Tag Archive for: quality improvement

doctor listening to girl's heart

Decision support tool for chest pain reduces unnecessary cardiology referrals

doctor listening to girl's heart

A new study in the journal Medical Decision Making reports how well a new decision-support tool assisted pediatricians to apply validated criteria and reduce referrals to cardiology for children with chest pain.

In 2017, cardiologists from Children’s National Hospital and other centers published criteria to reliably detect risk for cardiac disease in children presenting with chest pain. However, despite the validated criteria published more than three years ago, as many as half of the children with chest pain who are referred to cardiology from a primary care doctor continue not to meet these criteria.

In response, the cardiology and Children’s National Pediatricians & Associates (CNP&A) team developed a decision support tool based on the validated criteria that was then incorporated into the CNP&A electronic medical record. A study, Promoting Judicious Primary Care Referral of Patients with Chest Pain to Cardiology: A Quality Improvement Initiative, in the journal Medical Decision Making reports how well the tool assisted pediatricians to apply the criteria and reduced referrals to cardiology for children who do not meet criteria for consultation by a pediatric cardiac specialist.

“As stated by the Institute for Healthcare Improvement, improving the U.S. health care system requires simultaneous pursuit of three aims: improving the experience of care, improving the health of populations and reducing per capita costs of health care. Known as the Triple Aim, such improvement includes reducing referrals to specialists for conditions that could be managed in primary care. Fewer unnecessary referrals can reduce costs by decreasing unnecessary testing and specialist time and also has the potential to improve the patient experience by providing care in the medical home,” the authors note.

The study highlights the results of a focused healthcare improvement initiative that engaged pediatricians, nurses, trainees and nurse practitioners at primary care practices to implement the new decision support tool. With the tool in place, the team saw a 71% reduction (from 17% referred to 5% referred) in cardiology referrals for children presenting to cardiology who did not meet the criteria for a referral. At almost one year of follow up, the reduction in referrals based on the criteria did not lead to any missed detections of potential life-threatening events, either.

“This study shows that patients presenting with chest pain who do not meet clinical criteria for referral can be safely and confidently managed at their medical home by their primary care provider,” says Ashraf Harahsheh, M.D., director of Quality Outcomes in Cardiology at Children’s National Heart Institute, who led the study with colleagues. “Avoiding unnecessary referrals to cardiology may help prevent missed work and school days for families and children and will also make sure that the children who truly need a cardiology evaluation can be evaluated quickly.”

This collaboration between our specialty colleagues and primary care clinicians improves care for our patients by bringing an evidence-based approach to managing a condition in a manner that reduces the burden of anxiety for families by addressing their concerns in their medical home,” adds Ellen Hamburger, M.D., study co-author and medical director of the Pediatric Health Network.

After the success of the project at Children’s National Hospital in partnership with the CNP&A, the team is now in talks with UPMC Children’s Hospital of Pittsburgh and Phoenix Children’s Care Network to expand the quality improvement initiative to their primary care networks as well.

Ashraf S Harahsheh, Ellen K Hamburger, Lena Saleh, Lexi M Crawford, Edward Sepe, Ariel Dubelman, Lena Baram, Kathleen M Kadow, Christina Driskill, Kathy Prestidge, James E Bost, Deena Berkowitz. Promoting Judicious Primary Care Referral of Patients with Chest Pain to Cardiology: A Quality Improvement Initiative. Med Decis Making. 2021 Mar 3;272989X21991445. Online ahead of print. DOI: 10.1177/0272989X21991445

Baby in the NICU

Quality improvement initiative reduces vancomycin use in NICU

Baby in the NICU

A quality improvement initiative in the Neonatal Intensive Care Unit (NICU) at Children’s National Hospital led to a significant reduction in treatment with intravenous vancomycin, an antibiotic used for resistant gram positive infections, which is often associated with acute kidney injury.

A quality improvement initiative in the Neonatal Intensive Care Unit (NICU) at Children’s National Hospital led to a significant reduction in treatment with intravenous vancomycin, an antibiotic used for resistant gram positive infections, which is often associated with acute kidney injury. The findings, published in the journal Pediatrics, show the initiative reduced vancomycin use in patients by 66%, and the NICU has sustained the reduction for more than a year.

