Improving the Compliance of Intraoperative Antibiotic Redosing: A Quality Improvement Initiative.

INTRODUCTION: At Children's Hospital and Medical Center in Omaha, Nebraska, the intraoperative antibiotic redosing guidelines and the time frame considered compliant for redosing were unclear. This lack of clarity plus an ill-defined process for ensuring intraoperative antibiotic redosing resulted in a compliance rate of 11%. The organization's surgical site infection (SSI) rate was 3.19%, above the national benchmark of 1.87%. The primary project goal was to increase intraoperative antibiotic redosing compliance. The secondary project goal was to decrease SSIs. METHODS: With recommendations from the Infectious Disease Society of America, we developed new organizational redosing guidelines, as well as a new antibiotic-specific reminder alert in the electronic medical record. Implementation of the new guidelines and processes occurred after providing education to the anesthesiologists, surgeons, and circulating nurses. Monthly evaluation of data allowed for quick recognition of oversights followed by the initiation of process updates. RESULTS: Data showed that the initial compliance rate for the intraoperative redosing of antibiotics was 11%. Following interventions, compliance has reached and sustained an average of 99%. Survey results show that provider knowledge of the guidelines and process has improved. Though not directly related, the National Surgical Quality Improvement Program observed that the SSI rate decreased from 3.19% in 2014 to 2.3% in 2018. CONCLUSIONS: This project demonstrates that comprehensive education along with antibiotic-specific electronic medical record alerts significantly increased the compliance of intraoperative antibiotic redosing at Children's Hospital & Medical Center. Continuous education and monthly updates sustained results for over 40 months.

Don't Have a Doubt, Get the Catheter Out: A Nurse-Driven CAUTI Prevention Protocol.

Despite the use of sterile technique for indwelling urinary catheter insertion, as well as use of the defined catheter-associated urinary tract infection (CAUTI) bundle elements per Children's Hospitals' Solutions for Patient Safety, the CAUTI rate in the pediatric intensive care unit (PICU) at a free-standing pediatric hospital was increasing. In 2017, the PICU accounted for 87% of the organization's CAUTIs and 65% of the total indwelling catheter device days. With an important risk factor for CAUTIs being the duration of catheterization, the indication for catheters became an organizational executive priority. METHODS: An early 2017 review of the bundle elements identified that the indication for catheterization was not consistently addressed in daily patient rounds. A multidisciplinary project team applying the Plan, Do, Check, Act methodology developed an evidenced-based, nurse-driven indwelling urinary catheter removal protocol. This protocol allows nursing autonomy when removing a catheter by providing clinical indications for catheter use and promoting prompt removal when no longer indicated. RESULTS: Indwelling urinary catheter device days in the PICU decreased by 28% within 6 months of protocol implementation. The PICU CAUTI rate declined from 4.8 (per 1,000 device days) in 2017 to 0.8 in 2018, 1 year after protocol implementation. CONCLUSIONS: Providing the bedside nurse with an evidence-based protocol that is driven by specific patient indications and diagnoses allows them to practice autonomously in catheter removal. Prompt removal of indwelling urinary catheters results in decreased device days and decreased incidence of CAUTIs.

Disclosure of Adverse Events: A Guide for Clinicians.

INTRODUCTION: Children's Hospitals' Solutions for Patient Safety (SPS) acknowledged a recommendation from the American Academy of Pediatrics to develop education programs on the communication of adverse events with patients and families. SPS set out to create a guide that would outline a standardized disclosure process and provide a training curriculum and tools so that providers would feel better prepared to have effective disclosure conversations. METHODS: SPS disclosure work began with the development of a project team made up of 9 network hospitals. The team utilized key driver diagrams and process maps to show the relationship between the project aims, key drivers, and specific interventions. The team developed a training curriculum, guide, and tools for each area of improvement. To ensure these were effective, they were tested using case studies and plan-do-study-act cycles. RESULTS: One of the cohort hospitals piloted the curriculum and tools, training 48 physicians, nurses, executives, and other allied health professionals. Pretest to posttest scores improved from an average of 82.7% to 90.2%. Survey feedback was favorable with 100% of respondents noting that they strongly agree or agree that attending this educational activity increased or improved their competency, performance, and patient outcomes. CONCLUSIONS: Initial testing suggests that the developed curriculum is empowering for frontline clinicians. Materials are available in an electronic format on the SPS external website. As member hospitals implement these materials, they will be evaluating learner satisfaction and provider usage. SPS will seek out feedback from these hospitals to further develop the materials and support clinicians.

Reducing Serious Safety Events and Priority Hospital-Acquired Conditions in a Pediatric Hospital with the Implementation of a Patient Safety Program.

BACKGROUND: A freestanding children's hospital evaluated the impact of a patient safety program on serious safety events (SSEs) and hospital-acquired conditions (HACs). METHODS: The No Harm Patient Safety Program was developed throughout the organization using a multifaceted approach that included safety moments, leadership rounding, cause analysis changes, event reporting enhancements, error prevention training, leadership training, identifying priority HACs, Eye on Safety Campaign, and safety coaches. The organization set strategic goals for improvement of SSEs and priority HACs. RESULTS: The rate of SSEs decreased from 0.19 in 2014 to 0.09 in 2015. The rate significantly declined from 2015 to 2016 to a rate of 0.00, for a rate difference of -0.00009 (95% confidence interval [CI]: -0.00016, -0.00002; p = 0.012). The organization reached two years without an SSE in July 2017. The central line-associated bloodstream infection rate significantly declined from 2.8 per 1,000 line-days in 2015 to 1.6 in 2016, for a difference of -0.00118 (95% CI: -0.002270, -0.00008; p = 0.036). Surgical site infection rates declined from a 2015 rate of 3.8 infections per 100 procedures to a 2016 rate of 2.6 (p = 0.2962), and catheter-associated urinary tract infection rates declined from a 2015 rate of 2.7 per 1,000 catheter-days to a 2016 rate of 1.4 (p = 0.2770). CONCLUSION: The No Harm Patient Safety Program was interwoven into the organization's strategic mission and values, and key messaging was used to purposefully tie the many interventions being implemented back to it. These interventions were associated with improvements in patient safety outcomes.

Costs Associated with Ebola Preparedness at a Freestanding Pediatric Assessment Center.

The 2014-2016 West Africa Ebola outbreak led US hospitals to prepare to treat Ebola patients, with significant attributable costs. A nationwide preparedness transition to a tiered approach allowed regional allocation of preparedness resources for Ebola frontline, assessment, and treatment hospitals. Preparedness costs for assessment centers were significant and largely uncompensated. Infect Control Hosp Epidemiol 2017;38:1367-1369.