Hanchoi2256

Structured handoffs at transitions of care are vital components of patient safety. A safety culture survey showed that "handoffs and transitions" were among the lowest scoring dimensions at our hospital. We sought to improve physician handoffs and safety culture scores by implementing standardized handoff communication across multiple divisions of an academic pediatric department.

We used a modified learning collaborative model to implement an I-PASS program, including training, standardized verbal handoff processes, observation and feedback, and sustainment. The setting was the Department of Pediatrics (DoP) within a tertiary academic children's hospital encompassing 13 clinical divisions. The primary outcome was a change in the DoP staff physician "handoffs and transitions" score on the Agency for Healthcare Quality (AHRQ) Hospital Survey on Patient Safety Culture. Process measures included handoff duration and proportion of handoffs using the complete I-PASS mnemonic.

Five hundred sixty-seven physicians from clinical divisions participated over 14 months. One hundred percent of eligible physicians completed an introductory online I-PASS training module. The "handoffs and transitions" score improved from 46% to 54% from 2018 to 2020. From May 2019 to February 2020, the proportion of observed handoffs with all five elements of the I-PASS mnemonic improved from 62% to 100%, and the duration of handoffs per patient did not change.

We successfully implemented an I-PASS program across an academic department of pediatrics. The departmental staff physician safety culture "handoff and transitions" score improved. The adherence to the I-PASS mnemonic improved. The duration of handoffs did not change over the study period.

We successfully implemented an I-PASS program across an academic department of pediatrics. The departmental staff physician safety culture "handoff and transitions" score improved. The adherence to the I-PASS mnemonic improved. The duration of handoffs did not change over the study period.More severe presentations of diabetic ketoacidosis (DKA) have been reported during the coronavirus disease 2019 (COVID-19) pandemic, possibly due to avoidance of healthcare settings or reduced access to care. To date, no studies have utilized statistical process control to relate temporal COVID-19 events with DKA severity. Our objectives were (1) to determine whether the severity of pediatric DKA presentations changed during COVID-19 and (2) to temporally relate changes in severity with regional pandemic events.

This study was a retrospective chart review of 175 patients younger than 18 years with DKA presenting to a pediatric emergency department in the United States between 5/1/2019 and 8/15/2020. As part of our ongoing clinical standard work in ED management of DKA, DKA severity measures, including presenting pH, the proportion of PICU admissions, and admission length of stay, were analyzed using statistical process control.

During COVID-19, we found special cause variation with a downward shift in the importance of timely care for symptoms.There is broad variability in provider documentation for asthma encounters within the pediatric emergency department. Inadequate provider documentation leads to discrepancies between the ideal current procedural terminology (CPT) code and the assigned CPT code based on the care provided. Multiple studies demonstrate improvement in medical provider documentation after implementing standardized documentation templates and educational programs. The primary aim of this project was to improve the concordance between the ideal CPT code and assigned CPT code from a baseline of 71% to 85% in 12 months.

We introduced an asthma-specific note template in January 2018. We reviewed a random sample of 20 encounters per month to compare the ideal and assigned CPT codes in the baseline and intervention periods. The primary outcome measure was the percentage of encounters with agreement between ideal and assigned billing. The secondary outcome measure was the percentage of encounters with intravenous magnesium that were billed for critical care. The process measure was asthma note usage. Provider education and Plan-Do-Study-Act (PDSA) cycles continued throughout the intervention period. We used statistical process control to measure changes over time.

We reviewed 740 patient encounters over a 12-month baseline and 25-month intervention period. 5-Ethynyl-2'-deoxyuridine clinical trial The average agreement between ideal and assigned CPT code increased from 71% to 89%, with 84% usage of the asthma note template. The percentage of critical care billing for intravenous magnesium increased from 15% to 55%.

Implementation of an asthma-specific provider note template in the pediatric emergency department improved billing optimization and critical care billing.

Implementation of an asthma-specific provider note template in the pediatric emergency department improved billing optimization and critical care billing.Recent publications have highlighted the importance and impact of recognizing malnutrition in hospitalized children. After noting that patients with malnutrition frequently went unrecognized in our facility, we implemented an interprofessional intervention comprising hospital medicine physicians, dietitians, and the clinical documentation improvement team to improve recognition and documentation of malnutrition in these patients, thereby facilitating earlier intervention.

We implemented three separate plan-do-study-act cycles to improve the identification and documentation of malnutrition among patients hospitalized at our facility. The cycles consisted of identifying malnutrition using z-scores, educating providers, and implementing smart text within the medical record to help with consistent documentation. In addition, real-time communication between the disciplines (nutrition services, clinical documentation improvement providers, and hospitalists) was also employed to improve documentation quality. After completing the plan-do-study-act cycles, charts were reviewed to evaluate the nutritional interventions received.

