From reducing waste of a life-saving medication to improving how laboratory tests are sent out, learn more about the top Pediatric Quality Award entries for waste reduction and improved efficiency.
Waste reduction and improved efficiency lead to financial savings for a hospital, but can also improve quality and safety. Learn more about the top four entries for the waste reduction and improved efficiency category of the 2017 Pediatric Quality Award.
Reducing Waste of Isoproterenol, a High-Cost Medication, Across Multiple Hospital Settings
Isoproterenol is a life-saving medication for cardiac and pulmonary hypertension patients. When Valeant Pharmaceuticals became the sole manufacturer of isoproterenol in 2015, price per ampule jumped from $208 to $1,700. Later, hospitals faced a national shortage of the medication, prompting Children's Hospital of Philadelphia (CHOP) to initiate a waste reduction initiative and promote for efficient use of the drug.
Providers used the electronic health record (EHR) to determine how the drug was administered throughout the hospital. Data showed out of 274 cardiac anesthesia cases, isoproterenol was administered only 4.4 percent of the time. In the cases where the drug was used, 19 percent of the ampule was used at most. On average, only 5.6 percent of the ampule was used, leading to a significant waste in cost.
A team of pharmacists, cardiac anesthesia providers and quality improvement specialists established a plan to reduce waste of isoproterenol:
- Modify purchase and usage habits. After seeing the data, less isoproterenol was ordered than originally anticipated. The team also cut infusion syringe volume by 50 percent. These two initiatives resulted in a reduction of spend by about $88,000 per month.
- Reduce storage redundancy. In high-risk areas, the drug was stored in multiple locations to ensure it was readily available. For example, in cardiac operating rooms (OR), Isoproterenol was stored at the bedside for all high-risk patients, stocked in all anesthesia trays, all automatic dispensing stations and all advanced cardiac life support (ACLS) trays. After studying use patterns, ampules were removed from general OR trays and reduced from two to one in cardiac ORs.
- In the automatic medstations, the number of ampules was decreased from 122 to 86 and kept in all storage areas where there is a history of administering the drug. A close partnership with nurse educators allowed ampules to be removed from code trays, driving staff to the medstations as the primary location the drug was being stored. As a result, 159 fewer ampules were needed in storage.
The final tally after implementation was removing 379 ampules from anesthesia and ACLS trays and medstations, saving $416,000 annually. By reducing syringe volume and order quantities, CHOP saved an additional $1.06 million per year. Moving forward, the team plans to address how the intensive care unit and cardiac electrophysiology areas use and store isoproterenol to achieve waste reduction in those areas.
To learn more, register for CHOP's live webcast on Jan. 8.
Reduction in Hospital Days Using a Multidisciplinary Approach for Pediatric Patients with Sickle Cell Disease
Yale New Haven Children's Hospital in New Haven, Connecticut, has a sickle cell program with about 250 pediatric patients that averaged a combined 59.6 hospital days each month. With a goal to decrease total hospital stays for this patient population by 40 percent over five years, the team at Yale New Haven identified five key drivers and implemented a series of interventions.
A multi-disciplinary team met monthly to develop interventions that would significantly reduce the level of pain–and therefore hospital days–experienced by pediatric sickle cell patients. The hospital estimated the direct cost of one of these patients admitted for pain is $1,271 per day.
Pain crisis interventions included a combination of medication strategies and psycho-educational methods. Patients and families were educated on the escalation of pain medication at home based on the severity of a patient's pain and when it was appropriate to forgo medication for coping strategies:
- Parents were provided a pain action plan that detailed what medications to take and when, versus when to try alternative treatment options. With hospitalizations, the team would make modifications to a patient's plan as needed.
- A group for children 8 and older met twice weekly with a social worker and psychologist. Patients were given pain management strategies for when medication wasn't necessary. Strategies included diaphragmatic breathing, guided imagery and distraction techniques. Additionally, this was an opportunity for patients and families to receive continuing education on sickle cell disease, self-care and cognitive-behavioral strategies to help them cope with the stress of their condition.
- Patients who were identified as the highest utilizers of care were assigned a social worker, nurse practitioner or other health provider to improve the patient's mental health. This started with 10 patients, but was expanded to 30.
