Protecting Sleep Hygiene in the PICU: A Quality Improvement Project.

OBJECTIVES: To increase the number of nights without sleep interruptions for routine tasks in recovering PICU patients. DESIGN: Prospective quality improvement project. SETTING: Single-center, free-standing, tertiary children's hospital. PATIENTS: Patients admitted to the PICU for greater than 72 hours and eligible for early mobilization. INTERVENTIONS: A multidisciplinary sleep hygiene team was created to improve sleep hygiene in critically ill patients eligible for early mobilization. This team rewrote local nursing policies to avoid routine tasks between 11 pm and 5 am . The team provided periodic control chart updates to staff detailing progress made protecting sleep. Discussions of sleep hygiene were added to the daily goal sheet and a sleep hygiene order set was created. Finally, the PICU quality dashboard was modified to show whether a sleep hygiene order set was initiated in eligible patients. MEASUREMENTS AND MAIN RESULTS: Routine tasks were defined as daily chest radiographs, baths, routine tracheostomy care, central line dressing changes, twice daily medications, weights, and Foley care. After a year of data collection, avoidance of routine pupillary examinations was added to the sleep protection criteria. Baseline data was collected for 2 months prior to the creation of the sleep hygiene team. Screening of eligible patients occurred 1 week each month. The data were analyzed utilizing control charts. Baseline data demonstrated 32% of PICU patients without sleep interruptions. The centerline increased to 58% after the initial interventions but dropped to 33% after inclusion of pupillary checks. Following the introduction of the daily goal sheet, sleep hygiene order set, and tracking on the quality board, 49% of patients went without interruptions. CONCLUSIONS: The initiation of a sleep hygiene team along with retiming routine tasks, daily discussions on rounds with the daily goal sheet, introduction of a sleep hygiene order set, and transparent tracking improved the percentage of patients with protected sleep.

A Customized Triggers Program: A Children's Hospital's Experience in Improving Trigger Usability.

BACKGROUND: Despite the growth of patient safety programs across the United States, errors and adverse events remain a source of patient harm. Many hospitals rely on retrospective voluntary reporting systems; however, there are opportunities to improve patient safety using novel tools like trigger programs. METHODS: Children's National Hospital developed a unique pediatric triggers program that offers customized, near real-time reports of potential safety events. Our team defined a measure to quantify clinical utility of triggers, termed "trigger signal," as the percentage of cases that represent true adverse or near-miss events (numerator) per total triggers activated (denominator). Our key driver diagram focused on unifying the program structure, increasing data analytics, promoting organizational awareness, and supporting multidisciplinary end user engagement. Using the model for improvement, we aimed to double overall trigger signal from 8% to 16% and sustain for 12 months. RESULTS: The trigger signal increased from 8% to 41% and sustained during the coronavirus disease 2019 pandemic. A balancing measure of time to implement a new trigger decreased. Key interventions to increase trigger signal were change in the program structure, increasing stakeholder engagement, and development of self-service reports for end users. CONCLUSIONS: Children's National Hospital's triggers program highlights successful evolution of an iterative, customized approach to increase clinical utility that hospitals can implement to impact real-time patient care. This triggers program requires an iterative, customized approach rather than a "1-size-fits-all," static paradigm to add a new dimension to current patient safety programs.

Engagement and Bundle Compliance during COVID-19: A Virtual Strategy.

COVID-19 forced industries to change work processes; this was no different for those working to improve patient outcomes in healthcare. Due to competing priorities, many hospitals struggled with the upkeep of hospital-acquired condition (HAC) auditing and engagement. Children's National hospital developed a three-pronged approach for virtual engagement and sustainment of the processes necessary to achieve and maintain goal auditing and bundle compliance in three HACs: unplanned extubation, central line-associated bloodstream infections, and employee staff safety overexertion injuries. Methods: The overall goal was to create a flexible approach to maintaining engagement while relying on virtual communication. Aim: To maintain, without a decrease of more than 20%, the baseline bundle compliance per month for each HAC (unplanned extubation, central line-associated bloodstream infections, and employee staff safety) from March 2020 to March 2021. Our approach to increasing bundle compliance (primary outcome measure) and audits (process measure) included: regular leadership meetings using multiple virtual modalities, improving the audit process, and ensuring fidelity to bundle elements. Results: Qualitatively, we have found that microsystem leaders regularly engage with quality improvement staff and their teams using virtual touchpoints and ongoing communication. We exceeded the goal of maintaining our monthly bundle compliance, and we saw a significant positive change in the rate of audits after COVID-19. Conclusions: In a time of change during a pandemic, increased engagement in HAC work can adapt structure and processes. Our results are generalizable by increasing touchpoints using multiple virtual modalities.

Shifting the Paradigm: A Quality Improvement Approach to Proactive Cardiac Arrest Reduction in the Pediatric Cardiac Intensive Care Unit.

