Improving WeeFIM score completion rates: An interdisciplinary inpatient rehabilitation unit quality improvement project.

PURPOSE: The WeeFIM is a tool commonly used in pediatric rehabilitation settings to measure objective patient progress while receiving comprehensive therapy services on inpatient rehabilitation units. This Quality Improvement (QI) project aimed for 95% of inpatients to have complete, on-time documented and displayed WeeFIM scores upon admission and discharge by 12/2017. METHODS: An interdisciplinary team examined historic WeeFIM completion rates. Using Plan-Do-Study-Act cycles, a unified flowsheet was developed in the electronic health record (EHR) to revamp workflow and identify opportunities for improvement, data accuracy, and finally sustainability. Progress was monitored in real time via an automated data visualization tool which monitored score timeliness and completeness. RESULTS: On-time admission completion rates increased from 0% to 95% during the intervention period. On-time discharge completion rates increased from 0% to 89% during the intervention period. This change has been sustained over two years with on-time admission and discharge scores averaging 79.4% and 77.9% respectively, and 96.4% of scores completed. CONCLUSION: Changes in the completion rate of WeeFIMs are sustainable, evidenced by ongoing maintenance of our initial gains over the course of multiple months. The incorporation of WeeFIM documentation into the workflow increased on-time and overall completion rates. The success of this project shows that integrating new tasks into provider workflows helps drive completion.

Outcome Monitoring and Clinical Decision Support in Polyarticular Juvenile Idiopathic Arthritis.

OBJECTIVE: Inconsistent assessment and treatment may impair juvenile idiopathic arthritis (JIA) outcomes. We aimed to improve polyarticular JIA (rheumatoid factor-positive and -negative) outcomes by standardizing point-of-care disease activity monitoring and implementing clinical decision support (CDS) to reduce treatment variation. METHODS: We performed a quality improvement initiative in an outpatient pediatric rheumatology practice. The interventions, implemented from April to November 2016, included standardized disease activity measurement, disease activity target review, and phased introduction of polyarticular JIA CDS to guide medication selection, dosing, treatment duration, and tapering. Process measures included visit-level target attestation (goal: 50%) and CDS use (goal: 15%). Our goal was to reduce the polyarticular JIA clinical Juvenile Arthritis Disease Activity Score (cJADAS-10) by at least 10%. Included patients had at least 2 visits from April 2016 through July 2017, and were classified as having early (≤ 6 mos) or established disease (> 6 mos). RESULTS: Patients with polyarticular JIA (n = 97; 81% established disease) were observed for 10.3 months (interquartile range: 6.4-12.3). Target attestation and CDS use occurred in a mean of 77% and 45% of polyarticular JIA visits, respectively. The median cJADAS-10 decreased significantly in both early (16.5 to 2.7, p < 0.001) and established polyarticular JIA (2.1 to 1.0, p = 0.01). A high proportion of patients with early disease received biologic therapy (73.7%). In established disease, although prescription of nonbiologic and biologic disease-modifying antirheumatic drugs remained similar overall, adalimumab prescribing increased (12.8% to 23.1%, p = 0.008). CONCLUSION: Implementation of structured disease activity monitoring and CDS in polyarticular JIA was associated with significant reductions in disease activity scores in both early and established disease.

Reducing Unnecessary Postoperative Complete Blood Count Testing in the Pediatric Intensive Care Unit.

CONTEXT: Complete blood count (CBC) testing commonly occurs to determine the need for blood transfusions after surgical procedures. Many clinicians believe postoperative CBCs are "routine." OBJECTIVE: To decrease unnecessary routine CBC testing in a low-risk cohort of postoperative patients in the pediatric intensive care unit (PICU) at The Children's Hospital of Philadelphia by 50% in 6 months. DESIGN: Quality-improvement study. Data from our institution regarding frequency of ordering laboratory studies and transfusion requirements were collected for prior quality-improvement work demonstrating the safety and feasibility of avoiding routine postoperative CBCs in this cohort. Baseline survey data were gathered from key stakeholders on attitudes about and utilization of routine postoperative laboratory testing. Patient and clinician data were shared with all PICU clinicians. Simple Plan-Do-Study-Act cycles involving education, audit, and feedback were put into place. MAIN OUTCOME MEASURES: Percentage of postoperative patients receiving CBCs within 48 hours of PICU admission. Balancing measures were hemoglobin level below 8 g/dL in patients for whom CBCs were sent and blood transfusions up to 7 days postoperatively for any patients in this cohort. RESULTS: Sustained decreases below our 50% goal were seen after our interventions. There were no hemoglobin results below 8 g/dL or surgery-related blood transfusions in this cohort within 7 days of surgery. Estimated hospital charges related to routine postoperative CBCs decreased by 87% during 6 postintervention months. CONCLUSION: A simple approach to a systemic problem in the PICU of unnecessary laboratory testing is feasible and effective. By using local historical data, we were able to identify a cohort of patients for whom routine postoperative CBC testing is unnecessary.

Pediatric perioperative adverse events requiring rapid response: a retrospective case-control study.

BACKGROUND: Perioperative pediatric adverse events have been challenging to study within and across institutions due to varying definitions, low event rates, and incomplete capture. AIM: The aim of this study was to determine perioperative adverse event prevalence and to evaluate associated case characteristics and potential contributing factors at an academic pediatric quaternary-care center. METHODS: At the Children's Hospital of Philadelphia (CHOP), perioperative adverse events requiring rapid response assistance are termed Anesthesia Now (AN!) events. They have been accurately captured and entered into a quality improvement database since 2010. Adverse events involving open heart and cardiac catheterization cases are managed separately and not included in this database. We conducted a retrospective case-control study utilizing Compurecord (Phillips Healthcare, Andover, MA, USA), EPIC (EPIC, Verona, WI, USA), and Chartmaxx (MedPlus, Mason, OH, USA) systems matching AN! event cases to noncardiac controls (1 : 2) based on surgical date. RESULTS: From April 16, 2010 to September 25, 2012, we documented 213 AN! events in the noncardiac perioperative complex and remote sites at our main hospital. AN! prevalence was 0.0043 (1 : 234) with a 95% confidence interval (CI) (0.0037, 0.0049). Respiratory events, primarily laryngospasm, were most common followed by events of cardiovascular etiology. Median age was lower in the AN! group than in controls, 2.86 years (interquartile range 0.94, 10.1) vs 6.20 (2.85, 13.1), P < 0.0001. Odds ratios (with 95% CI) for age, 0.969 (0.941, 0.997); American Society of Anesthesiologists physical status, 1.67 (1.32, 2.12); multiple (≥2) services, 2.27 (1.13, 4.55); nonoperating room vs operating room location, 0.240 (0.133, 0.431); and attending anesthesiologist's experience, 0.976 (0.959, 0.992) were all significant. CONCLUSIONS: Decreased age, increased comorbidities, multiple (vs single) surgical services, operating room (vs nonoperating room) location, and decreased staff experience were associated with increased risk of AN! events, which were predominantly respiratory in origin.