• Article
  • July 30, 2018

4 Proven Ideas to Improve Quality and Safety at Children's Hospitals

Dedicated teams are overcoming the quality challenges facing their children's hospitals.

By Kelly Church

Children's hospitals are making strides every day to improve care for their patients. While lasting changes often take time, these hospitals invested resources to implement change and achieve results. See how the four semifinalists from the 2017 Pediatric Quality Award are improving quality and patient safety.


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Reduced Asthma Visits

Category: Clinical Care Project, Primary Care Award

Nationwide Children's Hospital in Columbus, Ohio, wanted to reduce the number of asthma visits—a leading cause of pediatric emergency department (ED) visits—to improve overall patient health and reduce hospital spend. "We prioritized this project because of the effect it could have on our large patient population," says Dane Snyder, M.D., section chief of ambulatory pediatrics. "Poor asthma control is associated with an increase in missed school days and impaired academic performance."

The hospital's project followed several quality improvement (QI) steps, including changes in assessment and documentation, improving patient and family education, and providing high-risk patients with extended-length appointments. Snyder credits the success of the project to hospital leaders who provided support and resources, particularly the amount of dedicated time from physicians to work on the project.

Snyder says the biggest shift during the project was in the patient culture and how families responded to asthma symptoms. "Families started to think about their child's asthma in a preventable way, instead of simply reacting when their child was sick," he says. Parents were included in the treatment and prevention process through education, using take-home action plans for post-hospital care.

Easy-to-implement Process Changes

Nationwide Children's took an approach other hospitals can adopt. "These methods could easily be followed at other institutions, but they would take persistence," Snyder says. This step-wise approach could also be used for other pediatric conditions.

Identify asthma patients. Asthma alerts were added to the EMR in addition to developing an asthma patient registry. All asthma patients were screened using asthma control tests (ACT) and examined further. Providers were alerted to asthma patients quicker, leading to more ACTs and higher quality of care.

Outline a model patient visit. By developing an ideal asthma encounter, the team had goals to work toward, including providing step-up therapy for poorly controlled patients; monitoring pharmacy claims data and ensuring patients had influenza vaccinations.

Reinforce patient-centered care from home. Two asthma health coaches were added to the Nationwide Children's team in 2013, and they proactively contacted high-risk patients at home. Eventually, they became a team of eight who provided care teams with daily reports on asthma patient ED visits, hospital discharges and appointment no-shows.

Improve patient education. Health coaches and asthma specialty clinics bridged care between the hospital and home. Additionally, providers developed care action plans for patients to take home. The plans used the traditional green, yellow and red zones, with the addition of an orange zone to indicate when the patient's family should call the clinic and avoid a visit to the ED.

Outcomes

  • $5.2 million in asthma ED costs avoided
  • 24% drop in asthma-related ED visits

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Rapid Antibiotic Administration

Category: Clinical Care Project, Specialty Care Award

For pediatric oncology patients who are neutropenic and have a fever, receiving antibiotics within an hour of evaluation is essential to preventing complications. Neutropenia, a condition where a patient has an abnormally low count of a type of white blood cell, puts these patients at a higher risk for infection. Monroe Carell Jr. Children's Hospital at Vanderbilt in Nashville, Tennessee, developed a QI process to ensure timely delivery of antibiotics for patients admitted to the ED, outpatient oncology clinic or the inpatient unit with a fever and neutropenia.

The goal was to increase the number of patients who received antibiotics within 60 minutes from 30 percent to 90 percent. "Standardization of care was the most important step," says Caroline Epps, M.S.N., RN, quality and patient safety advisor, performance management and improvement. "Reducing the variation of initial treatment for neutropenic patients with fever allowed the team to focus on identification of the patients upon arrival, and communicate about the plan of care."

Communication, Epps says, was critical to achieving the goal. Staffing changes in the ED created a challenge, and the team made efforts to close the communication loop. Nurses were encouraged to initiate the patient care process, gathering critical information, lab specimens and quickly notifying the appropriate physician.

Steps for Creating Change

"This process can be used when treating other medical conditions," Epps says. "With standard guidelines and an efficient identification process, decreased time to treatment can be achieved in many care settings." 

Start small. The team at Monroe Carell Jr. Children's Hospital started with focused efforts in the oncology clinic before spreading its work to the pediatric ED. This allowed team members to test inter-ventions before introducing them to the broader workforce. Weekly team huddles helped groups identify barriers and address them to achieve success.

Simplify the process. Cefepime was deemed the go-to antibiotic, except in the case of a patient allergy. The pharmacy began stocking the medication in the electronic dispensing unit for quicker, easier access to the drug.

