Learning from Each Other: A Multisite Collaborative to Reduce Electrolyte Testing.

Inpatient electrolyte testing rates vary significantly across pediatric hospitals. Despite evidence that unnecessary testing exists, providers still struggle with reducing electrolyte laboratory testing. We aimed to reduce serum electrolyte testing among pediatric inpatients by 20% across 5 sites within 6 months. METHODS: A national quality improvement collaborative evaluated standardized interventions for reducing inpatient serum electrolyte testing at 5 large tertiary and quaternary children's hospitals. The outcome measure was the rate of electrolyte laboratory tests per 10 patient-days. The interventions were adapted from a previous single-site improvement project and included cost card reminders, automated laboratory plans via electronic medical record, structured rounds discussions, and continued education. The collaborative utilized weekly conference calls to discuss Plan, Do, Study, Act cycles, and barriers to implementation efforts. RESULTS: The study included 17,149 patient-days across 5 hospitals. The baseline preintervention electrolyte laboratory testing rate mean was 4.82 laboratory tests per 10 patient-days. Postimplementation, special cause variation in testing rates shifted the mean to 4.19 laboratory tests per 10 patient-days, a 13% reduction. There was a wide variation in preintervention electrolyte testing rates and the effectiveness of interventions between the hospitals participating in the collaborative. CONCLUSIONS: This multisite improvement collaborative was able to rapidly disseminate and implement value improvement interventions leading to a reduction in electrolyte testing; however, we did not meet our goal of 20% testing reduction across all sites. Quality improvement collaboratives must consider variation in context when adapting previously successful single-center interventions to a wide variety of sites.

Evaluating Pediatric Sepsis Definitions Designed for Electronic Health Record Extraction and Multicenter Quality Improvement.

OBJECTIVES: To describe the Children's Hospital Association's Improving Pediatric Sepsis Outcomes sepsis definitions and the identified patients; evaluate the definition using a published framework for evaluating sepsis definitions. DESIGN: Observational cohort. SETTING: Multicenter quality improvement collaborative of 46 hospitals from January 2017 to December 2018, excluding neonatal ICUs. PATIENTS: Improving Pediatric Sepsis Outcomes Sepsis was defined by electronic health record evidence of suspected infection and sepsis treatment or organ dysfunction. A more severely ill subgroup, Improving Pediatric Sepsis Outcomes Critical Sepsis, was defined, approximating septic shock. INTERVENTIONS: Participating hospitals identified patients, extracted data, and transferred de-identified data to a central data warehouse. The definitions were evaluated across domains of reliability, content validity, construct validity, criterion validity, measurement burden, and timeliness. MEASUREMENTS AND MAIN RESULTS: Forty hospitals met data quality criteria across four electronic health record platforms. There were 23,976 cases of Improving Pediatric Sepsis Outcomes Sepsis, including 8,565 with Improving Pediatric Sepsis Outcomes Critical Sepsis. The median age was 5.9 years. There were 10,316 (43.0%) immunosuppressed or immunocompromised patients, 4,135 (20.3%) with central lines, and 2,352 (11.6%) chronically ventilated. Among Improving Pediatric Sepsis Outcomes Sepsis patients, 60.8% were admitted to intensive care, 26.4% had new positive-pressure ventilation, and 19.7% received vasopressors. Median hospital length of stay was 6.0 days (3.0-13.0 d). All-cause 30-day in-hospital mortality was 958 (4.0%) in Improving Pediatric Sepsis Outcomes Sepsis; 541 (6.3%) in Improving Pediatric Sepsis Outcomes Critical Sepsis. The Improving Pediatric Sepsis Outcomes Sepsis definitions demonstrated strengths in content validity, convergent construct validity, and criterion validity; weakness in reliability. Improving Pediatric Sepsis Outcomes Sepsis definitions had significant initial measurement burden (median time from case completion to submission: 15 mo [interquartile range, 13-18 mo]); timeliness improved once data capture was established (median, 26 d; interquartile range, 23-56 d). CONCLUSIONS: The Improving Pediatric Sepsis Outcomes Sepsis definitions demonstrated feasibility for large-scale data abstraction. The patients identified provide important information about children treated for sepsis. When operationalized, these definitions enabled multicenter identification and data aggregation, indicating practical utility for quality improvement.

Risk of Vascular Access Infection Associated With Buttonhole Cannulation of Fistulas: Data From the National Healthcare Safety Network.

RATIONALE & OBJECTIVE: Compared with conventional (rope-ladder cannulation [RLC]) methods, use of buttonhole cannulation (BHC) to access arteriovenous fistulas (AVFs) may be associated with increased risk for bloodstream infection and other vascular access-related infection. We used national surveillance data to evaluate the infection burden and risk among in-center hemodialysis patients with AVFs using BHC. STUDY DESIGN: Descriptive analysis of infections and related events and retrospective observational cohort study using National Healthcare Safety Network (NHSN) surveillance data. SETTING & PARTICIPANTS: US patients receiving hemodialysis treated in outpatient dialysis centers. PREDICTORS: AVF cannulation methods, dialysis facility characteristics, and infection control practices. OUTCOMES: Access-related bloodstream infection; local access-site infection; intravenous (IV) antimicrobial start. ANALYTIC APPROACH: Description of frequency and rate of infections; adjusted relative risk (aRR) for infection with BHC versus RLC estimated using Poisson regression. RESULTS: During 2013 to 2014, there were 2,466 access-related bloodstream infections, 3,169 local access-site infections, and 13,726 IV antimicrobial starts among patients accessed using BHC. Staphylococcus aureus was the most common pathogen, present in half (52%) of the BHC access-related bloodstream infections. Hospitalization was frequent among BHC access-related bloodstream infections (37%). In 2014, 9% (n=271,980) of all AVF patient-months reported to NHSN were associated with BHC. After adjusting for facility characteristics and practices, BHC was associated with significantly higher risk for access-related bloodstream infection (aRR, 2.6; 95% CI, 2.4-2.8) and local access-site infection (aRR, 1.5; 95% CI, 1.4-1.6) than RLC, but was not associated with increased risk for IV antimicrobial start. LIMITATIONS: Data for facility practices were self-reported and not patient specific. CONCLUSIONS: BHC was associated with higher risk for vascular access-related infection than RLC among in-center hemodialysis patients. Decisions regarding the use of BHC in dialysis centers should take into account the higher risk for infection. Studies are needed to evaluate infection control measures that may reduce infections related to BHC.

