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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.”