Improving anthropometric measurements in hospitalized children: A quality-improvement project.

BACKGROUND: The objective of this quality-improvement project was to increase documentation rates of anthropometrics (measured weight, length/height, and body mass index [BMI], which are critical to identify patients at malnutrition (undernutrition) risk) from <50% to 80% within 24 hours of hospital admission for pediatric patients. METHODS: Multidisciplinary champion teams on surgical, cardiac, and intensive care (ICU) pilot units were established to identify and iteratively test interventions addressing barriers to documentation from May 2016 to June 2018. Percentage of patients with documented anthropometrics <24 h of admission was assessed monthly by statistical process control methodology. Percentage of patients at malnutrition (undernutrition) risk by anthropometrics was compared by χ2 for 4 months before and after intervention. RESULTS: Anthropometric documentation rates significantly increased (P < 0.001 for all): BMI, from 11% to 89% (surgical), 33% to 57% (cardiac), and 16% to 51% (ICU); measured weight, from 24% to 88% (surgical), 69% to 83% (cardiac), and 51% to 67% (ICU); and length/height, from 12% to 89% (surgical), 38% to 57% (cardiac), and 26% to 63% (ICU). Improvement hospital-wide was observed (BMI, 42% to 70%, P < 0.001) with formal dissemination tactics. For pilot units, moderate/severe malnutrition (undernutrition) rates tripled (1.2% [24 of 2081] to 3.4% [81 of 2374], P < 0.001). CONCLUSION: Documentation of anthropometrics on admission substantially improved after establishing multidisciplinary champion teams. Goal rate (80%) was achieved within 26 months for all anthropometrics in the surgical unit and for weight in the cardiac unit. Improved documentation rates led to significant increase in identification of patients at malnutrition (undernutrition) risk.

Development of an outcome measure to monitor the effectiveness of pain management.

Attention to the pain that occurs during treatments and procedures for pediatric patients with cancer continues to be a priority. This article describes the development of a pain effectiveness outcome measure at an academic pediatric medical center in order to inform about the implementation of quality improvement strategies and evaluate the effect of these pain interventions within the hospital setting.

Lessons learned: use of event reporting by nurses to improve patient safety and quality.

The Magnet Recognition Program encourages nurse-initiated, data-driven quality projects. Using data gained from medical error event reporting has been cited as a strategy to improve safety and quality. This article describes a process by which nurses at the Children's Hospital Boston increased error reporting and used knowledge gained from event reports to provide education and implement practice changes. The medical and surgical units experienced a 35% increase in reported events and a decrease in the severity level of events over a 2-year period. Meaningful data from event reporting systems are critical in helping nurses develop interventions to prevent errors. The Magnet Model components are illustrated in the steps of this project.

Continuous non-invasive end-tidal CO2 monitoring in pediatric inpatients with diabetic ketoacidosis.

INTRODUCTION: Pediatric inpatients with diabetic ketoacidosis (DKA) are routinely subjected to frequent blood draws in order to closely monitor degree of acidosis and response to therapy. The typical level of acidosis monitoring is less than ideal, however, because of the high cost and invasiveness of frequent blood labs. Previous studies have validated end-tidal carbon dioxide (EtCO2) monitoring in the emergency department (ED) for varying periods of time. We extend these findings to the inpatient portion of the hospitalization during which the majority of blood tests are sent. METHODS: All patients admitted to an intermediate care unit in (InCU) a large children's hospital were fitted with an appropriately sized oral/nasal cannula capable of sensing EtCO2. Laboratory studies were obtained according to hospital clinical practice guidelines. In a retrospective analysis, EtCO2 values were correlated with serum total CO2 (stCO2), venous pH (vpH), venous pCO2 (vpCO2), and calculated bicarbonate from venous blood gas (vHCO3-). RESULTS: A total of 78 consecutive episodes of DKA in 72 patients aged 1-21 yr were monitored for 3-38 h with both capnography and laboratory testing, producing 334 comparisons. Initial values were as follows, reported as median (range): stCO2, 11 (4-22) mmol/L; vpH, 7.281 (6.998-7.441); vpCO2, 28.85 (9.3-43.3) mmHg; and vHCO3-, 14 (3-25) mmol/L. EtCO2 was correlated well with stCO2 (r = 0.84, p < 0.001), vHCO3- (r = 0.84, p < 0.001), and vpCO2 (r = 0.79, p < 0.001). CONCLUSIONS: These data support the findings of previous studies limited to ED populations and suggest that non-invasive EtCO2 monitoring is a valuable and reliable tool to continuously follow acidosis in the setting of the acutely ill pediatric patient with DKA. Continuous EtCO2 monitoring offers the practitioner an early warning system for unexpected changes in acidosis that augments the utility of intermittent blood gas determinations.