Closer to Home: A Quality Improvement Initiative to Optimize Satellite Site Bed Capacity.

BACKGROUND: The coronavirus disease 2019 pandemic resulted in the underutilization of inpatient beds at our satellite location. A lack of clarity and standardized admission criteria for the satellite led to frequent transfers to the main campus, resulting in patients traveling larger distances to receive inpatient care. We sought to optimize inpatient resource use at the satellite campus and keep patients "closer to home" by admitting eligible patients to that inpatient unit (LA4). Our aim was to increase bed capacity use at the satellite from 45% to 70% within 10 months. Our process measure was to increase the proportion of patients needing hospitalization who presented to the satellite emergency department (ED) and were then admitted to LA4 from 76% to 85%. METHODS: A multidisciplinary team used quality improvement methods to optimize bed capacity use. Interventions included (1) the revision and dissemination of satellite admission guidelines, (2) steps to create shared understanding of appropriate satellite admissions between ED and inpatient providers, (3) directed provider feedback on preventable main campus admissions, and (4) consistent patient and family messaging about the potential for transfer. Data were collected via chart review. Annotated run charts were used to assess the impact of interventions over time. RESULTS: Average LA4 bed capacity use increased from 45% to 69%, which was sustained for 1 year. The average percentage of patients admitted from the satellite ED to LA4 increased from 76% to 84%. CONCLUSIONS: We improved bed capacity use at our satellite campus through transparent admission criteria and shared mental models of patient care needs between ED and inpatient providers.

Implementation of a Children's Hospital Acute Care Behavior Response Team.

BACKGROUND: Pediatric patients with behavioral needs are frequently admitted to the hospital for medical care; when behavioral crises occur, patients and staff are at risk for injury. Our aim was to implement a behavior response team (BRT) to increase the days between employee injury due to aggressive patient interactions on the inpatient medical units from 99 to 150 over 1 year. METHODS: A multidisciplinary team used quality improvement methods to design and implement the BRT system that includes 2 options: huddle to proactively plan for patients exhibiting early signs of escalation and STAT for immediate help for patients with imminent risk of harm to self or others. Using run and statistical process control charts, we tracked events per month, days between Occupational Safety & Health Administration-recordable events, and violent restraint use over time for 1 year after implementation. Staff pre and postimplementation surveys were compared to assess staff perception of safety and support provided by the BRT intervention. RESULTS: The BRT was implemented across the inpatient system in July 2020, with an average number of 13 events per month. Days between Occupational Safety & Health Administration-recordable events remained stable with a maximum of 134 days. Restraint use remained stable at 0.74 per 1000 patient days. The perception of behavioral support available to staff increased significantly pre to postsurvey. CONCLUSIONS: The implementation of a BRT can improve staff perception of support and confidence in safely caring for patients with behavior needs on the inpatient medical unit, although additional provider- and system-level improvements are needed to prevent employee injuries.

Quality Improvement to Reduce High-Flow Nasal Cannula Overuse in Children With Bronchiolitis.

BACKGROUND: High-flow nasal cannula oxygen therapy (HFNC) is increasingly used to treat bronchiolitis. However, HFNC has not reduced time on supplemental oxygen, length of stay (LOS), or ICU admission. Our objective was to reduce HFNC use in children admitted for bronchiolitis from 41% to 20% over 2 years. METHODS: Using quality improvement methods, our multidisciplinary team formulated key drivers, including standardization of HFNC use, effective communication, knowledgeable staff, engaged providers and families, data transparency, and high-value care focus. Interventions included: (1) standardized HFNC initiation criteria, (2) staff education, (3) real-time feedback to providers, (4) a script for providers to use with families about expectations during admission, (5) team huddle for patients admitted on HFNC to discuss necessity, and (6) distribution of a bronchiolitis toolkit. We used statistical process control charts to track the percentage of children with bronchiolitis who received HFNC. Data were compared with a comparison institution not actively involved in quality improvement work around HFNC use to ensure improvements were not secondary to the COVID-19 pandemic alone. RESULTS: Over 10 months of interventions, we saw a decrease in HFNC use for patients admitted with bronchiolitis from 41% to 22%, which was sustained for >12 months. There was no change in HFNC use at the comparison institution. The overall mean LOS for children with bronchiolitis decreased from 60 to 45 hours. CONCLUSIONS: We successfully reduced HFNC use in children with bronchiolitis, improving delivery of high-value and evidence-based care. This reduction was associated with a 25% decrease in LOS.

How to Perform Quality Improvement Projects.

