Reducing NICU Unplanned Extubations From Tube Dislodgement.

OBJECTIVES: Unplanned extubations (UEs) can be a frequent problem and are associated with adverse outcomes. This quality improvement initiative sought to reduce UEs from tube dislodgement in a level IV NICU utilizing methods applicable to other ICUs and performed with minimal monetary funds. METHODS: From January 2019 to July 2023, an interdisciplinary quality improvement team used the Model for Improvement and performed sequential interventions to improve the outcome measure of UEs per 100 ventilator days. Process measures included adherence to a modified, site-specific UE care bundle derived from the Solutions for Patient Safety network, whereas the number of endotracheal tube-related pressure injuries was used as a balancing measure. Statistical process control charts and established rules for special cause variation were applied to analyze data. RESULTS: Sequential interventions reduced the rate of UEs from a baseline of 2.3 to 0.6 UEs per 100 ventilator days. Greater than 90% adherence with the UE care bundle and apparent cause analysis form completion occurred since December 2020. There were no endotracheal tube-related pressure injuries. CONCLUSIONS: A sustained reduction in UEs was demonstrated. Leveraging a multidisciplinary team allowed for continuous UE analysis, which promoted tailored consecutive interventions. UE care bundle audits and the creation of a postevent debrief guide, which helped providers share a common language, were the most impactful interventions. Next steps include disseminating these interventions to other ICUs across our hospital enterprise. These low-cost interventions can be scalable to other NICUs and PICUs.

A quality improvement initiative to reduce antibiotic use in transient tachypnea of the newborn.

OBJECTIVE: Evidence suggests that antibiotics are unnecessary in infants with transient tachypnea of the newborn (TTN) that are low-risk for early-onset sepsis. The aim was to reduce ampicillin and gentamicin days of therapy (DOT) in infants with suspected TTN by 10% within 12 months. STUDY DESIGN: We used the Model for Improvement to test interventions from August 2019 to September 2021 to decrease antibiotic utilization in low-risk infants with TTN. Interventions included the creation of an evidence-based clinical pathway, admission huddles, and prescriber audit and feedback. RESULTS: We reduced ampicillin and gentamicin use by 26% and 23%, respectively. In 123 infants with suspected TTN, we sequentially decreased starting antibiotics in this group from 71% to 41%, 13% and 0%. There were no cases of missed bacteremia. CONCLUSION: Creation of a multidisciplinary antimicrobial stewardship QI team and subsequent interventions were successful in safely reducing antibiotic use in infants with TTN.

Factors Correlated With Successful Pediatric Post-Discharge Phone Call Attempt and Connection.

OBJECTIVES: Postdischarge phone calls can identify discharge errors and gather information following hospital-to-home transitions. This study used the multisite Project IMPACT (Improving Pediatric Patient Centered Care Transitions) dataset to identify factors associated with postdischarge phone call attempt and connectivity. METHODS: This study included 0- to 18-year-old patients discharged from 4 sites between January 2014 and December 2017. We compared demographic and clinical factors between postdischarge call attempt and no-attempt and connectivity and no-connectivity subgroups and used mixed model logistic regression to identify significant independent predictors of call attempt and connectivity. RESULTS: Postdischarge calls were attempted for 5528 of 7725 (71.6%) discharges with successful connection for 3801 of 5528 (68.8%) calls. Connection rates varied significantly among sites (52% to 79%, P < .001). Age less than 30 days (P = .03; P = .01) and age 1 to 6 years (P = .04; P = .04) were independent positive predictors for both call attempt and connectivity, whereas English as preferred language (P < .001) and the chronic noncomplex clinical risk group (P = .02) were independent positive predictors for call attempt and connectivity, respectively. In contrast, readmission within 3 days (P = .004) and federal or state payor (P = .02) were negative independent predictors for call attempt and call connectivity, respectively. CONCLUSIONS: This study suggests that targeted interventions may improve postdischarge call attempt rates, such as investment in a reliable call model or improvement in interpreter use, and connectivity, such as enhanced population-based communication.

Improving Documentation of Postdischarge Issue Mitigation during Postdischarge Phone Calls.

