A theoretical and practical approach to quality improvement education.

Quality Improvement (QI) knowledge and skills are required at all levels of physician training. System improvement efforts need to include understanding of health disparities and design of interventions to reduce those disparities, thus health equity needs to be integrated into QI education. Payors, accreditation bodies and health systems' emphases on QI result in the need for QI curricula that meet the needs of diverse learners. This article presents a theoretical background and practical tools for designing, implementing, and evaluating a QI educational program across the spectrum of physician training with an emphasis on competency-based education and a goal of continuous practice improvement. Practice-based learning and improvement and systems-based practice are two core domains of competencies for readiness to practice. These competencies can be met through the health systems science framework for studying improvement in patient care and health care delivery coupled with QI science. Curricula should incorporate interactive learning of theory and principles of QI as well as mentored, experiential QI project work with multidisciplinary teams. QI projects often develop ideas and implement changes but are often inconsistent in studying intervention impacts or reaching the level of patient outcomes. Curriculum design should incorporate adult learning principles, competency based medical education, environmental and audience factors, and formats for content delivery. Key QI topics and how they fit into the clinical environment and teaching resources are provided, as well as options for faculty development. Approaches to evaluation are presented, along with tools for assessing learner's beliefs and attitudes, knowledge and application of QI principles, project evaluation, competency and curriculum evaluation. If the goal is to empower the next generation of change agents, there remains a need for development of scientific methodology and scholarly work, as well as faculty development and support by institutions.

Expansion of a multi-pronged safe sleep quality improvement initiative to three children's hospital campuses.

BACKGROUND: The American Academy of Pediatrics (AAP) recommends infants should be Alone, on their Back, and in a clear Crib to combat relatively stagnant rates of sudden unexpected infant death (SUID). These are referred to as the ABCs of safe sleep. Studies have shown these recommendations are not consistently followed in the hospital setting, but further investigation would determine how to improve the rate of adherence. The objective of this study was to evaluate the impact of an expanded safe sleep initiative at three Georgia free-standing children's hospital campuses before and after a multipronged safe sleep initiative. METHODS: A quality improvement program with a pre/post analysis was performed using a convenience method of sampling. Infants < 12 months old in three inpatient pediatric campuses were analyzed pre- and post- interventions. The intervention included: 1) nursing education, 2) identification of nurse "safe sleep" champions, 3) crib cards, 4) crib audits, and 5) weekly reporting of data showing nursing unit ABC compliance via tracking boards. The goal was ABC compliance of ≥25% for the post-intervention period. A standardized crib audit tool evaluated sleep position/location, sleep environment, and ABC compliance (both safe position/location and environment). Chi square analysis, Fisher's exact test, and logistic regression were used to compare safe sleep behaviors before and after the interventions. RESULTS: There were 204 cribs included pre-intervention and 274 cribs post-intervention. Overall, there was not a significant change in sleep position/location (78.4 to 76.6%, p = 0.64). There was a significant increase in the percent of infants sleeping in a safe sleep environment following the intervention (5.9 to 39.8%, p < 0.01). Overall ABC compliance, including both sleep position/location and environment, improved from 4.4% pre-intervention to 32.5% post-intervention (p < 0.01). There was no significant variability between the hospitals (p = 0.71, p = 1.00). CONCLUSIONS: The AAP's safe sleep recommendations are currently not upheld in children's hospitals, but safer sleep was achieved across three children's campuses in this study. Significant improvements were made in sleep environment and overall safe sleep compliance with this multi-pronged initiative.

Preventability of Pediatric 30-Day Readmissions following Ventricular Shunt Surgery.