Vancomycin is a broad-spectrum antibiotic often used to treat methicillin-resistant Staphylococcus aureus (MRSA) infection. It’s one of the most commonly prescribed antibiotics in NICUs, but its overuse poses an increased risk of morbidity. Benchmarking data showed that in 2017, vancomycin use at Children’s National Hospital was significantly higher than use at peer institutions, suggesting there was likely an opportunity to optimize use of this drug.

The intervention program was led by Rana Hamdy, M.D., M.S.C.E., M.P.H., an infectious diseases specialist at Children’s National, Lamia Soghier, M.D., medical unit director of the Children’s National NICU, and other team members from neonatologyinfectious diseases, pharmacy, nursing and quality improvement. The team accomplished the prescribing reduction by sequentially implementing a four-step approach involving interdisciplinary team building and provider education, pharmacist-initiated 48-hour time-outs, clinical pathway development and prospective audit with feedback.

“Our interdisciplinary quality improvement team was devoted to this project and implemented interventions that, early on, led not only to reduction in vancomycin use, but to better outcomes in our patients with fewer episodes of vancomycin-associated acute kidney injury,” said Dr. Hamdy. “This led to early buy-in from the prescribers, ultimately changing the culture of antibiotic prescribing in the NICU.”

Following the NICU’s intervention program to improve patient safety, vancomycin use in patients decreased from 112 days of therapy per 1,000 patient-days to 38 days of therapy per 1,000 patient-days. During the intervention program, the researchers noted that this was “the first work to show a significant change in vancomycin-associated acute kidney injury in neonates.”

Four key interventions were sequentially implemented to successfully achieve and sustain the reduction in vancomycin use. Intervention 1 was the development of an interdisciplinary and provider education team that addressed institutional antibiotic prescribing practices. Intervention 2, a pharmacist-initiated 48-hour time-out, involved clinical pharmacists identifying patients who have been on antibiotics for ≥ 48 hours and encouraged their providers to either discontinue vancomycin or to switch to a narrow-spectrum antibiotic. Intervention 3 consisted of the development of new clinical pathways including discontinuing vancomycin in infants at low risk for MRSA. Lastly, intervention 4, antimicrobial stewardship program (ASP) prospective audit and feedback, involved an ASP member reviewing all NICU vancomycin orders and issuing appropriate recommendations for NICU providers and pharmacists to be carried out within 24 hours.

This project was taken on as part of Children’s National Quality Improvement and Leadership Training (QuILT) course sponsored by the Quality & Safety Department. This notable work was highlighted in the 2019 annual Quality and Safety report and by the Magnet® program as an exemplary example of nursing-physician partnership working to improve patient care.

The associated article, “Reducing Vancomycin Use in a Level IV Neonatal Intensive Care Unit,” will be published July 1 in Pediatrics. The lead author is Dr. Rana Hamdy, an infectious diseases specialist and director of the Antimicrobial Stewardship Program. Twenty notable co-authors are also from Children’s National.

Billie Lou Short and Kurt Newman at Research and Education Week

Research and Education Week honors innovative science

Billie Lou Short and Kurt Newman at Research and Education Week

Billie Lou Short, M.D., received the Ninth Annual Mentorship Award in Clinical Science.

People joke that Billie Lou Short, M.D., chief of Children’s Division of Neonatology, invented extracorporeal membrane oxygenation, known as ECMO for short. While Dr. Short did not invent ECMO, under her leadership Children’s National was the first pediatric hospital to use it. And over decades Children’s staff have perfected its use to save the lives of tiny, vulnerable newborns by temporarily taking over for their struggling hearts and lungs. For two consecutive years, Children’s neonatal intensive care unit has been named the nation’s No. 1 for newborns by U.S. News & World Report. “Despite all of these accomplishments, Dr. Short’s best legacy is what she has done as a mentor to countless trainees, nurses and faculty she’s touched during their careers. She touches every type of clinical staff member who has come through our neonatal intensive care unit,” says An Massaro, M.D., director of residency research.

For these achievements, Dr. Short received the Ninth Annual Mentorship Award in Clinical Science.