Inpatient days for patients with sickle cell disease due to pain went from 59.6 days per month to 23.2 days per month, saving $555,120 in direct hospital costs in the final year of the project. Yale New Haven is exploring how to implement a similar project plan for patients with asthma.
Use of Toyota Production System (TPS) Principles to Improve Total Parenteral Nutrition Logistics and Clinical Outcomes in our Most Vulnerable Patient Population
At Children's Hospital of The King's Daughters (CHKD) in Norfolk, Virginia, total parenteral nutrition (TPN) is one of the most frequently used pharmacy products in the neonatal intensive care unit (NICU). TPN is the main source of nourishment for many premature babies, with 92 percent of the hospital's TPN being ordered from the NICU. Due to a lengthy processing time to receive a TPN infusion, the team at CHKD suspected lab samples didn't sufficiently measure the effect of the patient's infusion.
Using the Toyota Production System (TPS), the hospital's quality improvement team wanted to reduce the processing time of TPN for a longer infusion before labs were collected. The goal was to increase the infusion time by 48 percent.
TPS is a quality improvement strategy developed by Toyota that works under the philosophy of achieving a higher quality end result at the lowest cost in the shortest amount of time. Using this methodology, the team at CHKD focused on the pharmacy and the NICU for improvement:
- The layout of the IV rooms were changed, supply kits helped standardize the setup and breakdown of the compounder for plenty of TPN stock each day, and technicians were trained on new standard operating procedures. These changes led to a 17 percent decrease in turnaround time.
- Day shift NICU nurses were retrained on changing IV tubing and initiating TPN to take the burden off the evening nurses. The project team joined forces with the NICU central line associated blood stream infection (CLABSI) reduction project team to modify the standard of frequency for changing IV tubing. Instead of every 24 hours, IV tubing now is changed every 96 hours.
- TPN orders were sent to the pharmacy by 11 a.m., allowing the pharmacy to deliver back to the NICU by 2 p.m. Nurses were to complete the TPN infusion by 4 p.m. This process change allowed for 13.59 hours of TPN infusion, up from 8.75 hours.
- A visual guide was placed in the NICU and pharmacy for staff to know what steps need to be completed by who and by what time each day.
- CHKD partnered with Cerner to incorporate TPN order forms into the electronic health record and remove paper order forms.
With all steps implemented, the hospital saw a 67.65 percent increase in TPN infusion time, from 8.16 hours to 13.81 hours.
Improving the Value of Send-Out Laboratory Testing Through Laboratory Test Stewardship
Send-out tests require hospital management to ensure the correct test is ordered, necessary and preauthorized by the patient's insurance company. Errors and unnecessary tests can be costly for the patient and hospital, and a liability. Seattle Children's set out to implement a case review program with a team of laboratory genetic counselors and doctoral-level faculty to catch errors and prevent unnecessary tests, and costs, to patients and the institution.
The last few years at Seattle Children's has seen a steady increase in the cost for send-out tests–up to 15 percent of its lab budget. Additionally, the hospital cites cost recovery as insufficient because tests are costly and insurance reimbursement is inconsistent. Over the course of five years, Seattle Children's wanted to decrease unnecessary and expensive send-out tests by 20 percent.
After establishing a team to review send-out tests, specific criteria was established to determine which tests were reviewed. Certain types of orders were flagged:
- Tests costing the lab $700 or more
- All genetic tests
- Requests to send to non-preferred and international labs
- Tests that are typically performed within the hospital
Flagged lab tests were then reviewed by the team to:
- Confirm the right test was ordered
- Check that there was necessary documentation to justify the order
- Facilitate insurance preauthorization for genetic tests
- Suggest sequential test strategies when appropriate
Chart reviews typically coincided with the order review process, as were conversations with the provider. The review team let the provider decide if a test was necessary, but conversations prompted discussion on rationale and alternatives.
Prior to the project, 65 percent of genetic send-out tests were approved, and there was a 5 percent error rate. Now, Seattle Children's sees an 80 percent approval rate with a 2 percent error rate. Of 6,521 orders that were reviewed between Sept. 2011 and July 2017, 27 percent were modified or cancelled. Seattle Children's has seen $1.16 million in savings since Sept. 2011.
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