OBJECTIVE: To compare the preventability of 30-day pediatric ventricular shunt readmissions using clinical and administrative data review. STUDY DESIGN: We performed a retrospective chart review of one hundred forty-seven 30-day ventricular shunt readmissions at a tertiary pediatric center from May 2009-April 2013 under 2 scenarios: scenario 1 considered all ventricular shunt failures preventable; and scenario 2 considered shunt failures with excellent/good catheter positioning and no contributing deficiencies in care not preventable. Three physician reviewers independently assessed readmissions to determine their preventability and whether deficiencies in care existed that contributed to the readmission. We also evaluated the degree of interrater agreement in adjudicating readmission preventability. RESULTS: Only 42% of 30-day readmissions following ventricular shunt procedures were preventable when considering all shunt failures as preventable. When classifying shunts with excellent/good proximal catheter position as not preventable, 21% of ventricular shunt readmissions were deemed preventable. Interrater agreement on readmission preventability was high (kappa 0.88). Deficiencies in care existed in 29 readmissions (20%), the largest category being physician related, but not all deficiencies contributed to a readmission. CONCLUSIONS: Significant discrepancy exists in the preventability adjudication of ventricular shunt readmissions between administrative and chart review. Although using administrative data has determined that a majority of readmissions following pediatric ventricular shunt procedures are preventable, our review suggests a significantly lower degree of preventability.

Childhood immunization rates in rural Intibucá, Honduras: an analysis of a local database tool and community health center records for assessing and improving vaccine coverage.

BACKGROUND: Vaccines are highly effective at preventing infectious diseases in children, and prevention is especially important in resource-limited countries where treatment is difficult to access. In Honduras, the World Health Organization (WHO) reports very high immunization rates in children. To determine whether or not these estimates accurately depict the immunization coverage in non-urban regions of the country, we compared the WHO data to immunization rates obtained from a local database tool and community health center records in rural Intibucá, Honduras. METHODS: We used data from two sources to comprehensively evaluate immunization rates in the area: 1) census data from a local database and 2) immunization data collected at health centers. We compared these rates using logistic regression, and we compared them to publicly available WHO-reported estimates using confidence interval inclusion. RESULTS: We found that mean immunization rates for each vaccine were high (range 84.4 to 98.8 percent), but rates recorded at the health centers were significantly higher than those reported from the census data (p ≤ 0.001). Combining the results from both databases, the mean rates of four out of five vaccines were less than WHO-reported rates (p <0.05). Overall immunization rates were significantly different between townships (p=0.03). The rates by individual vaccine were similar across townships (p >0.05), except for diphtheria/tetanus/pertussis vaccine (p=0.02) and oral polio vaccine (p <0.01). CONCLUSIONS: Immunization rates in Honduras were high across data sources, though most of the rates recorded in rural Honduras were less than WHO-reported rates. Despite geographical difficulties and barriers to access, the local database and Honduran community health workers have developed a thorough system for ensuring that children receive their immunizations on time. The successful integration of community health workers and a database within the Honduran decentralized health system may serve as a model for other immunization programs in resource-limited countries where health care is less accessible.

A randomized, placebo-controlled trial of ondansetron, metoclopramide, and promethazine in adults.

OBJECTIVES: The objective of the study was to assess whether ondansetron has superior nausea reduction compared with metoclopramide, promethazine, or saline placebo in emergency department (ED) adults. METHODS: This randomized, placebo-controlled, double-blinded superiority trial was intended to enroll a convenience sample of 600 patients. Nausea was evaluated on a 100-mm visual analog scale (VAS) at baseline and 30 minutes after treatment. Patients with a minimum preenrollment VAS of 40 mm were randomized to intravenous ondansetron 4 mg, metoclopramide 10 mg, promethazine 12.5 mg, or saline placebo. A 12-mm VAS improvement in nausea severity was deemed clinically important. We measured potential drug adverse effects at baseline and 30 minutes. Patients received approximately 500 mL of saline hydration during the initial 30 minutes. RESULTS: Of 180 subjects who consented, 163 completed the study. The median age was 32 years (interquartile range, 23-47), and 68% were female. The median 30-minute VAS reductions (95% confidence intervals) and saline volume given for ondansetron, metoclopramide, promethazine, and saline were -22 (-32 to -15), -30 (-38 to -25.5), -29 (-40 to -21), and -16 (-25 to -3), and 500, 500, 500, and 450, respectively. The median 30-minute VAS differences (95% confidence intervals) between ondansetron and metoclopramide, promethazine, and saline were -8 (-18.5 to 3), -7 (-21 to -5.5), and 6 (-7 to 20), respectively. We compared the antiemetic efficacy across all treatments with the Kruskal-Wallis test (P = .16). CONCLUSIONS: Our study shows no evidence that ondansetron is superior to metoclopramide and promethazine in reducing nausea in ED adults. Early study termination may have limited detection of ondansetron's superior nausea reduction over saline.