Anna Penn, M.D., Ph.D., has provided new insights into the central role that the placental hormone allopregnanolone plays in orderly fetal brain development, and her research team has created novel experimental models that mimic some of the brain injuries often seen in very preterm babies – an essential step that informs future neuroprotective strategies. Dr. Penn, a clinical neonatologist and developmental neuroscientist, “has been a primary adviser for 40 mentees throughout their careers and embodies Children’s core values of Compassion, Commitment and Connection,” says Claire-Marie Vacher, Ph.D.

For these achievements, Dr. Penn was selected to receive the Ninth Annual Mentorship Award in Basic and Translational Science.

The mentorship awards for Drs. Short and Penn were among dozens of honors given in conjunction with “Frontiers in Innovation,” the Ninth Annual Research and Education Week (REW) at Children’s National. In addition to seven keynote lectures, more than 350 posters were submitted from researchers – from high-school students to full-time faculty – about basic and translational science, clinical research, community-based research, education, training and quality improvement; five poster presenters were showcased via Facebook Live events hosted by Children’s Hospital Foundation.

Two faculty members won twice: Vicki Freedenberg, Ph.D., APRN, for research about mindfulness-based stress reduction and Adeline (Wei Li) Koay, MBBS, MSc, for research related to HIV. So many women at every stage of their research careers took to the stage to accept honors that Naomi L.C. Luban, M.D., Vice Chair of Academic Affairs, quipped that “this day is power to women.”

Here are the 2019 REW award winners:

2019 Elda Y. Arce Teaching Scholars Award
Barbara Jantausch, M.D.
Lowell Frank, M.D.

Suzanne Feetham, Ph.D., FAA, Nursing Research Support Award
Vicki Freedenberg, Ph.D., APRN, for “Psychosocial and biological effects of mindfulness-based stress reduction intervention in adolescents with CHD/CIEDs: a randomized control trial”
Renee’ Roberts Turner for “Peak and nadir experiences of mid-level nurse leaders”

2019-2020 Global Health Initiative Exploration in Global Health Awards
Nathalie Quion, M.D., for “Latino youth and families need assessment,” conducted in Washington
Sonia Voleti for “Handheld ultrasound machine task shifting,” conducted in Micronesia
Tania Ahluwalia, M.D., for “Simulation curriculum for emergency medicine,” conducted in India
Yvonne Yui for “Designated resuscitation teams in NICUs,” conducted in Ghana
Xiaoyan Song, Ph.D., MBBS, MSc, “Prevention of hospital-onset infections in PICUs,” conducted in China

Ninth Annual Research and Education Week Poster Session Awards

Basic and Translational Science
Faculty:
Adeline (Wei Li) Koay, MBBS, MSc, for “Differences in the gut microbiome of HIV-infected versus HIV-exposed, uninfected infants”
Faculty: Hayk Barseghyan, Ph.D., for “Composite de novo Armenian human genome assembly and haplotyping via optical mapping and ultra-long read sequencing”
Staff: Damon K. McCullough, BS, for “Brain slicer: 3D-printed tissue processing tool for pediatric neuroscience research”
Staff: Antonio R. Porras, Ph.D., for “Integrated deep-learning method for genetic syndrome screening using facial photographs”
Post docs/fellows/residents: Lung Lau, M.D., for “A novel, sprayable and bio-absorbable sealant for wound dressings”
Post docs/fellows/residents:
Kelsey F. Sugrue, Ph.D., for “HECTD1 is required for growth of the myocardium secondary to placental insufficiency”
Graduate students:
Erin R. Bonner, BA, for “Comprehensive mutation profiling of pediatric diffuse midline gliomas using liquid biopsy”
High school/undergraduate students: Ali Sarhan for “Parental somato-gonadal mosaic genetic variants are a source of recurrent risk for de novo disorders and parental health concerns: a systematic review of the literature and meta-analysis”

Clinical Research
Faculty:
Amy Hont, M.D., for “Ex vivo expanded multi-tumor antigen specific T-cells for the treatment of solid tumors”
Faculty: Lauren McLaughlin, M.D., for “EBV/LMP-specific T-cells maintain remissions of T- and B-cell EBV lymphomas after allogeneic bone marrow transplantation”

