Development of an Electronic Pediatric All-Cause Harm Measurement Tool Using a Modified Delphi Method.

OBJECTIVES: To have impact on reducing harm in pediatric inpatients, an efficient and reliable process for harm detection is needed. This work describes the first step toward the development of a pediatric all-cause harm measurement tool by recognized experts in the field. METHODS: An international group of leaders in pediatric patient safety and informatics were charged with developing a comprehensive pediatric inpatient all-cause harm measurement tool using a modified Delphi technique. The process was conducted in 5 distinct steps: (1) literature review of triggers (elements from a medical record that assist in identifying patient harm) for inclusion; (2) translation of triggers to likely associated harm, improving the ability for expert prioritization; (3) 2 applications of a modified Delphi selection approach with consensus criteria using severity and frequency of harm as well as detectability of the associated trigger as criteria to rate each trigger and associated harm; (4) developing specific trigger logic and relevant values when applicable; and (5) final vetting of the entire trigger list for pilot testing. RESULTS: Literature and expert panel review identified 108 triggers and associated harms suitable for consideration (steps 1 and 2). This list was pared to 64 triggers and their associated harms after the first of the 2 independent expert reviews. The second independent expert review led to further refinement of the trigger package, resulting in 46 items for inclusion (step 3). Adding in specific trigger logic expanded the list. Final review and voting resulted in a list of 51 triggers (steps 4 and 5). CONCLUSIONS: Application of a modified Delphi method on an expert-constructed list of 108 triggers, focusing on severity and frequency of harms as well as detectability of triggers in an electronic medical record, resulted in a final list of 51 pediatric triggers. Pilot testing this list of pediatric triggers to identify all-cause harm for pediatric inpatients is the next step to establish the appropriateness of each trigger for inclusion in a global pediatric safety measurement tool.

Increasing Compliance With an Antibiotic Prophylaxis Guideline to Prevent Pediatric Surgical Site Infection: Before and After Study.

OBJECTIVES: To evaluate an intervention for improving antibiotic prophylaxis (AP) guideline compliance to prevent surgical site infections in children. BACKGROUND: Although appropriate AP reduces surgical site infection, and guidelines improve quality of care, changing practice is difficult. To facilitate behavioral change, various barriers need to be addressed. METHODS: A multidisciplinary task force at a pediatric hospital developed an evidence-based AP guideline. Subsequently, the guideline was posted in operating rooms and the online formulary, only recommended antibiotics were available in operating rooms, incoming trainees received orientation, antibiotic verification was included in time-out, computerized alerts were set for inappropriate postoperative prophylaxis, and surgeons received e-mails when guideline was not followed. AP indication and administration were documented for surgical procedures in July 2008 (preintervention), September 2011 (postintervention), and April-May 2013 (follow-up). Compliance was defined as complete--appropriate antibiotic, dose, timing, redosing, and duration when prophylaxis was indicated; partial--appropriate drug and timing when prophylaxis was indicated; and appropriate use--complete compliance when prophylaxis was indicated, no antibiotics when not indicated. Compliance at preintervention and follow-up was compared using χ(2) tests. RESULTS: AP was indicated in 43.9% (187/426) and 62.0% (124/200) of surgical procedures at preintervention and follow-up, respectively. There were significant improvements in appropriate antibiotic use (51.6%-67.0%; P < 0.001), complete (26.2%-53.2%; P < 0.001) and partial compliance (73.3%-88.7%, P = 0.001), correct dosage (77.5%-90.7%; P = 0.003), timing (83.3%-95.8%; P = 0.001), redosing (62.5%-95.8%, P = 0.003), and duration (47.1%-65.3%; P < 0.002). CONCLUSIONS: A multifaceted intervention improved compliance with a pediatric AP guideline.

Antibiotic Prophylaxis to Prevent Surgical Site Infections in Children: A Prospective Cohort Study.

