Quality and Safety

Stanley Thomas Fricke

Using IR imaging to improve lead apron inspection

Stanley Thomas Fricke

“When I researched how lead aprons are inspected, I learned that a combination of tactile and visual inspection is considered the gold standard. But many of the smallest holes can be missed this way,” says Stanley Thomas Fricke, Nucl. Eng., Ph.D., radiation safety officer at Children’s National Health System and study senior author.

Workers inspecting the lead aprons that shield patients from radiation during imaging tend to use tactile and visual inspections to find defects, running their fingers over the aprons since fingertips can detect even subtle changes to a surface. Yet findings from a new study could influence changes in this approach to improve inspection performance and better protect patients and inspectors.

Infrared (IR) thermal imaging is a much better detective, with 50 percent of study participants picking out all holes intentionally drilled into a test apron compared with just 6 percent of participants who detected the same defects using the tactile method, according to research published online Nov. 8, 2017 in Journal of the American College of Radiology. In addition to being a more accurate way to detect subtle defects, the IR imaging technology also reduces ionizing radiation exposure for inspectors checking the protective power of lead aprons.

“When I researched how lead aprons are inspected, I learned that a combination of tactile and visual inspection is considered the gold standard. But many of the smallest holes can be missed this way,” says Stanley Thomas Fricke, Nucl. Eng., Ph.D., radiation safety officer at Children’s National Health System and study senior author. “Unlike the fingertips, infrared light can penetrate the lead apron’s protective outer fabric and illuminate defects that are smaller than the defect size now used to reject a protective apron. This work challenges conventional wisdom and offers an inexpensive, readily available alternative.”

According to the study team, a growing number of health care settings use radiation-emitting imaging, from the operating room to the dentist’s office. Lead aprons and gonadal shields lower radiation doses experienced by health care staff and patients. In compliance with regulators, these protective devices are inspected regularly. A layer of lead inside keeps patients’ exposure to ionizing radiation at the lowest detectable level. The aprons are covered with nylon or polyester fabric for the patients’ comfort and for ease of cleaning.

“It is standard for health care institutions to use a tactile-visual approach to inspect radiation protective apparel,” Fricke says. “While increasingly common, that inspection method can allow aprons with holes and tears to slip by undetected due to the large surface area that needs to be inspected, the outer fabric that encloses the protective apron and other factors.”

Fricke recalled a news clip from years ago about an IR camera used to film swimmers at the pool that, like Superman’s powerful vision, could see through pool-goers’ clothing. The manufacturer quickly recalled the camera. But the IR technology is a perfect fit for inspectors looking for defects hidden under a lead apron’s fabric cover.

To validate this inspection alternative, the team drilled a series of nine holes ranging from 2 mm to 35 mm in diameter into a “phantom” lead apron and enclosed it within fabric that typically covers the protective shielding. The research team stapled the phantom apron to a wooden frame and placed dry wall under the frame.

Two of 31 radiation workers picked out all nine holes by touch and recorded the holes and their locations on written questionnaires.

For the IR method, the team used an infrared light to illuminate the lead apron from behind and relied on an infrared imaging camera to record 10 seconds of video from which still images were exported. Ten of 20 radiation technologists, radiology nurses and medical doctors identified all nine holes using those color photographs and recorded their entries on a questionnaire. An additional 20 percent identified eight of nine intentional defects to the phantom apron.

In both the tactile and IR groups, all participants found the largest hole and correctly recorded its location.

“Using the tactile method for inspection, most staff who work regularly with radiation-emitting devices were able to identify defects that would cause a lead apron to be rejected, which is 11 mm holes for thyroid shields and 15 mm holes for aprons,” Fricke says. “However, it is standard for these well-used aprons to develop smaller holes—which, over time, become bigger holes. Here at Children’s National, we care about every photon that touches a child.”

In the next phase of the research, the team will explore infrared flash photography, cooling the apron material and the impact of high-resolution cameras with greater depth of field.

Rahul Shah

Speaking up for safety: Virginia Hospital and HealthCare Association spotlights culture of reporting at Children’s National Health System

Rahul Shah

Rahul Shah, M.D., Vice President and Chief Quality and Safety Officer at Children’s National recently sat down with VHHA’s REVIEW magazine to share best practices and success strategies.