Staff: Iman A. Abdikarim, BA, for “Timing of allergenic food introduction among African American and Caucasian children with food allergy in the FORWARD study”
Staff: Gelina M. Sani, BS, for “Quantifying hematopoietic stem cells towards in utero gene therapy for treatment of sickle cell disease in fetal cord blood”
Post docs/fellows/residents: Amy H. Jones, M.D., for “To trach or not trach: exploration of parental conflict, regret and impacts on quality of life in tracheostomy decision-making”
Graduate students: Alyssa Dewyer, BS, for “Telemedicine support of cardiac care in Northern Uganda: leveraging hand-held echocardiography and task-shifting”
Graduate students: Natalie Pudalov, BA, “Cortical thickness asymmetries in MRI-abnormal pediatric epilepsy patients: a potential metric for surgery outcome”
High school/undergraduate students:
Kia Yoshinaga for “Time to rhythm detection during pediatric cardiac arrest in a pediatric emergency department”

Community-Based Research
Faculty:
Adeline (Wei Li) Koay, MBBS, MSc, for “Recent trends in the prevention of mother-to-child transmission (PMTCT) of HIV in the Washington, D.C., metropolitan area”
Staff: Gia M. Badolato, MPH, for “STI screening in an urban ED based on chief complaint”
Post docs/fellows/residents:
Christina P. Ho, M.D., for “Pediatric urinary tract infection resistance patterns in the Washington, D.C., metropolitan area”
Graduate students:
Noushine Sadeghi, BS, “Racial/ethnic disparities in receipt of sexual health services among adolescent females”

Education, Training and Program Development
Faculty:
Cara Lichtenstein, M.D., MPH, for “Using a community bus trip to increase knowledge of health disparities”
Staff:
Iana Y. Clarence, MPH, for “TEACHing residents to address child poverty: an innovative multimodal curriculum”
Post docs/fellows/residents:
Johanna Kaufman, M.D., for “Inpatient consultation in pediatrics: a learning tool to improve communication”
High school/undergraduate students:
Brett E. Pearson for “Analysis of unanticipated problems in CNMC human subjects research studies and implications for process improvement”

Quality and Performance Improvement
Faculty:
Vicki Freedenberg, Ph.D., APRN, for “Implementing a mindfulness-based stress reduction curriculum in a congenital heart disease program”
Staff:
Caleb Griffith, MPH, for “Assessing the sustainability of point-of-care HIV screening of adolescents in pediatric emergency departments”
Post docs/fellows/residents:
Rebecca S. Zee, M.D., Ph.D., for “Implementation of the Accelerated Care of Torsion (ACT) pathway: a quality improvement initiative for testicular torsion”
Graduate students:
Alysia Wiener, BS, for “Latency period in image-guided needle bone biopsy in children: a single center experience”

View images from the REW2019 award ceremony.

Preemie Baby

Getting micro-preemie growth trends on track

Preemie Baby

According to Children’s research presented during the Institute for Healthcare Improvement 2018 Scientific Symposium, standardizing feeding practices – including the timing for fortifying breast milk and formula with essential elements like zinc and protein – improves growth trends for the tiniest preterm infants.

About 1 in 10 infants is born before 37 weeks gestation. These premature babies have a variety of increased health risks, including deadly infections and poor lung function.

Emerging research suggests that getting their length and weight back on track could help. According to Children’s research presented during the Institute for Healthcare Improvement 2018 Scientific Symposium, standardizing feeding practices – including the timing for fortifying breast milk and formula with essential elements like zinc and protein – improves growth trends for the tiniest preterm infants.

The quality-improvement project at Children’s National Health System targeted very low birth weight infants, who weigh less than 3.3 pounds (1,500 grams) at birth. These fragile infants are born well before their internal organs, lungs, brain or their digestive systems have fully developed and are at high risk for ongoing nutritional challenges, health conditions like necrotizing enterocolitis (NEC) and overall poor development.

The research team measured progress by tracking the micro-preemies’ mean delta weight Z-score for weight gain, which measures nutritional status.

“In this cohort, mean delta weight Z-scores improved by 43 percent, rising from -1.8 to the goal of -1.0, when we employed an array of interventions. We saw the greatest improvement, 64 percent, among preterm infants who had been born between 26 to 28 weeks gestation,” says Michelande Ridoré, MS, Children’s NICU quality-improvement program lead who presented the group’s preliminary findings. “It’s very encouraging to see improved growth trends just six months after introducing these targeted interventions and to maintain these improvements for 16 months.”