An evidence-based strategy to achieve equivalency and interoperability for social-behavioral determinants of health assessment, storage, exchange, and use.

The interoperable exchange of social-behavioral determinants of health data is challenging due to complex factors including multiple recommendations, multiple tools with varying domains, scoring, and cutpoints, and lack of terminology code sets for storing assessments and findings. This article describes a strategy that permits scoring by social-behavioral determinants of health domain to create interoperability and equivalency across tools, settings, and populations. The three-tier scoring strategy converts social-behavioral determinants of health data to (1) be used immediately at point of care by identifying social needs or social risk factors, (2) be consumed within analytics and algorithms and for secondary analysis, and (3) produce total scores that reflect social determinant burden and behavioral determinant burden across populations and settings within a healthcare system. The strategy supports the six uses recommended by the National Academy of Medicine, provides flexibility in choice of social-behavioral determinants of health tool, and leverages the power of social-behavioral determinants of health data in healthcare delivery.

Capturing health literacy assessment in the electronic health record through evidence-based concept creation: A review of the literature and recommendations for action.

Health literacy is the capacity to understand and act upon health-related information and navigate the healthcare system. Published evidence demonstrates a relationship between health literacy and health status. Because of this, there are increasingly calls for a health literacy assessment to be collected and stored in the electronic health record for use by the healthcare team. This article describes the results of a literature review of health literacy assessment instruments with the goal of formulating semantically interoperable concepts that may be used to store the interpretation of the health literacy assessment in the electronic health record. The majority of health literacy instruments could be stored in the electronic health record using a three-concept solution of inadequate, marginal and adequate health literacy. This three-concept solution fully supports semantic interoperability needs across the patient care spectrum.

Determining Palliative Care Penetration Rates in the Acute Care Setting.

CONTEXT: Intermountain Healthcare, in collaboration with Cerner Corporation, developed a hospital-based electronic palliative care algorithm. OBJECTIVES: This study aims to improve identification of patients who would benefit from palliative care services, and calculate palliative care penetration rates. METHODS: This study used a mixed-methods nonrandomized retrospective study design. Three 30-day iterations of clinical data were analyzed for patients identified by the electronic algorithm. During the second and third 30-day iterations, palliative care clinicians conducted chart reviews on a weekly basis for identified patients and determined whether the patients were appropriate for a palliative care consult. Positive predictive values (PPVs) were calculated. Based on the PPV, palliative care consult penetration rates were also calculated. RESULTS: During the first iteration, the algorithm triggered 2995 times on 1384 unique patient encounters (69.3% of the total inpatient population). In the second iteration, the algorithm triggered 851 times on 477 unique patient encounters (26.4% of the total inpatient population). Eight hundred twenty-one chart reviews were completed on 420 unique patient encounters. The PPV was 68.3%. Based on the PPV, the projected palliative care penetration rate was 17.6%. During the third iteration, the algorithm triggered 1229 times on 539 unique patient encounters (33.3% of the total inpatient population). Nine hundred sixty-seven chart reviews were completed on 505 unique patient encounters. The PPV was 80.1%. Based on the PPV, the projected palliative care penetration rate was 26.4%. CONCLUSION: This study successfully optimized an electronic palliative care identification algorithm with a PPV of 80.1% and indicates appropriate palliative care penetration rates may be as high as 26.4% of the total inpatient population.

A Concise Set of Structure and Process Indicators to Assess and Compare Antimicrobial Stewardship Programs Among EU and US Hospitals: Results From a Multinational Expert Panel.

OBJECTIVES To develop common indicators, relevant to both EU member states and the United States, that characterize and allow for meaningful comparison of antimicrobial stewardship programs among different countries and healthcare systems. DESIGN Modified Delphi process. PARTICIPANTS A multinational panel of 20 experts in antimicrobial stewardship. METHODS Potential indicators were rated on the perceived feasibility to implement and measure each indicator and clinical importance for optimizing appropriate antimicrobial prescribing. RESULTS The outcome was a set of 33 indicators developed to characterize the infrastructure and activities of hospital antimicrobial stewardship programs. Among them 17 indicators were considered essential to characterize an antimicrobial stewardship program and therefore were included in a core set of indicators. The remaining 16 indicators were considered optional indicators and included in a supplemental set. CONCLUSIONS The integration of these indicators in public health surveillance and special studies will lead to a better understanding of best practices in antimicrobial stewardship. Additionally, future studies can explore the association of hospital antimicrobial stewardship programs to antimicrobial use and resistance. Infect Control Hosp Epidemiol 2016:1-11.