Safety and efficiency remain salient concerns for the US health-care system, especially in the face of growing health-care costs and morbidity from low-quality care. Current estimates suggest that more than 20% of health-care costs in the United States represent waste and low-value care, presenting numerous improvement opportunities. Although current guidelines and standards aim to address these problems, system processes and clinician behavior must also change to fill care gaps in the health-care system. Quality improvement (QI) is a systematic approach to safety or value gaps in care that uses data measured over time and then makes sequential, small changes to achieve a measurable aim. The Model for Improvement provides a general framework for approaching QI. In this review article, we describe the general approach to conducting QI studies in the health-care setting using the Model for Improvement as a guide, including identifying a problem, performing testing, measuring change, and implementing successful ideas. We also summarize common issues that QI teams face and should consider if sharing their QI work through publication. By following a systematic approach, QI teams can develop and implement interventions aimed at addressing gaps in care, thereby improving overall health-care value and safety for their patients.

Decreasing Time to Full Enteral Feeds in Hospitalized Children With Medical Complexity Experiencing Feeding Intolerance.

BACKGROUND AND OBJECTIVES: Children with medical complexity (CMC) with gastrostomy and jejunostomy tubes are commonly hospitalized with feeding intolerance, or the inability to achieve target enteral intake combined with symptoms consistent with gastrointestinal dysfunction. Challenges resuming feeds may prolong length of stay (LOS). Our objective was to decrease median time to reach goal feeds from 3.5 days to 2.5 days in hospitalized CMC with feeding intolerance. METHODS: A multidisciplinary team conducted this single-center quality improvement project. Key drivers included: standardized approach to feeding intolerance, parental buy-in and shared understanding of parental goals, timely formula delivery, and provider knowledge. Plan-do-study-act cycles included development of a feeding algorithm, provider education, near-real-time reminders and feedback. A run chart tracked the effect of interventions on median time to goal enteral feeds and median LOS. RESULTS: There were 225 patient encounters. The most common cooccurring diagnoses were viral gastroenteritis, upper respiratory infections, and urinary tract infections. Median time to goal enteral feeds for CMC fed via gastrostomy or gastrojejunostomy tubes decreased from 3.5 days to 2.5 days within 6 months and was sustained for 1 year. This change coincided with implementation of a feeding intolerance management algorithm and provider education. There was no change in LOS. CONCLUSIONS: Implementation of a standardized feeding intolerance algorithm for hospitalized CMC was associated with decreasing time to goal enteral feeds. Future work will include incorporating the algorithm into electronic health record order sets and spread of the algorithm to other services who care for CMC.

Improving Discharge Efficiency and Charge Containment on a Pediatric Acute Care Cardiology Unit.

BACKGROUND: Hospital discharge delays can negatively affect patient flow and hospital charges. Our primary aim was to increase the percentage of acute care cardiology patients discharged within 2 hours of meeting standardized medically ready (MedR) discharge criteria. Secondary aims were to reduce length of stay (LOS) and lower hospital charges. METHODS: A multidisciplinary team used quality improvement methods to implement and study MedR discharge criteria in our hospital electronic health record. The criteria were ordered on admission and modified on daily rounds. Bedside nurses documented the time when all MedR discharge criteria were met. A statistical process control chart measured interventions over time. Discharge before noon and 30-day readmissions were also tracked. Average LOS was examined, comparing the first 6 months of the intervention period to the last 6 months. Inpatient charges were reviewed for patients with >2 hours MedR discharge delay. RESULTS: The mean percentage of patients discharged within 2 hours of meeting MedR discharge criteria increased from 20% to 78% over 22 months, with more patients discharged before noon (19%-32%). Median LOS decreased from 11 days (interquartile range: 6-21) to 10 days (interquartile range: 5-19) (P = .047), whereas 30-day readmission remained stable at 16.3%. A total of 265 delayed MedR discharges beyond 2 hours occurred. The sum of inpatient charges from care provided after meeting MedR criteria was $332 038 (average $1253 per delayed discharge). CONCLUSIONS: Discharge timeliness in pediatric acute care cardiology patients can be improved by standardizing medical discharge criteria, which may shorten LOS and decrease medical charges.

Short-term Focused Feedback: A Model to Enhance Patient Engagement in Research and Intervention Delivery.