INTRODUCTION: Children with cardiac conditions are at higher risk of in-hospital pediatric cardiopulmonary arrest (CA), resulting in significant morbidity and mortality. Despite the elevated risk, proactive cardiac arrest prevention programs in the cardiac intensive care unit (CICU) remain underdeveloped. Our team developed a multidisciplinary program centered on developing a quality improvement (QI) bundle for patients at high risk of CA. METHODS: This project occurred in a 26-bed pediatric CICU of a tertiary care children's hospital. Statistical process control methodology tracked changes in CA rates over time. The global aim was to reduce CICU mortality; the smart aim was to reduce the CA rate by 50% over 12 months. Interprofessional development and implementation of a QI bundle included visual cues to identify high-risk patients, risk mitigation strategies, a new rounding paradigm, and defined escalation algorithms. Additionally, weekly event and long-term data reviews, arrest debriefs, and weekly unit-wide dissemination of key findings supported a culture change. RESULTS: After bundle implementation, CA rates decreased by 68% compared to baseline and 45% from the historical baseline. Major complications decreased from 17.1% to 12.6% (P < 0.001) and mortality decreased from 5.7% to 5.0% (P = 0.048). These results were sustained for 30 months. CONCLUSIONS: Cardiac arrest is a modifiable, rather than inevitable, metric in the CICU. Reduction is achievable through the interprofessional implementation of bundled interventions targeting proactive CA prevention. Once incorporated into widespread efforts to engage multidisciplinary CICU stakeholders, these patient-focused interventions resulted in sustained improvement.

A Quality Initiative for Reducing Postoperative Hypothermia for Neonatal Intensive Care Unit Surgical Patients.

INTRODUCTION: The association between hypothermia in the neonatal intensive care unit (NICU) patients and morbidity and mortality is well described. Neonates are at higher risk of perioperative hypothermia when compared to older children. Previous studies showed that quality improvement tools reduced postoperative hypothermia in NICU patients, but none showed sustained improvement at incidence rates of <10%. As a single institution, we aimed to reduce the percentage of postoperative temperatures < 36°C in NICU patients from 10% to 6% over 6 months and sustain for 6 months. METHODS: An interdisciplinary team created a key driver diagram and implemented interventions, including monthly reporting of postoperative hypothermia incidence to the anesthesiologists, individual feedback sessions with the anesthesiologists, use of a perioperative checklist, and continuous axillary temperature monitoring of the infant throughout the perioperative period. Data were collected retrospectively using a chart review of electronic medical records. The primary outcome was the percentage of hypothermic patients (T < 36°C) based on the first postoperative temperature taken in the NICU. We tracked this measure using a statistical control chart and evaluated it using Plan-Do-Study-Act cycles. RESULTS: From February 1, 2016 to May 30, 2018, data were collected for 554 patients (pre-intervention: 242 and post-intervention: 312). The percentage of surgical patients who returned to the NICU hypothermic decreased from 9.7% to 2.5% (P < 0.002)-a change sustained for greater than 12 months. CONCLUSIONS: Quality improvement tools are useful in reducing postoperative hypothermia in NICU surgical patients and in maintaining these results.

Reducing Vancomycin Use in a Level IV NICU.

BACKGROUND AND OBJECTIVES: Vancomycin remains one of the most commonly prescribed antibiotics in NICUs despite recommendations to limit its use for known resistant infections. Baseline data revealing substantially higher vancomycin use in our NICU compared to peer institutions informed our quality improvement initiative. Our aim was to reduce the vancomycin prescribing rate in neonates hospitalized in our NICU by 50% within 1 year and sustain for 1 year. METHODS: In the 60-bed level IV NICU of an academic referral center, we used a quality improvement framework to develop key drivers and interventions including (1) physician education with benchmarking antibiotic prescribing rates; (2) pharmacy-initiated 48-hour antibiotic time-outs on rounds; (3) development of clinical pathways to standardize empirical antibiotic choices for early-onset sepsis, late-onset sepsis, and necrotizing enterocolitis; coupled with (4) daily prospective audit with feedback from the antimicrobial stewardship program. RESULTS: We used statistical process u-charts to show vancomycin use declined from 112 to 38 days of therapy per 1000 patient-days. After education, pharmacy-initiated 48-hour time-outs, and development of clinical pathways, vancomycin use declined by 29%, and by an additional 52% after implementation of prospective audit with feedback. Vancomycin-associated acute kidney injury also declined from 1.4 to 0.1 events per 1000 patient-days. CONCLUSIONS: Through a sequential implementation approach of education, standardization of care with clinical pathways, pharmacist-initiated 48-hour time-outs, and prospective audit with feedback, vancomycin days of therapy declined by 66% over a 1-year period and has been sustained for 1 year.

Leveraging real-time data to drive quality improvement in a pediatric health system.

We are inundated by data; healthcare is no different. The electronic medical record, the numerous patient care monitors, and the thousands of medications to be reconciled with specific dosing parameters are a few examples of the omnipresent and intimidating nature of data in healthcare. Across the world, healthcare without data does not exist. The data represent many forms but are quickly moving towards electronic formats. As ubiquitous as data are the near universal finding that such data are lagging. There is an urgent need for real-time data in improving processes and ultimately outcomes in healthcare. If data lag by four to eight weeks, if not longer, then true change cannot occur and harm continues in that interval. This review article discusses the urgent need for real-time data and demonstrates examples of how Children's National Medical Center in Washington, DC uses real-time data to drive outcomes.