Within Children’s neonatal intensive care unit (NICU), micro-preemies live in an environment that mimics the womb, with dimmed lighting and warmed incubators covered by blankets to muffle extraneous noise. The multidisciplinary team relied on a number of interventions to improve micro-preemies’ long-term nutritional outcomes, including:

  • Reducing variations in how individual NICU health care providers approach feeding practices
  • Fortifying breast milk (and formula when breast milk was not available), which helps these extra lean newborns add muscle and strengthen bones
  • Early initiation of nutrition that passes through the intestine (enteral feeds)
  • Re-educating all members of the infants’ care teams about the importance of standardized feeding and
  • Providing a decision aid about feeding intolerance.

Dietitians were included in the daily rounds, during which the multidisciplinary team discusses each infant’s care plan at their room, and used traffic light colors to describe how micro-preemies were progressing with their nutritional goals. It’s common for these newborns to lose weight in the first few days of life.

  • Infants in the “green” zone had regained their birth weight by day 14 of life and possible interventions included adjusting how many calories and protein they consumed daily to reflect their new weight.
  • Infants in the “yellow” zone between day 15 to 18 of life remained lighter than what they weighed at birth and were trending toward lower delta Z-scores. In addition to assessing the infant’s risk factors, the team could increase calories consumed per day and add fortification, among other possible interventions.
  • Infants in the “red” zone remained below their birth weight after day 19 of life and recorded depressed delta Z-scores. These infants saw the most intensive interventions, which could include conversations with the neonatologist and R.N. to discuss strategies to reverse the infant’s failure to grow.

Future research will explore how the nutritional interventions impact newborns with NEC, a condition characterized by death of tissue in the intestine. These infants face significant challenges gaining length and weight.

Institute for Healthcare Improvement 2018 Scientific Symposium presentation

  • “Improved growth of very low birthweight infants in the neonatal intensive care unit.”

Caitlin Forsythe, MS, BSN, RNC-NIC, NICU clinical program coordinator, Neonatology, and lead author; Michelande Ridoré, MS, NICU quality-improvement program lead; Victoria Catalano Snelgrove, RDN, LD, CNSC, CLC, pediatric clinical dietitian; Rebecca Vander Veer, RD, LD, CNSC, CLC, pediatric clinical dietitian; Erin Fauer, RDN, LD, CNSC, CLC, pediatric clinical dietitian; Judith Campbell, RNC, IBCLC, NICU lactation consultant; Eresha Bluth, MHA, project administrator; Anna Penn, M.D., Ph.D., neonatologist; Lamia Soghier, M.D., MEd, Medical Unit Director, Neonatal Intensive Care Unit; and Mary Revenis, M.D., NICU medical lead on nutrition and senior author; all of Children’s National Health System.

inhaler

Keeping kids with asthma out of the hospital

inhaler

Pediatric asthma takes a heavy toll on patients and families alike. Affecting more than 7 million children in the U.S., it’s the most common nonsurgical diagnosis for pediatric hospital admission, with costs of more than $570 million annually. Understanding how to care for these young patients has significantly improved in the last several decades, leading the National Institutes of Health (NIH) to issue evidence-based guidelines on pediatric asthma in 1990. Despite knowing more about this respiratory ailment, overall morbidity – measured by attack rates, pediatric emergency department visits or hospitalizations – has not decreased over the last decade.

“We know how to effectively treat pediatric asthma,” says Kavita Parikh, M.D., M.S.H.S., a pediatric hospitalist at Children’s National Health System. “There’s been a huge investment in terms of quality improvements that’s reflected in how many papers there are about this topic in the literature.”

However, Dr. Parikh notes, most of those quality-improvement papers do not focus on inpatient discharge, a particularly vulnerable time for patients. Up to 40 percent of children who are hospitalized for asthma-related concerns come back through the emergency department within one year. One-quarter of those kids are readmitted.

“It’s clear that we need to do better at keeping kids with asthma out of the hospital. The point at which they’re being discharged might be an effective time to intervene,” Dr. Parikh adds.

To determine which interventions hold promise, Dr. Parikh and colleagues recently performed a systematic review of studies involving quality improvements after inpatient discharge. They published their findings in the May 2018 edition of the journal, Pediatrics. Because May is National Asthma and Allergy Awareness month, she adds, it’s a timely fit.

