Continuous positive airway pressure care for pediatric obstructive sleep apnea: A long-term quality improvement initiative.

Successful treatment of pediatric obstructive sleep apnea syndrome (OSAS) with continuous positive airway pressure (CPAP) is challenging due to behavioral, technical, medical, and systems factors. We undertook a quality improvement (QI) initiative involving physicians, nurses, psychologists, and respiratory therapists to improve CPAP outpatient care and processes. We aimed to: (1) increase the proportion of patients with a follow-up visit within 4 months of initiation of CPAP, (2) reduce the median time to first follow-up visit to under 4 months, and (3) increase the proportion of patients obtaining a post-initiation polysomnogram within 1 year to >50%. We also explored healthcare utilization (HCU) in a subsample of patients. Interventions focused on developing a tracking system and standardizing interdisciplinary clinical care. The proportion of patients returning to clinic within 4 months improved from 38.2% to 65.5% and median time to first follow-up visit improved from 133 to 56 days. The percentage of patients who returned for a post-initiation polysomnogram within 1 year was 71.1%. Subsample analyses showed significant reductions in the length of stay for emergency department visits from pre-CPAP initiation (Mdn = 3.00 h; interquartile range [IQR] = 7.00) to post-initiation (Mdn = 2.00 h, IQR = 5.00). The length of hospitalizations was also significantly shorter from pre (Mdn = 48.00 h, IQR = 243.00) to post-CPAP initiation (Mdn = 0.00 h, IQR = 73.00). A standardized, tracked approach to interdisciplinary outpatient CPAP care can improve follow-up care and potentially HCU.

Effective Reduction in Opioid Prescriptions for Ambulatory Lesion Excisions in Pediatric Patients.

Childhood opioid consumption is potentially deleterious to cognitive development and may predispose children to later addiction. Opioids are frequently prescribed for outpatient surgery but may not be necessary for adequate pain control. We aimed to reduce opioid prescriptions for outpatient pediatric skin and soft tissue lesion excisions using quality improvement (QI) methods. METHODS: A multidisciplinary team identified drivers for opioid prescriptions. Interventions were provider education, improving computer order set defaults, and promoting non-narcotic pain control strategies and patient-family education. Outcomes included percentage of patients receiving opioid prescriptions and patient-satisfaction scores. Data were retrospectively collected for 3 years before the QI project and prospectively tracked over the 8-month QI period and the following 18 months. RESULTS: The percentage of patients receiving an opioid prescription after outpatient skin or soft tissue excision dropped significantly from 18% before intervention to 6% at the end of the intervention period. Patient-reported satisfaction with pain control improved following the QI intervention. Satisfaction with postoperative pain control was independent of closure size or receipt of a postoperative opioid prescription. Intraoperative use of lidocaine or bupivacaine significantly decreased the incidence of postoperative opioid prescription in both bivariate and multivariate analyses. Results were maintained at 18 months after the conclusion of the QI project. CONCLUSION: Raising provider awareness, educating patients on expected postoperative pain management options, and prioritizing non-narcotic medications postoperatively successfully reduced opioid prescription rates in children undergoing skin and soft tissue lesion excisions and simultaneously improved patient-satisfaction scores.

The Reducing Opioid Use in Children with Clefts Protocol: A Multidisciplinary Quality Improvement Effort to Reduce Perioperative Opioid Use in Patients Undergoing Cleft Surgery.

BACKGROUND: Cleft repair requires multiple operations from infancy through adolescence, with repeated exposure to opioids and their associated risks. The authors implemented a quality improvement project to reduce perioperative opioid exposure in their cleft lip/palate population. METHODS: After identifying key drivers of perioperative opioid administration, quality improvement interventions were developed to address these key drivers and reduce postoperative opioid administration from 0.30 mg/kg of morphine equivalents to 0.20 mg/kg of morphine equivalents. Data were retrospectively collected from January 1, 2015, until initiation of the quality improvement project (May 1, 2017), tracked over the 6-month quality improvement study period, and the subsequent 14 months. Metrics included morphine equivalents of opioids received during admission, administration of intraoperative nerve blocks, adherence to revised electronic medical record order sets, length of stay, and pain scores. RESULTS: The final sample included 624 patients. Before implementation (n =354), children received an average of 0.30 mg/kg of morphine equivalents postoperatively. After implementation (n = 270), children received an average of 0.14 mg/kg of morphine equivalents postoperatively (p < 0.001) without increased length of stay (28.3 versus 28.7 hours; p = 0.719) or pain at less than 6 hours (1.78 versus 1.74; p = 0.626) or more than 6 hours postoperatively (1.50 versus 1.49; p = 0.924). CONCLUSIONS: Perioperative opioid administration after cleft repair can be reduced in a relatively short period by identifying key drivers and addressing perioperative education, standardization of intraoperative pain control, and postoperative prioritization of nonopioid medications and nonpharmacologic pain control. The authors' quality improvement framework has promise for adaptation in future efforts to reduce opioid use in other surgical patient populations. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Reducing Albuterol Use in Children With Bronchiolitis.