OBJECTIVE: To investigate the association between antibiotic prophylaxis (AP) and surgical-site infection in pediatric patients. BACKGROUND: Surgical-site infections (SSIs) are a major cause of postoperative morbidity and mortality. Despite numerous studies in adults, benefit of AP in preventing SSIs in children is uncertain. METHODS: Patients aged 0 to 21 years who underwent surgical procedures at a pediatric acute care hospital from April 1, 2009, to December 31, 2010, were assessed. Antibiotic prophylaxis indication and administration according to an evidence-based guideline were recorded. Complete compliance was defined as AP given, when indicated, within 60 minutes before incision. Surgical-site infections were identified using the Centers for Disease Control and Prevention criteria and documented in the medical records using the International Classification of Diseases, Tenth Revision. Multiple logistic regressions adjusting for age, sex, American Society of Anesthesiologists status, wound classification, admission status, surgical discipline, and surgical duration evaluated association of AP compliance and SSI. RESULTS: Of 5309 patients for whom antibiotics were indicated, 3901 (73.5%) with complete compliance had an infection rate of 3.0%, whereas 1408 (26.5%) who were not compliant had an infection rate of 4.3% (adjusted relative risk: 0.7; 95% confidence interval: 0.5-0.9; P = 0.02). Of 4156 patients for whom antibiotics were not indicated, the 895 (21.5%) who received antibiotics had an infection rate of 1.7% compared with 0.7% in the 3261 (78.5%) who did not receive antibiotics (adjusted relative risk: 1.6; 95% confidence interval: 0.8-3.1; P = 0.18). CONCLUSIONS: In pediatric surgery, complete compliance with AP was associated with 30% decreased risk of SSI.

Adverse events among children in Canadian hospitals: the Canadian Paediatric Adverse Events Study.

BACKGROUND: Limited data are available on adverse events among children admitted to hospital. The Canadian Paediatric Adverse Events Study was done to describe the epidemiology of adverse events among children in hospital in Canada. METHODS: We performed a 2-stage medical record review at 8 academic pediatric centres and 14 community hospitals in Canada. We reviewed charts from patients admitted from April 2008 through March 2009, evenly distributed across 4 age groups (0 to 28 d; 29 to 365 d; > 1 to 5 yr and > 5 to 18 yr). In stage 1, nurses and health records personnel who had received training in the use of the Canadian Paediatric Trigger Tool reviewed medical records to detect triggers for possible adverse events. In stage 2, physicians reviewed the charts identified as having triggers and described the adverse events. RESULTS: A total of 3669 children were admitted to hospital during the study period. The weighted rate of adverse events was 9.2%. Adverse events were more frequent in academic pediatric centres than in community hospitals (adjusted odds ratio [OR] 2.98, 95% confidence interval [CI] 1.65-5.39). The incidence of preventable adverse events was not significantly different between types of hospital, but nonpreventable adverse events were more common in academic pediatric centres (adjusted OR 4.39, 95% CI 2.08-9.27). Surgical events predominated overall and occurred more frequently in academic pediatric centres than in community hospitals (37.2% v. 21.5%, relative risk [RR] 1.7, 95% CI 1.0-3.1), whereas events associated with diagnostic errors were significantly less frequent (11.1% v. 23.1%, RR 0.5, 95% CI 0.2-0.9). INTERPRETATION: More children have adverse events in academic pediatric centres than in community hospitals; however, adverse events in the former are less likely to be preventable. There are many opportunities to reduce harm affecting children in hospital in Canada, particularly related to surgery, intensive care and diagnostic error.

The value of a quality improvement project in promoting interprofessional collaboration.

The teamwork that is required for interprofessional collaboration in healthcare is not an inherent attribute of the current system, and must be fostered. Education, training, and role modelling are important enablers. From our experience we posit that participating in a quality improvement project can be also be an excellent vehicle to promote interprofessional collaboration.

Attitudes and beliefs, not just knowledge, influence the effectiveness of environmental cleaning by environmental service workers.