Postdischarge phone calls (PDPCs) are recommended to identify and mitigate postdischarge issues such as missed follow-up appointments, medication errors, and failure to activate contingency plans. A current state assessment showed variability in documenting PDPC content and postdischarge issue mitigation. Therefore, the primary aim was to improve the postdischarge issue mitigation documentation rate from 65% to 100% over 16 months. Methods: An interdisciplinary quality improvement team used the Model for Improvement to perform planned sequential interventions over 16 months. The outcome measure was documentation of postdischarge issue mitigation. Process measures included PDPC template use and completion and postdischarge issue identification. Balancing measures included call attempts and caller perceptions of ease of documentation. Interventions included creating a flowsheet note template, creating caller template training sessions, and sharing team data and feedback. We gathered data via reports generated from the electronic medical record, chart review, and survey. Data were analyzed using statistical process control charts and established rules for detecting special cause variation. Results: The postdischarge issue mitigation documentation increased from 65% to 91% over 16 months. Template use and completion increased from 0% to 100% and 98%, respectively. The number of postdischarge issues identified remained unchanged. Call attempts increased from 40% to 59%. Caller perceptions remained unchanged. Conclusions: Documentation of postdischarge issues and issue mitigation promotes adequate communication with the patient's care providers, improving the quality and safety of care. Data sharing to promote team engagement was the key factor in improving documentation of postdischarge issue mitigation.

Improving Caregiver Understanding of Liquid Acetaminophen Administration at Primary Care Visits.

OBJECTIVES: Liquid medication dosing errors are common in pediatrics. Our outpatient clinic identified gaps in caregiver education based on a 2015 American Academy of Pediatrics policy statement on prescribing liquid medications. This quality improvement (QI) initiative sought to improve caregiver's understanding of liquid acetaminophen administration at the 2-month well-child visit from 30% to 70% over a 32-month period. METHODS: A resident-led interdisciplinary QI team performed sequential interventions to improve our outcome measure: the percentage of caregivers with an adequate understanding of 4 essential components of liquid acetaminophen administration (name, indication, dose, and frequency). Outcome data were collected via a 4-item verbal assessment of caregiver's understanding by nursing staff, with correct answers to all items considered adequate understanding. Process measures (medications prescribed and education provided), and balancing measures (anticipatory guidance items discussed) were gathered via electronic health record review. Shewhart "P" charts and established rules for detecting special cause variation were used to analyze data. Scatter plots assessed the association between the provision of syringes and caregiver understanding of medication administration. RESULTS: In 636 caregivers, overall understanding of medication use improved from 39.8% to 74%. Knowledge of accurate dosage improved from 50.9% to 76.8%. Correlation between syringe provision and caregiver understanding was strong (R = .84). CONCLUSIONS: Resident-led QI improved caregiver's understanding of liquid acetaminophen administration in infants. The most impactful interventions were implementation of English and Spanish pictograms and provision of dose-demarcated oral syringes, coupled with teach-back. Future interventions will examine generalizability to other medications and expansion to other services.

Improving Antibiotic Stewardship for Inpatients with Reported Beta-Lactam Allergies and Limited Access to Penicillin Skin Testing.

BACKGROUND: Penicillin allergy is commonly reported, but true allergy is rare. Inpatients with reported beta-lactam allergy are often treated with alternative antibiotics. Penicillin skin testing (PST) is not universally available for inpatients. METHODS: We designed a four-phase quality improvement project aimed to increase the percentage of inpatients on medical services with reported beta-lactam allergy who safely receive beta-lactam antibiotics at two hospitals with limited access to PST. First, we updated our hospital guideline to allow for cephalosporin graded challenge without antecedent PST. Second, we educated physicians, physician assistants, and nurses about the new guideline and beta-lactam allergy classification and management. Third, we designed a pocket card to reinforce the education. Last, we used antimicrobial stewardship software to screen our daily census to identify opportunities to improve management of patients with reported beta-lactam allergies. RESULTS: We observed a 29.2% increase in the percentage of patients who received beta-lactam antibiotics (excluding carbapenems) among those with reported beta-lactam allergy, from 42.2% (470/1,115) at baseline to 54.5% (379/696), p < 0.001, during the project period. There was a decrease in the use of alternative antibiotics, no change in hospital-onset Clostridioides difficile cases, and no increase in the number of infectious disease or allergy consults. The number of graded challenges increased during the project period, without any anaphylaxis events. CONCLUSION: A multiphase quality improvement project aimed to improve management of beta-lactam allergies and access to graded challenges led to an increase in beta-lactam utilization without an increase in anaphylaxis, even with limited access to PST.