BACKGROUND: Our grant from the Patient-Centered Outcomes Research Institute (PCORI) focused on the use of nurse home visits postdischarge for primarily pediatric hospital medicine patients. While our team recognized the importance of engaging parents and other stakeholders in our study, our project was one of the first funded to address transitions of care issues in patients without chronic illness; little evidence existed about how to engage acute stakeholders longitudinally. OBJECTIVE: This manuscript describes how we used both a short-term focused feedback model and longitudinal engagement methods to solicit input from parents, home care nurses, and other stakeholders throughout our 3-year study. RESULTS: Short-term focused feedback allowed the study team to collect feedback from hundreds of stakeholders. Initially, we conducted focus groups with parents with children recently discharged from the hospital. We used this feedback to modify our nurse home visit intervention, then used quality improvement methods with continued short-term focus feedback from families and nurses delivering the visits to adjust the visit processes and content. We also used their feedback to modify the outcome collection. Finally, during the randomized controlled trial, we added a parent to the study team to provide longitudinal input, as well as continued to solicit short-term focused feedback to increase recruitment and retention rates. CONCLUSION: Research studies can benefit from soliciting short-term focused feedback from many stakeholders; having this variety of perspectives allows for many voices to be heard, without placing an undue burden on a few stakeholders.

Building a doctor, one skill at a time: Rethinking clinical training through a new skills-based feedback modality.

The Accreditation Council for Graduate Medical Education milestones and entrustable professional activities (EPAs) are important assessment approaches but may lack specificity for learners seeking improvement through daily feedback. As in other professions, clinicians grow best when they engage in deliberate practice of well-defined skills in familiar contexts. This growth is augmented by specific, actionable coaching from supervisors. This article proposes a new feedback modality called microskills, which are derived from the psychology, negotiation, and business literature, and are unique in their ability to elicit targeted feedback for trainee development. These microskills are grounded in both clinical and situational contexts, thereby mirroring learners' cognitive schemas and allowing for more natural skill selection and adoption. When taken as a whole, microskills are granular actions that map to larger milestones, competencies, and EPAs. This article outlines the theoretical justification for this new skills-based feedback modality, the methodology behind the creation of clinical microskills, and provides a worked example of microskills for a pediatric resident on a hospital medicine rotation. Ultimately, microskills have the potential to complement milestones and EPAs and inform feedback that is specific, actionable, and relevant to medical learners.

Decreasing Hospital Observation Time for Febrile Infants.

BACKGROUND: Febrile infants aged 0 to 60 days are often hospitalized for a 36-to-48 hour observation period to rule out invasive bacterial infections (IBI). Evidence suggests that monitoring blood and cerebrospinal fluid (CSF) cultures for 24 hours may be appropriate for most infants. We aimed to decrease the average culture observation time (COT) from 38 to 30 hours among hospitalized infants 0 to 60 days old over 12 months. METHODS: This quality improvement initiative occurred at a large children's hospital, in conjunction with development of a multidisciplinary evidence-based guideline for the management of febrile infants. We included infants aged 0 to 60 days admitted with fever without a clear infectious source. We excluded infants who had positive blood, urine, or CSF cultures within 24 hours of incubation and infants who were hospitalized for other indications (eg, bronchiolitis). Interventions included guideline dissemination, education regarding laboratory monitoring practices, standardized order sets, and near-time identification of failures. Our primary outcome was COT, defined as time between initiation of culture incubation and hospital discharge in hours. Interventions were tracked on an annotated statistical process control chart. Our balancing measure was identification of IBI after hospital discharge. RESULTS: In our cohort of 184 infants aged 0 to 60 days, average COT decreased from 38 hours to 32 hours after structured guideline dissemination and order-set standardization; this decrease was sustained over 17 months. IBI was not identified in any patients after discharge. CONCLUSIONS: Implementation of an evidence-based guideline through education, transparency of laboratory procedures, creation of standardized order sets, and near-time feedback was associated with shorter COT for febrile infants aged 0 to 60 days.

Performance of Pediatric Readmission Measures.

BACKGROUND: Readmission rates are frequently used as a hospital quality metric; yet multiple measures exist to evaluate pediatric readmission rates. We sought to assess how four different measures of pediatric readmission compare with assessment of both preventable and unplanned readmission. METHODS: Clinicians on hospital medicine, cardiology, neonatology, and neurology teams reviewed medical records for 30-day readmissions using an abstraction tool with high interrater reliability for preventability assessment. Readmissions between July 2014 and June 2016 were classified separately as preventable or not preventable and planned or unplanned. We compared the classifications to four existing readmission metrics: all-cause readmission, unplanned readmission/time flag classification, the pediatric all-condition readmission, and potentially preventable readmission. We calculated sensitivity and specificity for all readmission metrics. RESULTS: Among 30-day readmissions considered, 1,643 were eligible for medical record review; 1,125 reviews were completed by the clinical teams (68%). On medical record review, the majority of readmissions were determined not preventable (85%). Only 15% were classified as unplanned and preventable. None of the four readmission measures had appropriate sensitivity or specificity for identifying preventable readmission. The unplanned readmission/time flag classification had the highest sensitivity (95%) and specificity (90%) in identifying unplanned readmissions. CONCLUSION: None of the existing pediatric readmission measures can reliably determine preventability. The unplanned readmission/time flag measure performed best in identifying unplanned readmissions.

