Establishing Baseline Metrics of Heart Failure Medication Use in Children: A Collaborative Effort from the ACTION Network.

Heart failure metrics specific to the pediatric population are required to successfully implement quality improvement initiatives in children with heart failure. Medication use at the time of discharge following admission for decompensated heart failure has been identified as a potential quality metric in this population. This study aimed to report medication use at discharge in the current era for children admitted with acute decompensated heart failure. All patients < 21 years of age with an index admission (1/1/2011-12/31/2019) for acute heart failure and a coexisting diagnosis of cardiomyopathy were identified from the Pediatric Health Information System. Medication use patterns were described and compared across age groups and centers. A total of 2288 patients were identified for inclusion. An angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker (ACEi/ARB) was prescribed in 1479 (64.6%), beta blocker in 1132 (49.5%), and mineralocorticoid receptor antagonist (MRA) in 864 (37.8%) patients at discharge. The use of ACEi/ARB at discharge has decreased over time (64.6% vs. 69.6%, p = 0.001) and the use of beta blockers has increased (49.5% vs. 36.8%, p < 0.001) compared to a historical cohort (2001-2010). There is considerable variability in medication use across centers with an overall increase in beta blocker and decrease in ACEi/ARB use over time. Collaborative efforts are needed to standardize care and define quality metrics to identify best practices in the management of pediatric heart failure.

Managing Diagnostic Uncertainty in Pediatric Sepsis Quality Improvement with a Two-Tiered Approach.

Severe sepsis requires timely, resource-intensive resuscitation, a challenge when a sepsis diagnosis is not confirmed. The overall goals were to create a pediatric sepsis program that provided high-quality critical care in severe sepsis (Sepsis Stat), and, in possible sepsis, flexible evaluation and treatment that promoted stewardship (Sepsis Yellow). The primary aims were to decrease time to antibiotics and the intensive care unit requirement. METHODS: A 2-tiered clinical pathway was implemented at 6 pediatric emergency departments and urgent care centers, incorporating order sets, education, paging. The Sepsis Stat pathway included 2 nurses, hand delivery of antibiotics, resuscitation room use. The Sepsis Yellow pathway included prioritized orders, standardized procedures, close monitoring, and evaluation of whether antibiotics were warranted. RESULTS: From April 2012 to December 2017, we treated 3,640 patients with suspected and confirmed sepsis. Among the 932 severe sepsis patients, the 30-day, in-hospital mortality was 0.9%. Arrival to recognition time improved from 50 to 4 minutes. Recognition to antibiotic time demonstrated an in-control process in our goal range with a median of 43 minutes for Sepsis Stat patients, 59 minutes for Sepsis Yellow patients. The proportion of severe sepsis patients requiring intensive care unit care declined from 45% to 34%. On the Sepsis Yellow pathway, 23% were de-escalated with discharge to home without antibiotics. CONCLUSIONS: This novel 2-tiered approach to pediatric sepsis quality improvement in varied emergency care settings improved process and outcome measures in severe sepsis while promoting stewardship and de-escalation where appropriate. Matching resources to the degree of illness was important in supporting quality care in potentially septic children.

Interventions to Reduce Over-Utilized Tests and Treatments in Bronchiolitis.

OBJECTIVES: The American Academy of Pediatrics published bronchiolitis clinical practice guidelines in 2014 recommending against the routine use of bronchodilators, chest radiographs, or respiratory viral testing in children with a clinical diagnosis of bronchiolitis. Our aim in this project was to align care with the American Academy of Pediatrics clinical practice guidelines by decreasing the overuse of these interventions. METHODS: This study included patients who were admitted to a non-ICU setting with a primary or secondary diagnosis of bronchiolitis. The team used a multidisciplinary kickoff event to understand the problem and develop interventions, including sharing provider-specific data and asking providers to sign a pledge to reduce use. We used a novel, real-time data dashboard to collect and analyze data. RESULTS: Special cause variation on control charts indicated improvement for all outcomes for inpatients during the intervention season. Pre- and postanalyses in which we compared baseline to intervention values for all admitted patients and patients who were discharged from the emergency department or urgent care revealed a significant reduction in the ordering of chest radiographs (from 22.7% to 13.6%; P ≤ .001), respiratory viral testing (from 12.5% to 9.8%; P = .001), and bronchodilators (from 17.5% to 10.3%; P = .001) without changes in balancing measures (eg, hospital readmission within 7 days [1.7% (preanalysis) and 1.0% (postanalysis); P = .21]) for bronchiolitis. CONCLUSIONS: This multidisciplinary improvement initiative resulted in a significant reduction in use for bronchiolitis care at our institution. Our approach, which included a novel, real-time data dashboard and interventions such as individual providers pledging to reduce use, may have the potential to reduce overuse in other settings and diseases.