RESUMEN
OBJECTIVES: Obtaining urine samples in younger children undergoing urinary tract infection (UTI) screening can be challenging in busy emergency departments (EDs), and sterile techniques, like catheterization, are invasive, traumatizing, and time consuming to complete. Noninvasive techniques have been shown to reduce catheterization rates but are variably implemented. Our aim was to implement a standardized urine bag UTI screening approach in febrile children aged 6 to 24 months to decrease the number of unnecessary catheterizations by 50% without impacting ED length of stay (LOS) or return visits (RVs). METHODS: After forming an interprofessional study team and engaging key stakeholders, a multipronged intervention strategy was developed using the Model for Improvement. A urine bag screening pathway was created and implemented using Plan, Do, Study Act (PDSA) cycles for children aged 6 to 24 months being evaluated for UTIs. A urine bag sample with point-of-care (POC) urinalysis (UA) was integrated as a screening approach. The outcome measure was the rate of ED urine catheterizations, and balancing measures included ED LOS and RVs. Statistical process control methods were used for analysis. RESULTS: During the 3-year study period from January 2019 to June 2022, the ED catheterization rate successfully decreased from a baseline of 73.3% to 37.7% and was sustained for approximately 2 years. Unnecessary urine cultures requiring microbiology processing decreased from 79.8% to 40.7%. The ED LOS initially decreased; however, it increased by 17 minutes during the last 8 months of the study. There was no change in RVs. CONCLUSION: A urine bag screening pathway was successfully implemented to decrease unnecessary, invasive catheterizations for UTI screening in children with only a slight increase in ED LOS. In addition to the urine bag pathway, an ED nursing champion, strategic alignment, and broad provider engagement were all instrumental in the initiative's success.
RESUMEN
OBJECTIVE: Intra-abdominal injury occurs in less than 15% of pediatric trauma activations but can be life-threatening. Computed tomography (CT) imaging is commonly ordered in pediatric trauma, even when intra-abdominal injury risk is low. We aimed to reduce abdominal/pelvic CT rates in children at very low risk for intra-abdominal injury requiring trauma activation at our pediatric trauma centre. METHODS: We implemented a quality improvement initiative using the Model for Improvement in children 0-15.99 years of age who activated a trauma response and were evaluated for intra-abdominal injury. Interventions included clinical decision support, institutional education, and individual audit and feedback. Our primary outcome was abdominal/pelvic CT rate in patients at very low risk for intra-abdominal injury. Balancing measures included CT scans ordered within 24 h of emergency department (ED) assessment and return to ED or hospitalization within 72 h for missed intra-abdominal injury. Statistical process control was used to evaluate rates over time. RESULTS: The baseline period (April 1, 2016 - November 30, 2017) included 359 trauma patients with a CT rate of 26.8% (95% CI 20.5-33.8%) in those at low risk for intra-abdominal injury. The intervention period (Dec 1, 2017-Dec 31, 2019) included 445 patients with a CT rate in low-risk patients of 6.8% (95% CI 3.2-12.6%), demonstrating an absolute reduction of 20.0% (95% CI 12.2-27.7%, p < 0.05). Interventions resulted in a significant decrease in abdominal/pelvic CT imaging corresponding with special cause variation. No clinically significant intra-abdominal injuries were missed. CONCLUSIONS: This quality improvement initiative reduced abdominal/pelvic CT rates in pediatric trauma patients at low risk for intra-abdominal injury without any missed cases of significant injury. Leveraging standardized decision tools to reduce unnecessary CT imaging can be successfully accomplished without compromising care.
RéSUMé: OBJECTIF: Les lésions intra-abdominales surviennent dans moins de 15 % des activations de traumatismes pédiatriques, mais peuvent mettre la vie en danger. L'imagerie par tomodensitométrie (TDM) est couramment prescrite en cas de traumatisme pédiatrique, même lorsque le risque de lésion intra-abdominale est faible. Nous avons cherché à réduire les taux de tomodensitométrie abdominale/pelvienne chez les enfants à très faible risque de lésion intra-abdominale nécessitant l'activation d'un traumatisme dans notre centre de traumatologie pédiatrique. MéTHODES: Nous avons mis en Åuvre une initiative d'amélioration de la qualité à l'aide du modèle d'amélioration chez les enfants de 0-15,99 ans qui ont activé une réaction traumatique et ont été évalués pour les lésions intra-abdominales. Les interventions comprenaient une aide à la décision clinique, une formation institutionnelle, ainsi qu'un audit et un retour d'information individuels. Notre principal résultat a été le taux de TDM abdominale/pelvienne chez les patients à très faible risque de lésion intra-abdominale. Les mesures d'équilibre comprenaient les tomodensitométries demandées dans les 24 heures suivant l'évaluation aux urgences et le retour aux urgences ou l'hospitalisation dans les 72 heures en cas de lésion intra-abdominale manquée. Le contrôle statistique des processus a été utilisé pour évaluer les taux au fil du temps. RéSULTATS: La période de référence (du 1er avril 2016 au 30 novembre 2017) comprenait 359 patients traumatisés ayant un taux de tomodensitométrie de 26,8 % (IC à 95 % de 20,5 % à 33,8 %) chez ceux qui présentaient un faible risque de lésion intra-abdominale. La période d'intervention (1er décembre 2017-31 décembre 2019) a inclus 445 patients avec un taux de TDM chez les patients à faible risque de 6,8 % (IC à 95 % de 3,2 % à 12,6 %), démontrant une réduction absolue de 20,0 % (IC à 95 % 12,2 % à 27,7 %, p < 0,05). Les interventions ont entraîné une diminution significative de l'imagerie TDM abdominale/pelvienne correspondant à une variation de cause particulière. Aucune lésion intra-abdominale cliniquement significative n'a été manquée. CONCLUSIONS: Cette initiative d'amélioration de la qualité a réduit les taux de TDM abdominale/pelvienne chez les patients pédiatriques traumatisés à faible risque de lésion intra-abdominale sans qu'il y ait de cas manqués de blessure importante. Il est possible d'utiliser des outils de décision standardisés pour réduire les examens d'imagerie par scanner inutiles sans compromettre les soins.