Baseline data revealed that only 13% of patients with z-scores indicative of malnutrition were identified as such in attending physicians' documentation. Upon implementation of our plan-do-study-act cycles, documentation of these patients increased to greater than 64%. Patients with documented malnutrition received nutritional interventions at least 81% of the time, increasing from 35% at baseline.

Our findings demonstrate that an interprofessional approach can dramatically enhance the identification and documentation of malnutrition in hospitalized children, leading to earlier intervention.

Our findings demonstrate that an interprofessional approach can dramatically enhance the identification and documentation of malnutrition in hospitalized children, leading to earlier intervention.Meaningful engagement in quality improvement (QI) projects by trainees is often challenging. A fellow-led QI project aimed to improve adherence to a blood culture clinical decision algorithm and reduce unnecessary cultures in pediatric oncology inpatients.

We visualized preintervention rates of blood cultures drawn on pediatric oncology inpatients using a control chart. Following the introduction of the algorithm to our division, an Ishikawa fishbone diagram of cause-and-effect identified two areas for improvement prescriber education on the algorithm and targeted feedback on its use. We developed two interventions to support algorithm awareness and use (1) bundled educational interventions and (2) targeted chart review and feedback. Fellows reviewed >750 blood culture episodes and adjudicated each as "adherent" or "nonadherent" to the algorithm. In addition, fellows provided direct feedback to prescribers regarding nonadherent episodes and discussed strategies for algorithm adherence.

Blood culture rates in preintervention, intervention, and follow-up periods were 33.35, 25.24, and 22.67 cultures/100 patient-days, respectively. The proportion of nonadherent culture episodes decreased from 47.14% to 11.11%. The use of the algorithm did not prolong the time to cultures drawn on patients with new fever. Seventy-five percent of fellows provided feedback to inpatient teams on algorithm use. Following this project, trainees reported feeling more qualified to apply QI principles to patient care.

Implementation of a clinical decision algorithm reduced the rate of cultures drawn on pediatric oncology inpatients. Fellow-led education of the care team decreased the proportion of nonadherent culture episodes and provided active engagement in QI.

Implementation of a clinical decision algorithm reduced the rate of cultures drawn on pediatric oncology inpatients. Fellow-led education of the care team decreased the proportion of nonadherent culture episodes and provided active engagement in QI.Epinephrine is the only medication that prevents morbidity and mortality in anaphylaxis. Systemic corticosteroids and H2 receptor antagonists (H2RA) may benefit select cases but are not universally indicated. This study aims to de-implement the universal use of steroids and H2RAs and emphasize epinephrine-focused care for children with anaphylaxis during acute care visits. The study aims to reduce steroid and H2RA use from 81% and 60%, respectively, to 30% by December 2019.

The primary outcome measures were the percent of patients receiving steroids and H2RAs in the emergency department (ED) or urgent care (UC). Process measure was the frequency of intravenous (IV) line placement. Balancing measures were ED/UC length of stay, admission rate, and ED/UC return visit rate. In addition, a multidisciplinary team designed the following interventions (1) anaphylaxis clinical pathway to emphasize epinephrine-focused care, outline criteria for second-line therapies and a provider guideline for ED/UC observation; (2) standardize unit-based anaphylaxis medication kits; (3) optimize electronic medical record tools, including order sets and discharge instructions to be concordant with guideline recommendations.

The study included 870 patients. There was special cause variation in the use of steroids (81%-33%) and H2RAs (60%-11%), ED/UC Length of stay decreased (6.2-5.0 hours). There was no special cause variation in admission rates or ED/UC return visit rates.

Universal use of systemic steroids and H2RAs can be safely de-implemented in pediatric patients with anaphylaxis using quality improvement methods.

Universal use of systemic steroids and H2RAs can be safely de-implemented in pediatric patients with anaphylaxis using quality improvement methods.Employee safety and the reduction of Days Away, Restricted, or Transferred are a focus of the Solutions for Patient Safety Network. One significant contributor to the Days Away, Restricted, or Transferred rate at Children's National Hospital is employee slips, trips, or falls.

Children's National Hospital implemented a multidisciplinary quality improvement with executive leadership vision and support. We implemented quality techniques (including Key Driver Diagrams, Pareto Charts, and continuous Plan-Do-Study-Act) and designed novel Environmental Services interventions.

Children's National Hospital achieved a 44.3% reduction in monthly average reported slips, trips, or fall events from baseline and sustained over a 2-year study period.

A leadership-driven multidisciplinary approach to quality initiatives with team leaders capable of making and enacting real-time policy changes led to novel interventions and a successful reduction of employee slips, trips, and falls events over time, which are broadly generalizable.