The researchers combed the literature, looking for research that tested various interventions at the point of discharge for their effect on hospital readmission anywhere from fewer than 30 days after discharge to up to one year later. They specifically searched for papers published from 1991, the year after the NIH issued its original asthma care guidelines, until November 2016.

Their search netted 30 articles that met these criteria. A more thorough review of each of these studies revealed common themes to interventions implemented at discharge:

  • Nine studies focused on standardization of care, such as introducing or revising a specific clinical pathway
  • Nine studies focused on education, such as teaching patients and their families better self-management strategies
  • Five studies focused on tools for discharge planning, such as ensuring kids had medications in-hand at the time of discharge or assigning a case manager to navigate barriers to care and
  • Seven studies looked at the effect of multimodal interventions that combined any of these themes.

When Dr. Parikh and colleagues examined the effects of each type of intervention on hospital readmission, they came to a stunning conclusion: No single category of intervention seemed to have any effect. Only multimodal interventions that combined multiple categories were effective at reducing the risk of readmission between 30 days and one year after initial discharge.

“It’s indicative of what we have personally seen in quality-improvement efforts here at Children’s National,” Dr. Parikh says. “With a complex condition like asthma, it’s difficult for a single change in how this disease is managed to make a big difference. We need complex and multimodal programs to improve pediatric asthma outcomes, particularly when there’s a transfer of care like when patients are discharged and return home.”

One intervention that showed promise in their qualitative analysis of these studies, Dr. Parikh adds, is ensuring patients are discharged with medications in hand—a strategy that also has been examined at Children’s National. In Children’s focus groups, patients and their families have spoken about how having medications with them when they leave the hospital can boost compliance in taking them and avoid difficulties is getting to an outside pharmacy after discharge. Sometimes, they have said, the chaos of returning home can stymie efforts to stay on track with care, despite their best efforts. Anything that can ease that burden may help improve outcomes, Dr. Parikh says.

“We’re going to need to try many different strategies to reduce readmission rates, engaging different stakeholders in the inpatient and outpatient side,” she adds. “There’s a lot of room for improvement.”

In addition to Dr. Parikh, study co-authors include Susan Keller, MLS, MS-HIT, Children’s National; and Shawn Ralston, M.D., M.Sc., Children’s Hospital of Dartmouth-Hitchcock.

Funding for this work was provided by the Agency for Healthcare Research and Quality (AHRQ) under grant K08HS024554. The content is solely the responsibility of the authors and does not necessarily represent the official views of AHRQ.

Doctor-putting-mask-on

Promoting a culture of safety with 10,000 good catches

Doctor-putting-mask-on

In today’s fast-paced health care environment, it has become increasingly important to create a culture of safety where improvement opportunities are recognized and welcomed. With medical errors cited as the one of the leading causes of morbidity and mortality in the United States, health care organizations are working to rapidly identify and respond to errors before long-term issues develop.

Improving event reporting is a critical step. To create an effective culture of safety, employees from throughout a hospital or health system must be empowered. They must be educated and have the ability to easily raise awareness of potential problems and risks and they must be able to proactively resolve problems. With this mindset, Children’s National Health System set out to double the number of voluntary safety event reports submitted over a three-year period; the intent was to increase reliability and promote safety culture by hardwiring employee event reporting. With the goal of growing from 4,668 reports in fiscal year 2014 to 9,336 in 2017, the initiative became known as 10,000 Good Catches. And, the positive framing of the endeavor added to a sense of ownership and reporting among staff members.

Following a Donabedian quality improvement framework of structure, process and outcomes, Children’s National formed a multidisciplinary team and identified three key areas for improvement:

  1. Technology: Make reporting user-friendly, fast and easy
  2. Safe to Report: Create a non-punitive environment in which staff feel secure reporting safety events
  3. Makes a Difference: Develop a culture and system to provide feedback and advance meaningful improvements stemming from safety event reporting

Over the next three years, the team, via subcommittees, routinely solicited feedback from front-line users and met as a larger group monthly to propose interventions, review quantitative data and prioritize next steps. In tandem, employees were educated through internal communications on how, what and when to report. The primary outcome measure was the number of safety event reports submitted through the electronic reporting platform. Event report submission time, number of departments submitting events and percent of safety event reports submitted anonymously were also tracked.