BACKGROUND: Hospital environmental service workers (ESWs) play an important role in interrupting the chain of infection because the environment is a reservoir for nosocomial pathogens. Improving ESWs' knowledge through education has been shown to improve ESW cleaning, but the behavioral determinants of their work have not been studied. Understanding and targeting ESWs' attitudes and beliefs may inform strategies to improve environmental cleaning. METHODS: With the theory of planned behavior as framework, we used questionnaires and focus groups to examine intensive care unit ESWs' attitudes, beliefs [behavioral, normative, and control], and control) and intent about their job. Baseline quantitative microbial cultures of high-touch services were performed before and after cleaning. After an educational intervention addressing their attitudes, beliefs, and general infection control knowledge, attitudes, beliefs, and microbial contamination were reassessed. RESULTS: Beliefs were uniformly strong (4.5/5-5/5), and normative beliefs correlated best with intent to clean (R(2) = 0.3). Themes elicited from the focus groups included "me versus them," lack of appreciation, pride in work, and "if it were me." The rate of environmental contamination was significantly improved after the intervention (P = .0074 vs P = .0023, respectively); the measured relationship among attitudes, beliefs, and intent was not significantly changed. CONCLUSION: ESWs' attitudes and beliefs about their job may impact their intent to clean and in turn the effectiveness of their efforts. Understanding and addressing these attitudes and beliefs can be used to inform strategies for sustained improvement of environmental cleaning.

Description of the development and validation of the Canadian Paediatric Trigger Tool.

OBJECTIVE: To describe the process of developing and validating the Canadian Association of Paediatric Health Centres Trigger Tool (CPTT). METHODS: Five existing trigger tools were consolidated with duplicate triggers eliminated. After a risk analysis and modified Delphi process, the tool was reduced from 94 to 47 triggers. Feasibility of use was tested, reviewing 40 charts in three hospitals. For validation, charts were randomly selected across four age groups, half medical/half surgical diagnoses, from six paediatric academic health sciences centres. 591 charts were reviewed by six nurses (for triggers and adverse events (AEs)) and three physicians (for AEs only). The incidence of trigger- and AE-positive charts was documented, and the sensitivity and specificity of the tool to identify charts with AEs were determined. Identification of AEs by nurses and physicians was compared. The positive predictive value (PPV) of each trigger was calculated and the ratio of false- to true-positive AE predictors analysed for each trigger. RESULTS: Nurses rated the CPTT easy to use and identified triggers in 61.1% (361/591; 95% CI 57.2 to 65.0) of patient charts; physicians identified AEs in 15.1% (89/ 591, 95% CI 0.23 to 0.43). Over a third of patients with AEs were neonates. The sensitivity and specificity were 0.88 and 0.44, respectively. Nurse and physician AE assessments correlated poorly. The PPV for each trigger ranged from 0 to 88.3%. Triggers with a false/true-positive ratio of >0.7 were eliminated, resulting in the final 35-trigger CPTT. CONCLUSIONS: The CPTT is the first validated, comprehensive trigger tool available to detect AEs in children hospitalised in acute care facilities.

An outbreak of vancomycin-resistant Enterococcus faecium in an acute care pediatric hospital: Lessons from environmental screening and a case-control study.

BACKGROUND: The present study describes a vancomycin-resistant enterococci (VRE) outbreak investigation and a case-control study to identify risk factors for VRE acquisition in a tertiary care pediatric hospital. OBJECTIVE: To report an outbreak investigation and a case-control study to identify risk factors for VRE colonization or infection in hospitalized children. METHODS: Screening for VRE cases was performed by culture or polymerase chain reaction. A case-control study of VRE-colonized patients was undertaken. Environmental screening was performed using standard culture and susceptibility methods, with pulsed-field gel electrophoresis to determine relationships between VRE isolates. Statistical analysis was performed using SAS version 9.0 (SAS Institute Inc, USA). RESULTS: Thirty-four VRE-positive cases were identified on 10 wards between February 28, 2005, and May 27, 2005. Pulsed-field gel electrophoresis analysis confirmed a single outbreak strain that was also isolated from a video game found on one affected ward. Multivariate analysis identified cephalosporin use as the major risk factor for VRE colonization. CONCLUSIONS: In the present study outbreak, VRE colonization was significantly associated with cephalosporin use. Because shared recreational items and environmental surfaces may be colonized by VRE, they warrant particular attention in housekeeping protocols, particularly in pediatric institutions.

Identification badges: a potential fomite?