Add visual cues. In addition to adding the word "fever" to the electronic white board on the wall of the clinic to identify patients who needed to be triaged immediately, a digital clock was placed at the nurse's station whenever a code yellow patient was in the clinic. The clock helped staff manage how quickly antibiotics were administered. Yellow cards with the patient's diagnosis information were also given to families to quickly identify them as oncology patients.

Outcomes

89% of targeted patient populations received antibiotics within 60 minutes


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Zero Unplanned Extubations

Category: Patient Safety and Reduction of Harm

When Ochsner Hospital for Children in New Orleans set out to reduce unplanned extubation (UE) events, the goal was to decrease events in the pediatric intensive care unit (PICU) by 50 percent within two years. The staff, however, reached that goal within one year, adjusting the target to zero UEs by the original deadline. "Because this began as a grassroots effort at the unit level, staff members were engaged from the beginning," says Anne Pirrone, B.S.N., RN, CCRN, clinical coordinator. Ochsner has not had an UE event since September 2015.

Before the start of the project, there were 66 UE events out of 6,117 ventilator days over five years—about 1.1 UEs for every 100 ventilator days. Of that, about 40 percent of UEs required reintubation. "UE is associated with an increase in costs due to increased supply usage, additional imaging and laboratory studies and increased staffing requirements," Pirrone says. The result of having no UEs in more than two years has resulted in $240,000 in costs avoided for the organization.

STEP-BY-STEP LEARNING

Using the Plan-Do-Study-Act (PDSA) methodology, Ochsner eliminated UE events. "It took six years and repeated failures before we got to zero, but we learned from each hiccup and kept looking for ways to do better," Pirrone says.

Evaluate current protocols. Before this project started, providers were not always following sizing and application recommendations from the endotracheal tube manufacturer. The project team took steps to educate providers by using online manufacturer videos and re-securing tubes during daily bedside rounds.

Test and establish improved protocols. Project team members created a sedation order set for the EMR to evaluate patient comfort levels. They also tested new methods of securing tubes on man-nequins repeatedly to determine the best taping technique, which included getting buy-in from PICU nurses, respiratory therapists, unit nurses, respiratory leaders and the unit's medical director.

Use culture to your advantage. "Culture was the biggest key to this project's success," Pirrone says. The hospital focuses on safety as part of its culture, which allowed for candid conversations about each UE event that occurred. Additionally, nurses and respiratory therapists were recognized in real time for their work efforts in reducing UEs.

Outcomes

  • $240,000 in costs avoided
  • 43 fewer unnecessary hospital days

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Less Medication Waste

Category: Waste Reduction/Improved Efficiency

A substantial price increase in 2015 drove the cost of isoproterenol from $208 per milligram to $1,700 per milligram. The life-saving drug is used in patients with cardiac and pulmonary hypertension. Children's Hospital of Philadelphia (CHOP) keeps the medication prepared in the cardiac operating room and intensive care units for high-risk patients. A national shortage in January 2017 and the high price point created a need to reduce waste of the drug.

The team at CHOP wanted to first see a reduction of isoproterenol waste in cardiac anesthesia cases of 40 percent. And then they worked toward a 40 percent reduction in the number of ampules needed in storage, saving the hospital $300,000.

Actions that Lead to Savings

"All hospitals likely have a degree of waste in their system for medication use," says Neil Patel, Pharm.D., BCOP, manager of clinical pharmacy services. Here's what he suggests:

Review the numbers. The team analyzed data from July 2015 through June 2016 to understand usage patterns of isoproterenol in cardiac anesthesia cases. Only 4.4 percent of cardiac anesthesia cases used isoproterenol. Of those, providers used only 19 percent of the syringe, leaving 81 percent as cost and drug waste. The hospital decreased its orders, and syringes were filled with 50 percent less drug. "Being methodical in looking at historical data helped ensure everyone involved was on board and agreed with making the improvement effort work," Patel says.

Look at storage options. At CHOP, isoproterenol was stored in high-risk areas in several places. The team determined how fewer ampules could be stored without affecting the availability of the drug to high-risk patients. Additionally, medication dispensing station locations were examined, and the team removed isoproterenol from code trays due to drug's availability with the automated dispensing systems. The result was 159 fewer ampules stored.

Recognize other departments. The next steps for this project team include reducing isoproterenol waste in other areas of the hospital, as well as the waste of other medications. "We are taking a strategic method to optimize data analytics, match patterns of waste reduction across other drugs and settings, and engage stakeholders for continued waste and inefficient drug use reduction," Patel says.

Outcomes

  • $1.2 million drug spend savings
  • $1.4 million annual waste cost reduction

Send questions or comments to magazine@childrenshospitals.org.