Factorial Analysis Quantifies the Effects of Pediatric Discharge Bundle on Hospital Readmission.

BACKGROUND AND OBJECTIVES: Factorial design of a natural experiment was used to quantify the benefit of individual and combined bundle elements from a 4-element discharge transition bundle (checklist, teach-back, handoff to outpatient providers, and postdischarge phone call) on 30-day readmission rates (RRs). METHODS: A 24 factorial design matrix of 4 bundle element combinations was developed by using patient data (N = 7725) collected from January 2014 to December 2017 from 4 hospitals. Patients were classified into 3 clinical risk groups (CRGs): no chronic disease (CRG1), single chronic condition (CRG2), and complex chronic condition (CRG3). Estimated main effects of each bundle element and their interactions were evaluated by using Study-It software. Because of variation in subgroup size, important effects from the factorial analysis were determined by using weighted effect estimates. RESULTS: RR in CRG1 was 3.5% (n = 4003), 4.1% in CRG2 (n = 1936), and 17.6% in CRG3 (n = 1786). Across the 3 CRGs, the number of subjects in the factorial groupings ranged from 16 to 674. The single most effective element in reducing RR was the checklist in CRG1 and CRG2 (reducing RR by 1.3% and 3.0%) and teach-back in CRG3 (by 4.7%) The combination of teach-back plus a checklist had the greatest effect on reducing RR in CRG3 by 5.3%. CONCLUSIONS: The effect of bundle elements varied across risk groups, indicating that transition needs may vary on the basis of population. The combined use of teach-back plus a checklist had the greatest impact on reducing RR for medically complex patients.

Simulation-Based Discharge Education Program for Caregivers of Children With Tracheostomies.

OBJECTIVES: To design, implement, and evaluate a simulation-based education (SBE) program for caregivers of children with tracheostomy. METHODS: Self-reported comfort and confidence in knowledge as well as tracheostomy care skills were assessed before and after a single SBE session for 24 consecutively enrolled caregivers of children with tracheostomies aged <21 years who were hospitalized at an academic medical center from August 2018 to September 2019 by using a survey and checklist, respectively. Mean individual and aggregated scores were compared by using a paired samples t-test, and association between instruments was determined with Spearman correlation. RESULTS: Post-SBE, there was a significant improvement in both self-reported comfort and confidence (P < .001) and checklist assessment of most tracheostomy care skills (P < .001). There were no significant correlations between caregivers' self-reported comfort and confidence and skills pre-SBE (ρ = 0.13) or post-SBE (ρ = 0.14). Cronbach's α coefficients for the survey ranged from 0.93 to 0.95 and for the checklist from 0.58 to 0.67. Seventeen percent of caregivers competently completed the entire checklist post-SBE, with most caregivers missing 1 or 2 critical skills such as obturator removal after tracheostomy insertion. CONCLUSIONS: In this pilot study, we demonstrated successful design and implementation of an SBE program for caregivers of children with tracheostomies, revealing improvements in self-reported comfort and confidence as well as in their performance of tracheostomy care skills. Further optimization is needed, and caregivers may benefit from additional SBE sessions to achieve complete skills competency. Future research on the long-term impact of SBE and the peer-to-peer support element of the program is needed.

A TeamSTEPPS® implementation plan for recently assigned interns and nurses.