For Children’s National Health System, fostering a culture of safety meant empowering everyone to play a role, from front line staff to providers to the C-suite. Recently, pediatric quality and safety experts at Children’s National sat down with Virginia Hospital & Health Association (VHHA)’s REVIEW magazine to share best practices, success strategies and leadership from Children’s National in this arena. Rahul Shah, M.D., MBA, Children’s National vice president and chief quality and safety officer, and Lisbeth Fahey, MSN, RN, executive director for quality, safety, accreditation, regulatory and emergency preparedness, discussed how establishing a non-punitive culture of reporting where anyone can raise a concern led to improved safety outcomes.

“Our approach has been to make it fun, make it exciting and to reward people,” said Shah, noting the inverse correlation between reporting frequency and safety results.

Read the full story here (pages 10-12) to learn more about how Children’s National is leading the way in quality and safety and the importance of giving all employees permission to speak up.

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.”

Happy girl in hospital bed surrounded by doctors

Addressing MB-CLABSI through innovation – and dedication – to pediatric safety

Happy girl in hospital bed surrounded by doctors

With mucosal barrier central line-associated blood stream infections (MB-CLABSI) posing a serious risk to cancer and other immunocompromised patients, Children’s National Health System was intent on finding a way to prevent them. Through a focused initiative, the hospital experienced great success, cutting infection rates by more than half.

This was a daunting proposition. Historically MB-CLABSI has not been viewed as a preventable infection due to the side effects typically associated with bone marrow transplants in this patient population. Sores and mucosal disruption that develops in the oral cavity post-transplant are fairly common and make it exceedingly difficult to keep the mouth clean and clear of bacteria. Without regimented oral hygiene in this type of environment, the mouth can quickly develop bacteria putting the patient at risk of a MB-CLABSI.

“We challenged the notion that we could not prevent MB-CLABSI and set out on a journey to try to prevent these types of infections from occurring,” says vice president and chief quality and safety officer, Rahul Shah, M.D. “With leadership from our nursing teams and the infection control and prevention group working together with the physicians, we were able to approach this issue from a unique perspective.”

In 2013, Children’s National launched a MB-CLABSI prevention program focused around saline rinses to improve oral hygiene. The goal was to keep the mouth cleaner to avoid bacteria from forming and ultimately entering the blood stream.

Children’s National put the plan into action through the following measures:

Provider

  • Simplified ordering of saline rinses to increase accountability and compliance with the practice and make it easier for providers
  • Implemented reminders to order saline rinses during daily rounds
  • Added saline rinses to the Medication Administration Record to drive compliance in administration of the task

Administrative

  • Saline rinses were chosen as an indicator to be displayed on public-facing quality boards throughout the hospital
  • Implemented daily audits of the quality board to track opportunities for improving compliance and reducing omissions and errors
  • Standardized daily medical rounds to include review of the quality boards

Patient/Caregiver

  • Implemented discussion of saline rinses of the mouth for oncology and bone marrow transplant patients during daily rounds
  • Standardized education for caregivers of children with central lines

“Through strategic programs like this, our patients are safer and Children’s National continues to be a national pediatric quality leader,” says Dr. Shah.

Children's National Red Badge Project

The Red Badge Project: expediting ED care

Children's National Red Badge Project

A red badge allows newly diagnosed cancer patients and BMT patients to bypass security and triage so they can receive lifesaving antibiotics within an hour of fighting fever.

Chemotherapy and bone marrow transplant procedures leave cancer patients with compromised immune systems, leading many to develop life-threatening infections or other complications. In particular, neutropenia, or abnormally low levels of white blood cells that are critical to fighting off infections, is prevalent among this population. Fever with neutropenia can be fatal.

As part of the Children’s National Health System commitment to deliver better outcomes and safer care through innovative approaches, the Hematology/Oncology/Bone Marrow Transplant (BMT) Family Advisory team developed a protocol to rapidly identify BMT and cancer patients with suspected neutropenia to receive antibiotics within 60 minutes of arriving at the Emergency Department (ED). The Red Badge Project was born with the following goals:

• Decrease the median triage-to-antibiotic time in cancer patients with fever and suspected neutropenia or bone marrow transplant patients to 30 minutes
• Increase the proportion of patients receiving antibiotics within one hour to 90 percent

As part of the protocol, newly diagnosed cancer and bone marrow transplant patients receive a Red Badge and education regarding how to use it. If they run a fever and need medical attention, the patient and family present the Red Badge upon arrival at the ED in order to bypass the welcome desk and ED triage. This action accelerates the process, keeps the child from waiting in an area where there are other sick children and ensures the patient receives lifesaving antibiotics as fast as possible.

