RESUMO
Introduction: The American Academy of Pediatrics recommends using isotonic intravenous fluids (IVF) for maintenance needs to decrease the risk of hyponatremia. We conducted a quality improvement project to increase the use of isotonic maintenance IVF in pediatric patients admitted to three sites in a community hospital network to >85% within 12 months. Methods: We used improvement methodology to identify causes of continued hypotonic fluid use, which involved provider behavior and systems factors. We implemented interventions to address these factors including: (1) education; (2) clinical decision support; and (3) stocking automated medication dispensing systems with isotonic IVF. We compared isotonic IVF use before and after interventions in all admitted patients aged 28 days to 18 years who received maintenance IVFs at the rate of at least 10 mL/hour. We excluded admissions of patients with active chronic medical conditions like diabetic ketoacidosis. Balancing measures were the occurrence of adverse events from hypo- or hypernatremia. Data were analyzed using Laney P' statistical process control charts. Results: Isotonic IVF use among patients requiring maintenance fluids at all three sites surpassed the goal of >85% within 12 months. There were no reports of hypo- or hypernatremia or other adverse outcomes related to the use of isotonic IVF. Conclusion: A combination of interventions aimed at provider behavior and systems factors was critical to successfully adopting the American Academy of Pediatrics guideline regarding the use of maintenance isotonic IVF in hospitalized children.
RESUMO
OBJECTIVES: Our objective was to increase human immunodeficiency virus (HIV) screening in adolescents presenting to our community pediatric emergency department with symptoms suggestive of a sexually transmitted infection (STI) and who were being tested for gonorrhea and chlamydia. Specifically, we aimed to increase the monthly average proportion of adolescents concurrently screened for HIV in this target group from 11% to 50% in 6 months. METHODS: We identified barriers to HIV screening, focusing on physician-related challenges and adolescents' concerns about confidentiality. We designed interventions targeting these barriers and implemented them in plan-do-study-act cycles beginning in February 2020. We educated physicians and nurses about screening recommendations, emphasized a physician-conducted private interview during which confidential contact information could be obtained, and assured confidentiality on after visit summaries by removing STI results. We also provided regular feedback to physicians on the screening rate. In addition, we implemented an electronic health record quick order set and a documentation tool. Using a statistical process control chart, we measured the average monthly proportion of adolescents in the target group who were offered HIV screening or tested for HIV before and after interventions. RESULTS: A total of 140 adolescents in the target group presented to our pediatric emergency department from February 2020 through December 2021. After plan-do-study-act cycles, the average monthly screening rate increased to 80%. CONCLUSIONS: Raising physician awareness of HIV screening recommendations and the importance of conducting a private interview improved screening rates. Assuring adolescent minors of confidentiality in a private interview, removing STI results from the after visit summary, and obtaining confidential contact information were important measures to overcome confidentiality barriers.