Interns and newly assigned nurses are expected to assimilate rapidly and begin functioning as members of interprofessional teams. This mixed-method pilot research assessed the impact of a Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS®) implementation plan in an urban academic teaching hospital that included a cohort of newly assigned pediatric interns and nurses (N = 23). We collected pre- and post-intervention course knowledge and team performance data from two teams in two separate simulation cases. We also surveyed the learners using an open-ended survey to ask about the value of their interprofessional learning experience. TeamSTEPPS® course knowledge improved from pre- to post-intervention (p < 0.001). Team performance scores were tallied and descriptively compared between pre- and post-intervention. Teams performed higher in both post-intervention simulation cases than in the pre-assessments. Post-intervention groups were assessed scores of 4 and 5 in more areas of the team performance checklist. Knowledge scores were compared between pre- and post- intervention by a Wilcoxon rank-sum test. Median scores improved from 17 to 20 following the intervention. Six themes emerged from the coding process that expressed a learned appreciation for contributing to a culture where the expectation is that team members speak up to support patient safety and other team members. As shown by this pilot research, TeamSTEPPS® training approaches that follow the 4-phase brain-based lesson plan for simulation and include interprofessional membership can be promising for integrating newly assigned members into existing clinical teams.

A Saturated Approach to the Four-Phase, Brain-Based Simulation Framework for TeamSTEPPS® in a Pediatric Medicine Unit.

INTRODUCTION: Although many organizations have reported successful outcomes as a result of Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS), implementation can be challenging, with its share of administrative obstacles and lack of research that shows observable change in practice. METHODS: This quantitative, pretest/posttest design pilot research used a combination of classroom simulation-based instruction and in situ simulation in a Pediatrics department in an urban academic center. All personnel with direct patient care responsibilities (n = 547) were trained in TeamSTEPPS in an 8-week period. TeamSTEPPS course knowledge scores were compared pretraining to posttraining using the Wilcoxon rank-sum test. The performance of two-day and overnight shift teams, pre- and postintervention was assessed using the TeamSTEPPS Team Performance Observation Tool. RESULTS: TeamSTEPPS course knowledge improved from the beginning of the course to completion with median scores of 16 and 19, respectively (P < 0.001). Both day and evening postintervention groups demonstrated greater team performance scores than their control counterparts. Specifically, postintervention day shift team showed the greatest improvement and demonstrated more TeamSTEPPS behaviors. CONCLUSION: This pilot study involving 1 department in an urban hospital showed that TeamSTEPPS knowledge and performance could be improved to increase patient safety and reduce medical errors. However, teams need to be trained within a shorter period so they can apply a shared-model of teamwork and communication. Leaders and educators throughout the department must also reinforce the behaviors and include them in every education intervention.

Project IMPACT Pilot Report: Feasibility of Implementing a Hospital-to-Home Transition Bundle.

BACKGROUND AND OBJECTIVES: To improve hospital to home transitions, a 4-element pediatric patient-centered transition bundle was developed, including: a transition readiness checklist; predischarge teach-back education; timely and complete written handoff to the primary care provider; and a postdischarge phone call. The objective of this study was to demonstrate the feasibility of bundle implementation and report initial outcomes at 4 pilot sites. Outcome measures included postdischarge caregiver ability to teach-back key home management information and 30-day reuse rates. METHODS: A multisite, observational time series using multiple planned sequential interventions to implement bundle components with non-technology-supported and technology-supported patients. Data were collected via electronic health record reviews and during postdischarge phone calls. Statistical process control charts were used to assess outcomes. RESULTS: Four pilot sites implemented the bundle between January 2014 and May 2015 for 2601 patients, of whom 1394 had postdischarge telephone encounters. Improvement was noted in the implementation of all bundle elements with the transitions readiness checklist posing the greatest feasibility challenge. Phone contact connection rates were 69%. Caregiver ability to teach-back essential home management information postdischarge improved from 18% to 82%. No improvement was noted in reuse rates, which differed dramatically between technology-supported and non-technology-supported patients. CONCLUSIONS: A pediatric care transition bundle was successfully tested and implemented, as demonstrated by improvement in all process measures, as well as caregiver home management skills. Important considerations for successful implementation and evaluation of the discharge bundle include the role of local context, electronic health record integration, and subgroup analysis for technology-supported patients.

Risk factors for unexplained medication discrepancies during transitions in care.

