Eliminating Catheter-Associated Urinary Tract Infections in a Pediatric Cardiac ICU.

OBJECTIVES: To eliminate catheter-associated urinary tract infections in a pediatric cardiac ICU. DESIGN: Quality improvement methodology. SETTING: Twenty-five bed cardiac ICU in a quaternary freestanding children's hospital. PATIENTS: All patients with an indwelling urinary catheter admitted to the cardiac ICU. INTERVENTIONS: Catheter-associated urinary tract infection was defined according to National Healthcare Safety Network criteria. Failure modes and effects analysis and Pareto charts were used to determine etiology of process failures. We implemented a team-based multi-interventional approach in 2012 using the Model for Improvement, which included as follows: 1) establish indications for inserting and/or maintaining bladder catheterization, 2) standardization of maintenance care for the indwelling urinary catheters, 3) protocol for management of the leaking urinary catheters, 4) incorporation of urinary catheter days and prompts for removal in daily rounds, and 5) review of all cases of prolonged indwelling urinary catheter use (> 3 d). Process control charts were used to evaluate change. MEASUREMENTS AND MAIN RESULTS: From 2011 to 2018, we showed an early and sustained improvement in catheter-associated urinary tract infection prevention standards compliance from 44% to 96% (52% improvement). These interventions showed a reduction and then elimination of catheter-associated urinary tract infections from January 2012 to the present day, despite fluctuations in total indwelling urinary catheter days. CONCLUSIONS: Utilization of quality improvement methodology allowed us to identify components of care that contributed to catheter-associated urinary tract infections. After addressing these issues, we noted a substantial reduction and then elimination of catheter-associated urinary tract infections in our pediatric cardiac ICU. Widely disseminating these interventions across multiple pediatric hospitals to determine the ability to achieve similar results are important next steps.

Usability Testing of an Interactive Dashboard for Surgical Quality Improvement in a Large Congenital Heart Center.

BACKGROUND: Interactive data visualization and dashboards can be an effective way to explore meaningful patterns in large clinical data sets and to inform quality improvement initiatives. However, these interactive dashboards may have usability issues that undermine their effectiveness. These usability issues can be attributed to mismatched mental models between the designers and the users. Unfortunately, very few evaluation studies in visual analytics have specifically examined such mismatches between these two groups. OBJECTIVES: We aimed to evaluate the usability of an interactive surgical dashboard and to seek opportunities for improvement. We also aimed to provide empirical evidence to demonstrate the mismatched mental models between the designers and the users of the dashboard. METHODS: An interactive dashboard was developed in a large congenital heart center. This dashboard provides real-time, interactive access to clinical outcomes data for the surgical program. A mixed-method, two-phase study was conducted to collect user feedback. A group of designers (N = 3) and a purposeful sample of users (N = 12) were recruited. The qualitative data were analyzed thematically. The dashboards were compared using the System Usability Scale (SUS) and qualitative data. RESULTS: The participating users gave an average SUS score of 82.9 on the new dashboard and 63.5 on the existing dashboard (p = 0.006). The participants achieved high task accuracy when using the new dashboard. The qualitative analysis revealed three opportunities for improvement. The data analysis and triangulation provided empirical evidence to the mismatched mental models. CONCLUSION: We conducted a mixed-method usability study on an interactive surgical dashboard and identified areas of improvements. Our study design can be an effective and efficient way to evaluate visual analytics systems in health care. We encourage researchers and practitioners to conduct user-centered evaluation and implement education plans to mitigate potential usability challenges and increase user satisfaction and adoption.

Differences in Cost of Care by Palliation Strategy for Infants With Ductal-Dependent Pulmonary Blood Flow.

BACKGROUND: In infants with ductal-dependent pulmonary blood flow, initial palliation with patent ductus arteriosus (PDA) stent or modified Blalock-Taussig (BT) shunt have comparable mortality but discrepant length of stay, procedural complication rates and reintervention burdens, which may influence cost. The relative economic impact of these palliation strategies is unknown. METHODS AND RESULTS: Retrospective study of infants with ductal-dependent pulmonary blood flow palliated with PDA stent (n=104) or BT shunt (n=251) from 2008 to 2015 at 4 centers of the Congenital Catheterization Research Collaborative. Inflation-adjusted inpatient hospital costs were calculated for first year of life using Pediatric Health Information System data. Costs derived from outpatient catheterizations not in Pediatric Health Information System were imputed. Costs were compared using propensity score-adjusted multivariable models, to account for baseline differences between groups. After propensity score adjustment, first year of life costs were significantly lower in PDA stent ($215 825 [190 644-244 333]) than BT shunt ($249 855 [230 693-270 609]) patients ( P=0.05). After addition of imputed costs, first year of life costs were not significantly different between PDA stent ($226 403 [200 274-255 941]) and BT shunt ($252 072 [232 955-272 759]) groups ( P=0.15). Patient characteristics associated with higher costs included: younger gestational age, genetic syndrome, noncardiac diagnoses, procedural complications, extracorporeal membrane oxygenation, duration of ventilation, intensive care unit and hospital length of stay and reintervention ( P≤0.02 for all). CONCLUSIONS: In this first multicenter comparative cost study of PDA stent or BT shunt as palliation for infants with ductal-dependent pulmonary blood flow, adjusted for baseline differences, PDA stent was associated with lower to equivalent costs over the first year of life. Combined with previous evidence suggesting clinical noninferiority, these findings suggest that PDA stent provides competitive health care value.