BACKGROUND: Staff identification badges are mandatory in all hospitals. The purpose of this study was to assess microbial contamination of identification badges at a Canadian tertiary centre. Risk factors for badge contamination were also investigated. METHODS: Badges were cultured from 118 subjects including secretaries, physicians, nurses, and allied health workers. Subjects also completed a demographic questionnaire. Badge contamination was analyzed according to profession, workplace, duration of badge use, presence of a plastic cover, how the badge was worn, and cleaning frequency. RESULTS: 13.6% of the badges were contaminated with significant pathogens. S. aureus was isolated in 6.8% of the badges, gram-negative bacilli in 5.9%. Contamination was highest in nurses (21.4% versus 9.4-14.3% in other professions) and in the ICU (22.6% versus 8.3%-14.3% at other locations). Neither association was statistically significant. Covered and non-covered badges had similar contamination rates (12% and 17.1%) as did badges worn around the neck compared with those worn clipped to clothing (13.0% versus 14.6%). Contamination of recently cleaned badges was not statistically different from those that had not. CONCLUSION: Identification badges do not appear to be a major reservoir for pathogenic organisms. Badges can, however, harbour disease-causing organisms and should be cleaned regularly.

A study of provider-caregiver communication in paediatric ambulatory care.

BACKGROUND: Provider-caregiver communication is a key ingredient in quality health care and patient safety, and effective communication has been shown to affect compliance and outcomes. OBJECTIVES: To identify and compare communication issues among three paediatric outpatient clinics. METHODS: In this prospective, qualitative study, a questionnaire was used to survey physicians, nurse practitioners and caregivers at three different infectious diseases clinics. RESULTS: There was a statistically significant preponderance of families in the tuberculosis clinic for whom English was not the mother tongue and who were not fluent in English. Patients in the HIV clinic were less likely to be at their first appointment than were patients attending the other clinics. Patients in the general clinic were less likely to have been seen by the same physician on the previous visit. Parents from all three clinics were satisfied with the care they received, with communication and with rapport with their child. There was a trend toward parents in the tuberculosis clinic being happier with their clinic visit and less likely to complain about the wait time. CONCLUSIONS: Language proficiency and lack of continuity of provider care were identified as potential risks for patient safety in the ambulatory setting. Further studies are necessary to identify language and cultural issues that may affect patient care in a tertiary paediatric hospital servicing a multiethnic population.

Nosocomial urinary tract infections in children in a pediatric intensive care unit: a follow-up after 10 years.

OBJECTIVE: To define nosocomial urinary tract infection (NUTI) rates in a pediatric intensive care unit, and determine whether practice recommendations have been sustained after 10 yrs. DESIGN: Retrospective, descriptive observational study followed by point prevalence audits of duration of urinary tract catheterization. SETTING: A 32-bed pediatric intensive care unit in a multidisciplinary, 300-bed, university-affiliated tertiary care hospital. SUBJECTS: The retrospective review included patients admitted to the pediatric intensive care unit between December 1997 and July 1999 who developed a NUTI. The audits of duration of urinary tract catheterization were performed in December 2001. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary outcome measure was the development of NUTI. Out of 2,832 consecutive admissions, 25 patients developed 27 episodes of NUTI (rate, 0.95/100 admissions). Previous surgery for congenital heart disease was the primary risk factor for NUTI. All 18 patients for whom the duration of catheterization was available had been catheterized for at least 3 days. Gram-negative bacilli and yeast accounted for 82% of NUTI pathogens. Twenty percent of bacterial pathogens were antibiotic resistant. Audits of the duration of urinary tract catheterization done on five separate occasions revealed that the mean duration of catheterization ranged from 3.5 to 4.7 days, with a peak absolute value of 16 days. CONCLUSIONS: NUTIs in children in our pediatric intensive care unit were associated with previous cardiovascular surgery and with urinary tract catheterization of at least 3 days. The need for careful fluid monitoring by catheterization must be balanced against the increased risk of catheter-related urinary tract infection. Removal of urinary catheters at the earliest opportunity will prevent many infections. Ongoing education or innovative strategies will be required to sustain optimal practice.