Nutrition and Preventative Medicine Across the Lifespan: Implementation of a Physician Assistant Team-Based Learning Curriculum on Pediatric Preventative Medicine.

PURPOSE: Physician assistants (PAs) will increasingly fill an important primary care gap in pediatrics. This study implemented a pediatric preventative care curriculum using a team-based learning (TBL) strategy and then evaluated the effect on first-year PA students' knowledge and attitudes toward TBL as a teaching method. METHODS: The curriculum was developed and implemented during a one-semester course. Students completed knowledge-based questions precourse and postcourse; the mean scores for individual students were then compared using a paired t test. Descripted statistics were used to analyze the postcourse survey that evaluated students' attitudes toward TBL. RESULTS: Of the 31 PA students who participated, 27 (87%) completed the surveys and were included in the analysis. The mean correct pretest and posttest scores were 17/39 and 31/39, respectively, resulting in a change of 14 points (p < .05). The majority of students (85%) rated TBL as effective, and most students (75%) reported that it led to retention of the presented content. CONCLUSIONS: A TBL-based curriculum in pediatric preventative care was effective in increasing PA student knowledge, and the students reported it as effective. This strategy could be considered for other PA courses.

Paediatric clinical and social concerns identified by home visit nurses in the immediate postdischarge period.

AIM: To describe paediatric postdischarge concerns manifesting in the first 96 hr after hospital discharge. DESIGN: Analysis of nursing documentation generated as part of a randomized controlled trial evaluating the effect of a nurse home visit on healthcare re-use. METHODS: We analysed home visit records of 651 children (age <18) hospitalized at a large Midwestern children's hospital in 2015 and 2016 who were enrolled in the trial. Registered nurses documented concerns in structured fields and free-text notes in visit records. Descriptive statistics were used to summarize visit documentation. Free-text visit notes were reviewed and exemplars illustrative of quantitative findings were selected. RESULTS: Overall, nurses documented at least one concern in 56% (N = 367) of visits. Most commonly, they documented concerns about medication safety (15% or 91 visits). Specifically, in 11% (N = 58) of visits nurses were concerned that caregivers lacked a full understanding of medications and in 8% (N = 49) of visits families did not have prescribed discharge medications. Pain was documented as present in 9% of all visits (N = 56). Nurses completed referrals to other providers/services in 12% of visits (N = 78), most frequently to primary care providers. In 13% of visits (N = 85) nurses documented concerns considered beyond the immediate scope of the visit related to social needs such as housing and transportation. CONCLUSION: Inpatient and community nurses and physicians should be prepared to reconcile and manage discharge medications, assess families' medication administration practices and anticipate social needs after paediatric discharge. IMPACT: Little empirical data are available describing concerns manifesting immediately after paediatric hospital discharge. Concerns about medication safety were most frequent followed by concerns related to housing and general safety. The results are important for clinicians preparing children and families for discharge and for community clinicians caring for discharged children.

A Qualitative Study of Increased Pediatric Reutilization After a Postdischarge Home Nurse Visit.

BACKGROUND: The Hospital to Home Outcomes (H2O) trial was a 2-arm, randomized controlled trial that assessed the effects of a nurse home visit after a pediatric hospital discharge. Children randomized to the intervention had higher 30-day postdischarge reutilization rates compared with those with standard discharge. We sought to understand perspectives on why postdischarge home nurse visits resulted in higher reutilization rates and to elicit suggestions on how to improve future interventions. METHODS: We sought qualitative input using focus groups and interviews from stakeholder groups: parents, primary care physicians (PCP), hospital medicine physicians, and home care registered nurses (RNs). A multidisciplinary team coded and analyzed transcripts using an inductive, iterative approach. RESULTS: Thirty-three parents participated in interviews. Three focus groups were completed with PCPs (n = 7), 2 with hospital medicine physicians (n = 12), and 2 with RNs (n = 10). Major themes in the explanation of increased reutilization included: appropriateness of patient reutilization; impact of red flags/warning sign instructions on family's reutilization decisions; hospital-affiliated RNs "directing traffic" back to hospital; and home visit RNs had a low threshold for escalating care. Major themes for improving design of the intervention included: need for improved postdischarge communication; individualizing home visits-one size does not fit all; and providing context and framing of red flags. CONCLUSION: Stakeholders questioned whether hospital reutilization was appropriate and whether the intervention unintentionally directed patients back to the hospital. Future interventions could individualize the visit to specific needs or diagnoses, enhance postdischarge communication, and better connect patients and home nurses to primary care.

