenesis of asthma, steroid hormones (eg, glucocorticoids) are ubiquitous in the short-term and long-term management of all types of asthma. Overall, steroid hormones are a class of widely relevant, biologically active compounds originating from cholesterol and altered in a stepwise fashion, but maintain a basic 17-carbon, 4-ring structure. Steroids are lipophilic molecules that diffuse readily through cell membranes to directly and/or indirectly affect gene transcription. In addition, they use rapid, nongenomic actions to affect cellular products. Steroid hormones comprise several groups (including glucocorticoids, sex steroid hormones, and secosteroids) with critical divergent biological and physiological functions relevant to health and disease. However, the conserved homology of steroid hormone molecules, receptors, and signaling pathways suggests that each of these is part of a dynamic system of hormone interaction, likely involving an overlap of downstream signaling mechanisms. Therefore, we will review the similarities and differences of these 3 groups of steroid hormones (ie, glucocorticoids, sex steroid hormones, and secosteroids), identifying nuclear factor κB as a common inflammatory mediator. Despite our understanding of the impact of individual steroids (eg, glucocorticoids, sex steroids and secosteroids) on asthma, research has yet to explain the interplay of the dynamic system in which these hormones function. To do so, there needs to be a better understanding of the interplay of classic, nonclassic, and nongenomic steroid hormone functions. However, clues from the conserved homology steroid hormone structure and function and signaling pathways offer insight into a possible model of steroid hormone regulation of inflammation in asthma through common nuclear factor κB-mediated downstream events.