These efforts paid off, as Children’s National more than doubled the number of voluntary safety event reports filed over the three-year period from 4,668 in fiscal year 2014 to 10,971 in 2017, with steady annual improvements. Other metrics included decreased event reporting time and anonymous reports. Interestingly, there was a marked increase in the number of departments submitting reports.

This successful initiative not only resulted in increased safety reporting and engagement, but was an important step toward improving organizational reliability and building a culture of safety first. Future steps will focus on how to sustain improvement, how to more efficiently leverage reporting data and how to apply the data to prevent future safety events.

Baby in the NICU

Reducing harm, improving quality in the NICU

Baby in the NICU

American health care is some of the most expensive in the world. To help make it more affordable, numerous efforts in all areas of medicine – from cancer care to primary care to specialized pediatrics – are focused on finding ways to improve quality and patient safety while also cutting costs.

About half a million babies born in the United States – or 10 percent to 15 percent of U.S. births – end up in the neonatal intensive care unit (NICU), most due to prematurity and very low birth weights. These vulnerable babies often need respiratory support in the form of a ventilator, which supplies oxygen to their lungs with a plastic endotracheal tube (ETT).

The typical care for these infants often involves frequent X-rays to verify the proper position of the tube. However, the American Academy of Pediatrics has counseled health care providers that ordering a daily chest X-ray simply to verify positioning of the ETT ratchets up costs without improving patient safety.

A quality-improvement initiative by Children’s National Health System’s NICU finds that these chest X-rays can be performed just twice weekly, lessening the chances of a breathing tube popping out accidentally, reducing infants’ exposure to radiation and saving an estimated $1.6 million per year.

“The new Children’s National protocol reduced the rate of chest X-rays per patient day without increasing the rate of unintended extubations,” says Michelande Ridoré, M.S., program lead in Children’s division of neonatology, who presented the research during the 2017 American Academy of Pediatrics (AAP) national conference. “That not only helps to improve patient safety – for newborns who are admitted to the NICU for longer periods, there is the additional benefit of providing significant savings to the health care system.”

Children’s NICU staff assessed how many chest X-rays were being performed per patient day before and after the protocol change, which applied to all intubated newborns in the NICU whose health condition was stable. Newborns had been undergoing a median of 0.45 chest X-rays per patient day. After the quality improvement project, that figure dropped to 0.23 chest X-rays per patient day.

When the project started in July 2015, the NICU’s monthly X-ray expenditure was $289,520. By the end of 2015, that monthly X-ray spend had fallen to $159,424 – resulting in nearly $1.6 million in annual savings.

The more restrictive strategy for ordering chest X-rays was a core component of a broader quality improvement effort aimed at lowering the number of unplanned extubations, which represent the fourth most common complication experienced by newborns in the nation’s NICUs.

“When you reduce the frequency of patients in the unit being moved, you decrease the chances of the breathing tube coming out accidentally,” Ridoré says. “By reducing unplanned extubations in the NICU, we can improve overall clinical outcomes, reduce length of stay, lower costs and improve patient satisfaction.”

When a breathing tube is accidentally dislodged, newborns can experience hypoxia (oxygen deficiency), abnormally high carbon dioxide levels in the blood, trauma to their airway, intraventricular hemorrhage (bleeding into the fluid-filled areas of the brain) and code events, among other adverse outcomes. What’s more, a patient with an unintended extubation can experience a nearly doubled hospital stay compared with the length of stay for newborns whose breathing tubes remain in their proper places. Each unplanned extubation can increase the cost of care by $36,000 per patient per admission.

To tackle this problem, Children’s National created the Stop Unintended Extubations “SUN” team. The team created a package of interventions for high-risk patients. Within one month, unintended extubations dropped from 1.18 events per 100 ventilator days to 0.59 events during the same time frame. And, within five months, that plummeted even further to 0.41 events per 100 ventilator days.

Their ultimate goal is to whittle that rate down even further to 0.3 events per 100 ventilator days, which has occurred sporadically. And the NICU notched up to 75 days between unintended extubations.

“Unintended extubation rates at Children’s National are lower than the median reported on various quality indices, but we know we can do more to enhance patient safety,” Ridoré says. ”Our SUN team will continue to address key drivers of this quality measure with the aim of consistently maintaining this rate at no more than 0.3 events per 100 ventilator days.”