Improving the Transition of Intravenous to Enteral Antibiotics in Pediatric Patients with Pneumonia or Skin and Soft Tissue Infections.

BACKGROUND: Despite national recommendations for early transition to enteral antimicrobials, practice variability has existed at our hospital. OBJECTIVE: The aim of this study was to increase the proportion of enterally administered antibiotic doses for Pediatric Hospital Medicine patients aged >60 days admitted for uncomplicated community-acquired pneumonia or skin and soft tissue infections from 44% to 75% in eight months. METHODS: This quality improvement study was conducted at a large, urban, academic children's hospital. The study population included Hospital Medicine patients aged >60 days with diagnoses of pneumonia or skin and soft tissue infections. Interventions included education on intravenous and enteral antibiotic charge differentials, documentation of transition plan, structured discussions of transition criteria, and real-time identification of failures with feedback. Our process measure was the total number of enteral antibiotic doses divided by all antibiotic doses in patients receiving enteral medications on the same day. An annotated statistical process control chart tracked the impact of interventions on the administration route of antibiotic doses over time. Additional outcome measures included antimicrobial costs per patient encounter using average wholesale prices and length of stay. RESULTS: The percentage of enterally administered antibiotic doses increased from 44% to 80% within eight months. Antimicrobial costs per patient encounter and the associated standard deviation of costs for our target diagnoses decreased by 70% and 84%, respectively. Average length of stay did not change. CONCLUSIONS: Standardized communication about criteria for transition from intravenous to enteral antibiotics can lead to earlier transitions for patients with pneumonia or skin and soft tissue infections, subsequently reducing costs and prescribing variability.

Improving Efficiency of Pediatric Hospital Medicine Team Daily Workflow.

BACKGROUND AND OBJECTIVES: Workflow inefficiencies by medical teams caring for hospitalized patients may affect patient care and team experience. At our institution, complexity and clinical volume of the pediatric hospital medicine (HM) service have increased over time; however, efficient workflow expectations were lacking. We aimed to increase the percentage of HM teams meeting 3 efficiency criteria (70% nurses present for rounds, rounds completed by 11:30 am, and HM attending notes completed by 5 pm) from 28% to 80% within 1 year. METHODS: Improvement efforts targeted 5 HM teams at a large academic hospital. Our multidisciplinary team, including HM attending physicians, pediatric residents, and nurses, focused on several key drivers: shared expectations, enhanced physician and nursing buy-in and communication, streamlined rounding process, and data transparency. Interventions included (1) daily rounding expectations with prerounds huddle, (2) visible reminders, (3) complex care team scheduled rounds, (4) real-time nurse notification of rounds via electronic platform, (5) workflow redesign, (6) attending feedback and data transparency, and (7) resource attending implementation. Attending physicians entered efficiency data each day through a Research Electronic Data Capture survey. Annotated control charts were used to assess the impact of interventions over time. RESULTS: Through sequential interventions, the percentage of HM teams meeting all 3 efficiency criteria increased from 28% to 61%. Nursing presence on rounds improved, and rounds end time compliance remained high, whereas attending note completion time remained variable. CONCLUSIONS: Inpatient workflow for pediatric providers was improved by setting clear expectations and enhancing team communication; competing demands while on service contributed to difficulty in improving timely attending note completion.

Comparison of Parent Report with Administrative Data to Identify Pediatric Reutilization Following Hospital Discharge.

Healthcare providers rely on historical data reported by parents to make medical decisions. The Hospital to Home Outcomes (H2O) trial assessed the effects of a onetime home nurse visit following pediatric hospitalization for common conditions. The H2O primary outcome, reutilization (hospital readmission, emergency department visit, or urgent care visit), relied on administrative data to identify reutilization events after discharge. We sought to compare parent recall of reutilization events two weeks after discharge with administrative records. Agreement was relatively high for any reutilization (kappa 0.74); however, this high agreement was driven by agreement between sources when no reutilization occurred (sources agreed 98%-99%). Agreement between sources was lower when reutilization occurred (48%-76%). Some discrepancies were related to parents misclassifying the site of care. The possibility of inaccurate parent report of reutilization has clinical implications that may be mitigated by confirmation of parent-reported data through verification with additional sources, such as electronic health record review.