Implementing PDSA Methodology for Pediatric Appendicitis Increases Care Value for a Tertiary Children's Hospital.

INTRODUCTION: We used the plan-do-study-act (PDSA) framework to develop and implement an evidence-based clinical practice guideline (CPG) within an urban, tertiary children's referral center. METHODS: We developed an evidence-based CPG for appendicitis using iterative PDSA cycles. Similar CPGs from other centers were reviewed and modified for local implementation. Adjuncts included guideline-specific order sets and operative notes in the electronic medical record system. Outcomes included length of stay (LOS), 30-day readmissions, hospital costs, and patient and family experience (PFE) scores. Our team tracked outcome, process, and balancing measures using Statistical Process Charts. Outcome measures were compared over 2 fiscal quarters preimplementation and 3 fiscal quarters postimplementation, using interrupted time series, student t test, and chi-square tests when appropriate. RESULTS: LOS for simple (uncomplicated) appendicitis decreased to 0.87 days (interquartile range [IQR] 0.87-0.94 days) from 1.1 days (IQR 0.97-1.42 days). LOS for complicated appendicitis decreased to 4.96 days (IQR 4.95-6.15) from 5.58 days (IQR 5.16-6.09). This reduction equated to an average cost-savings of $1,122/patient. Thirty-day readmission rates have remained unchanged. PFE scores increased across all categories and have remained higher than national benchmarks. CONCLUSION: Development and Implementation of a CPG for pediatric appendicitis using the PDSA framework adds value to care provided within a large tertiary center.

Multidisciplinary Kaizen Event to Improve Adherence to a Sepsis Clinical Care Guideline.

INTRODUCTION: Since 2015, the Ann and Robert H. Lurie Children's Hospital Emergency Department (ED) has improved the recognition and treatment of pediatric sepsis and septic shock. Despite existing clinical care guidelines, the ED had not yet achieved the Surviving Sepsis Campaign timeliness goals for fluid and antibiotic administration. METHODS: The team conducted a multidisciplinary Kaizen event to evaluate clinical workflows and identify opportunities to improve sepsis care adherence. Using rigorous quality improvement methodology, frontline providers mapped workflows to identify barriers and prioritize emerging solutions. RESULTS: Thirty-seven staff members across 17 disciplines participated. Nurses and physicians identified communication gaps at pathway initiation. Access to supplies, inadequate task delegation, and a lack of urgency for a subset of pathway patients delayed treatment. Prioritized interventions included scripted communication tools, a delineated response plan, and standardized reassessment processes. Revisions to the key driver diagram were made after the improvement event, guiding future plan-do-study-act cycles. CONCLUSIONS: Frontline provider participation in the Kaizen event uncovered barriers to care and identified the root causes of ineffective communication and system process inefficiencies. Engaging key stakeholders from multiple care areas in a candid context was a novel approach to process improvement within our department. The Kaizen methodology is fundamental to developing sustainable quality improvement practices, creating momentum for a continuous improvement culture to engrain quality improvement in practice. The success of Kaizen will shape the format of future ED improvement projects.

Two Simulation Cases to Prepare for a Public Festival: Pediatric Methylenedioxymethamphetamine (MDMA) Ingestion and Alcohol Toxicity.

Introduction Emergency departments (EDs) see a surge of intoxicated patients during large public summer events. These patients can be distracting and complicated for ED staff to care for. Methods We developed two cases to prepare emergency department staff for an anticipated surge of patients related to a large music festival that occurs proximal to our pediatric hospital. We developed and performed cases of simulated patients with alcohol intoxication and methylenedioxymethamphetamine (MDMA) ingestion to review medical management of these patients, as well as to review many of the social aspects of the cases. We surveyed simulation (sim) session participants to assess the degree to which the sessions were helpful and to glean ideas on how to improve sessions for future use. Results Over the course of two years, we have hosted eight simulations, for a total of 57 participants comprising various healthcare roles. We achieved an 85% response rate in the post-simulation surveys. The sessions were overall well-received and left participants feeling better prepared to care for intoxicated patients. Discussion Despite having a large number of staff from many disciplines working varied schedules, we were able to provide simulation training to many of them in preparation for an expected surge of intoxicated patients. Participants appreciated the training and gave feedback to improve sessions in the future.

Empiric Antibiotic Use and Susceptibility in Infants With Bacterial Infections: A Multicenter Retrospective Cohort Study.

OBJECTIVES: To assess hospital differences in empirical antibiotic use, bacterial epidemiology, and antimicrobial susceptibility for common antibiotic regimens among young infants with urinary tract infection (UTI), bacteremia, or bacterial meningitis. METHODS: We reviewed medical records from infants <90 days old presenting to 8 US children's hospitals with UTI, bacteremia, or meningitis. We used the Pediatric Health Information System database to identify cases and empirical antibiotic use and medical record review to determine infection, pathogen, and antimicrobial susceptibility patterns. We compared hospital-level differences in antimicrobial use, pathogen, infection site, and antimicrobial susceptibility. RESULTS: We identified 470 infants with bacterial infections: 362 (77%) with UTI alone and 108 (23%) with meningitis or bacteremia. Infection type did not differ across hospitals (P = .85). Empirical antibiotic use varied across hospitals (P < .01), although antimicrobial susceptibility patterns for common empirical regimens were similar. A third-generation cephalosporin would have empirically treated 90% of all ages, 89% in 7- to 28-day-olds, and 91% in 29- to 89-day-olds. The addition of ampicillin would have improved coverage in only 4 cases of bacteremia and meningitis. Ampicillin plus gentamicin would have treated 95%, 89%, and 97% in these age groups, respectively. CONCLUSIONS: Empirical antibiotic use differed across regionally diverse US children's hospitals in infants <90 days old with UTI, bacteremia, or meningitis. Antimicrobial susceptibility to common antibiotic regimens was similar across hospitals, and adding ampicillin to a third-generation cephalosporin minimally improves coverage. Our findings support incorporating empirical antibiotic recommendations into national guidelines for infants with suspected bacterial infection.