Work done before the patient walks through the ED doors contributes to the success of this program. When a patient runs a fever, the family is instructed to call the Hematology Oncology Fellow on-call. If it is determined that the patient needs to come to the ED, the Fellow then: 1) receives the patient’s estimated arrival time so that staff can clean and prep a room 2) reminds them to apply their topical analgesia to numb the port site where the antibiotic will be administered 3) reminds them to bring their Red Badge.

From there, swift action is taken. By the time the patient arrives, he or she has already been registered and the appropriate medications have been ordered. The patient bypasses security and triage using their Red Badge as a visual cue and is then directed to a prepped room complete with medications ready for administration.

To date, the median time from triage to administration of antibiotics has decreased nearly 50 percent while the proportion of patients who received antibiotics within 60 minutes of triage improved to 90 percent.

Leveraging that success, the next step is to develop education for non-English speaking families in order to extend the reach of this lifesaving practice.

Children’s National receives top safety and quality award

John M. Eisenberg Patient Safety and Quality Awar

As part of a collaborative of researchers, hospitalists and medical education specialists, Children’s National Health System was recently recognized with the highest patient safety and quality award in the country: The prestigious John M. Eisenberg Patient Safety and Quality Award. Administered by The Joint Commission and the National Quality Forum (NQF), two leading organizations that set standards in patient care, this award recognizes Children’s commitment to ensure safe and high-quality care for all patients.

The team at Children’s National helped develop a package of interventions used by more than 50 leading hospitals in the U.S. as part of a collaborative initiative called the I-PASS Study Group. The group helps standardize communications during handoffs of patients from one care team to another. This award-winning program was also shown to reduce harmful medical errors in a multi-center study published in the New England Journal of Medicine.

Patient handoffs happen multiple times per day in every hospital in the country, making it vitally important that the process is seamless and free of miscommunications.

Children’s National safety experts share strategies

Rahul Shah

Rahul Shah, M.D., Vice President and Chief Quality and Safety Officer at Children’s National Health System (CNHS), and his team joined pediatric quality and safety leaders from across the country in Orlando, Fla. for the Children’s Hospital Association’s 2017 Quality & Safety in Children’s Health Conference.

Earlier this month, Rahul Shah, M.D., Vice President and Chief Quality and Safety Officer at Children’s National Health System (CNHS), and his team joined pediatric quality and safety leaders from across the country in Orlando, Fla. for the Children’s Hospital Association’s 2017 Quality & Safety in Children’s Health Conference. Dr. Shah shared findings and strategies that have led Children’s National to be a leader in this field, and collaborated with peers to move the needle on pediatric safety in hospitals and improving the quality of care hospitals deliver.

Notable presentations from the Children’s National team included:

  • The Children’s National utilization of a safety culture survey called the Safety Attitude Questionnaire (SAQ), and the crucial role of ensuring leadership alignment in the survey process. Obtaining leadership buy-in and alignment allowed Children’s to accelerate the spread of identified opportunities for improvement within the organization.
  • The importance of an ongoing multi-disciplinary approach to care for psychiatry patients, a patient population that that continues to increase in American pediatric healthcare and requires innovative approaches. Children’s National team members emphasized the importance of training the hospital’s security teams and front-line caregivers in therapeutic interventions to seek optimal outcomes for patients, while respecting the complexity of their diagnoses.
  • How to drive reliability through apparent cause analyses. Kristen Crandall, Director of Patient Safety at Children’s National, shared examples of how to leverage data to effectively drive change in cause analyses. Cause analyses are fundamental tools for implementing improvement. The team highlighted the upcoming launch of a High Reliability Toolkit© developed at CNHS to ensure that action plans created from cause analyses are of adequate depth and sophistication to drive improvements.

Dr. Shah and his team also had the honor of delivering an Impact session on the final day of the conference, in which they discussed the applications of merging patient safety with patient experience. The team also shared the Children’s National approach to safety and service, which includes delivering a unified framework of high reliability through consistent messaging to demonstrate that when safety and service integrate and align, the sum is greater than the parts.