OBJECTIVES: In 2014, the American Academy of Pediatrics published bronchiolitis guidelines recommending against the use of bronchodilators. For the winter of 2015 to 2016, we aimed to reduce the proportion of emergency department patients with bronchiolitis receiving albuterol from 43% (previous winter rate) to <35% and from 18% (previous winter rate) to <10% in the inpatient setting. METHODS: A team identified key drivers of albuterol use and potential interventions. We implemented changes to our pathway and the associated order set recommending against routine albuterol use and designed education to accompany the pathway changes. We monitored albuterol use through weekly automated data extraction and reported results back to clinicians. We measured admission rate, length of stay, and revisit rate as balancing measures for the intervention. RESULTS: The study period included 3834 emergency department visits and 1119 inpatient hospitalizations. In the emergency department, albuterol use in children with bronchiolitis declined from 43% to 20% and was <3 SD control limits established in the previous year, meeting statistical thresholds for special cause variation. Inpatient albuterol use decreased from 18% to 11% of patients, also achieving special cause variation and approaching our goal. The changes in both departments were sustained through the entire bronchiolitis season, and admission rate, length of stay, and revisit rates remained unchanged. CONCLUSIONS: Using a multidisciplinary group that redesigned a clinical pathway and order sets for bronchiolitis, we substantially reduced albuterol use at a large children's hospital without impacting other outcome measures.

Standardization of prophylactic platelet transfusion dosing in a pediatric oncology population: a quality improvement project.

BACKGROUND: Oncology patients are frequent recipients of prophylactic platelet transfusions. Recent studies have demonstrated that lower prophylactic doses of platelets were not associated with a higher incidence of bleeding. At our institution, we found wide variation in platelet dosing due to lack of guidance and support for standardized dosing. STUDY DESIGN AND METHODS: A collaborative process improvement project between oncology, hematology, intensivists, and the transfusion service established guidelines for dosing of prophylactic platelet transfusions in nonbleeding oncology patients: 10 mL/kg or less of apheresis platelets for patients weighing up to 20 kg and 1 unit of apheresis platelets patients weighing 20 kg or more, with our stated goal of standardizing transfusion practice. A graphic data display tool that draws on the electronic medical record to monitor platelet ordering was created, with a target goal of greater than 80% compliance with the dosing guidelines. We implemented decision support for dosing consistent with the guideline, and provided educational materials to prescribers at various levels of training within oncology over multiple plan-do-study-act cycles. RESULTS: We were able to consistently achieve between 85 and 90% compliance of prophylactic platelet transfusion orders without an increase in the number of emergency department visits for bleeding or platelet transfusions or changing the time between platelet transfusions after guideline implementation. CONCLUSION: This project demonstrates that reducing the volume of prophylactic platelet transfusions to doses consistent with published studies was safe and that a process of guideline consensus based on published studies, well-designed decision support for computerized physician order entry, and targeted educational efforts, were effective in changing practice at a large academic hospital.

Comparative evaluation of the indigenous microbial diversity vs. drilling fluid contaminants in the NEEM Greenland ice core.

Demonstrating that the detected microbial diversity in nonaseptically drilled deep ice cores is truly indigenous is challenging because of potential contamination with exogenous microbial cells. The NEEM Greenland ice core project provided a first-time opportunity to determine the origin and extent of contamination throughout drilling. We performed multiple parallel cultivation and culture-independent analyses of five decontaminated ice core samples from different depths (100-2051 m), the drilling fluid and its components Estisol and Coasol, and the drilling chips collected during drilling. We created a collection of diverse bacterial and fungal isolates (84 from the drilling fluid and its components, 45 from decontaminated ice, and 66 from drilling chips). Their categorization as contaminants or intrinsic glacial ice microorganisms was based on several criteria, including phylogenetic analyses, genomic fingerprinting, phenotypic characteristics, and presence in drilling fluid, chips, and/or ice. Firmicutes and fungi comprised the dominant group of contaminants among isolates and cloned rRNA genes. Conversely, most Proteobacteria and Actinobacteria originating from the ice were identified as intrinsic. This study provides a database of potential contaminants useful for future studies of NEEM cores and can contribute toward developing standardized protocols for contamination detection and ensuring the authenticity of the microbial diversity in deep glacial ice.

The human protein PRR14 tethers heterochromatin to the nuclear lamina during interphase and mitotic exit.

The nuclear lamina is a protein meshwork that lies under the inner nuclear membrane of metazoan cells. One function of the nuclear lamina is to organize heterochromatin at the inner nuclear periphery. However, very little is known about how heterochromatin attaches to the nuclear lamina and how such attachments are restored at mitotic exit. Here, we show that a previously unstudied human protein, PRR14, functions to tether heterochromatin to the nuclear periphery during interphase, through associations with heterochromatin protein 1 (HP1) and the nuclear lamina. During early mitosis, PRR14 is released from the nuclear lamina and chromatin and remains soluble. Strikingly, at the onset of anaphase, PRR14 is incorporated rapidly into chromatin through HP1 binding. Finally, in telophase, PRR14 relocalizes to the reforming nuclear lamina. This stepwise reassembly of PRR14 suggests a function in the selection of HP1-bound heterochromatin for reattachment to the nuclear lamina as cells exit mitosis.