BACKGROUND AND OBJECTIVES: Unexplained discrepancies between patient reported- and physician-prescribed medication regimens are an important source of potential harm to patients after hospital discharge. However, there are limited data available identifying risk factors associated with discrepancies in medications. Our objective was to describe the epidemiology of unexplained medication discrepancies and identify patient risk factors for these discrepancies. METHODS: This prospective observational study is part of a larger study conducted from August 2009 to February 2011 in an academic hospital and affiliated office practices. We compared medication lists from hospital discharge, the first ambulatory visit, and patient self-report. Medication lists were gathered from the inpatient and outpatient electronic health records. Demographic and health-related predictor variables were collected through an inpatient survey and chart review. RESULTS: Among 100 patients, 291 unexplained medication discrepancies were identified (31%, n=930). Of these, 98 had high potential for harm (34%). Omitted medications were the most common type of unexplained discrepancy (72%, n=210). In multivariable analysis, having more than five outpatient visits during the previous year and having less than high school education independently predicted a higher number of unexplained discrepancies. Having Medicaid insurance and receiving care from a third-year resident during the first follow-up visit were protective. CONCLUSIONS: Unexplained medication discrepancies are common at the first ambulatory visit post-hospital discharge and underscore the need to maintain accurate medication lists across the continuum of care. Individual-level characteristics may potentially be used to identify patients who need special attention for their medication management.

Assessment of pediatric residents' communication and interpersonal skills during family-centered rounds.

OBJECTIVES: Residency training programs are required to assess and document residents' competency in communication. Multisource evaluations that include direct resident observations are preferred. Previous studies have often used methods of asking faculty members to evaluate residents on behaviors they did not witness. METHODS: Twenty first year pediatric residents (interns) were evaluated preand post-FCR introduction by a faculty member, a parent, and a nurse after the encounter with the patients and their families during rounds. All participants used the CAT. Mean CAT scores and associations between the evaluator groups were determined. RESULTS: Nurses and faculty were significantly more likely to observe how interns communicated with the parents in the post-FCR period (P < .001). Pre-FCR, compared to parent scores, intern scores were significantly lower (P < .05) and the scores were not correlated (P = .84). Post-FCR, the difference in internparent scores disappeared and their scores were significantly correlated (r18 = 0.73, P < .001). Intern scores did not correlate with faculty and nurse scores. Cronbach a coefficients for the CAT ranged from 0.90 to 0.99. CONCLUSIONS: Family-centered rounds provide more opportunities for direct observation of residents' competence in accordance with Accreditation Council for Graduate Medical Education guidelines. This rounds format also encourages a climate that improves residents' ability to self-assess. Residents' communication skills can be assessed by using the Communication Assessment Tool in an efficient and timely manner, because all evaluators are present at the bedside during family-centered rounds.

Effects of implementing family-centered rounds (FCRs) in a neonatal intensive care unit (NICU).

OBJECTIVES: (1) Evaluate impact of FCR on provider satisfaction and collaboration. (2) Evaluate impact of FCR on parent satisfaction with provider communication. METHODS: Collaboration and Satisfaction about Care Decisions (CSACD) questionnaire was given to staff on 4 patients 2 days a week for 5 weeks prior to and 6 months after implementation of FCR. Parents received a Parents Stress Scale and Neonatal Instrument of Parent Satisfaction before discharge, prior to and 6 months after starting FCR. RESULTS: 278/288 (97%) staff surveys were completed, 142 pre and 136 post. On the CSACD survey NNPs and fellows showed increased (p < 0.05) collaboration and satisfaction post FCR. No group had decreased satisfaction. Twenty-eight of 45 (62%) parent surveys were completed, 12 pre and 16 post. Parents' satisfaction scores increased (p < 0.01) pre vs. post on survey items regarding communication, meeting with physicians, and obtaining information about their infants. CONCLUSIONS: FCR was associated with enhanced collaboration among team members for NNPs and fellows. Parents' satisfaction scores increased post FCR on survey items regarding communication. Since NNPs and fellows are the primary communicators with parents, the increased satisfaction may reflect improved communication due to FCR. This added opportunity for open dialogue may also contribute to the increased parent satisfaction.