Notes

Cost-effectiveness of 4 vedolizumab compared to subcutaneous adalimumab regarding moderately to be able to greatly lively ulcerative colitis.
The primary outcome was the percentage of hypothermic patients (T < 36°C) based on the first postoperative temperature taken in the NICU. We tracked this measure using a statistical control chart and evaluated it using Plan-Do-Study-Act cycles.

From February 1, 2016 to May 30, 2018, data were collected for 554 patients (pre-intervention 242 and post-intervention 312). The percentage of surgical patients who returned to the NICU hypothermic decreased from 9.7% to 2.5% (
< 0.002)-a change sustained for greater than 12 months.

Quality improvement tools are useful in reducing postoperative hypothermia in NICU surgical patients and in maintaining these results.
Quality improvement tools are useful in reducing postoperative hypothermia in NICU surgical patients and in maintaining these results.
Greater than 70% of children who die in our institution annually die in an intensive care unit (ICU) setting. Family privacy, visitation policies, and an inability to perform religious rituals in the ICU are barriers to provide children with culturally competent, family-centered care when a child dies. The goal of this project was to profoundly understand family and staff experiences surrounding pediatric death in our institution to identify unique opportunities to design improved, novel delivery models of pediatric end of life (EOL) care.

This project utilized a structured process model based on the Vogel and Cagan's 4-phase integrated new product development process model. The 4 phases are identifying, understanding, conceptualizing, and realizing. We utilized an adaptation of this process model that relies on human-centered and design thinking methodologies in 3 phases research, ideation, and refinement of a process or product opportunity.

There were 2 primary results of this project 5 process and opd staff.
The performance and interpretation of point-of-care ultrasound (POCUS) should be documented appropriately in the electronic medical record (EMR) with correct billing codes assigned. We aimed to improve complete POCUS documentation from 62% to 80% and improve correct POCUS billing codes to 95% or higher through the implementation of a quality improvement initiative.

We collected POCUS documentation and billing data from the EMR. Interventions included (1) staff education and feedback, (2) standardization of documentation and billing, and (3) changes to the EMR to support standardization. We used P charts to analyze our outcome measures between January 2017 and June 2018.

Six hundred medical records of billed POCUS examinations were included. Complete POCUS documentation rate rose from 62% to 91%, and correct CPT code selection for billing increased from 92% to 95% after our interventions.

The creation of a standardized documentation template incorporated into the EMR improved complete documentation compliance.
The creation of a standardized documentation template incorporated into the EMR improved complete documentation compliance.
Discharge prescription errors from the pediatric emergency department (ED) are common. Despite the implementation of clinical pathways for common infections recommending specific antibiotic therapy and aids built into the electronic health record, errors in antibiotic prescriptions for patients discharged home from the ED persist.

We developed and implemented ED antibiotic discharge order panels for urinary tract infection (UTI) and skin and soft tissue infections (SSTI) that modeled antibiotic therapy from our institutional clinical pathways. We aimed to reduce antibiotic prescription errors by 50% within 6 months of implementation.

With the implementation of the ED discharge order panels, the overall error rate for prescriptions for UTI and SSTI improved from a baseline rate of 29.3% to 12.6% (
< 0.001). Individually, the baseline number of prescriptions with errors for UTI and SSTI improved from 26.1% and 32.8%, respectively, to 13.8% and 12.5% within 6 months. Sustained improvement continued for 17 months after the implementation of the order panels.

Development and implementation of ED antibiotic discharge order panels decrease antibiotic prescription errors for UTI and SSTI by improving compliance with institutional clinical pathways. Additional order panels should be developed and implemented for other conditions to help reduce discharge prescription errors.
Development and implementation of ED antibiotic discharge order panels decrease antibiotic prescription errors for UTI and SSTI by improving compliance with institutional clinical pathways. Additional order panels should be developed and implemented for other conditions to help reduce discharge prescription errors.
Appropriate use criteria (AUC) guide initial transthoracic echocardiogram (TTE) use in outpatient pediatrics. We sought to improve pediatric cardiologist TTE ordering appropriateness (mean AUC score) with a quality improvement initiative.

The outcome of interest was the prospective AUC score for all initial outpatient TTEs ordered between November 2016 and August 2017, categorized per the AUC "appropriate" (score 7-9), "may be appropriate" (4-6), "rarely appropriate" (1-3). Interventions included a didactic review of 2014 AUC and participant documentation of AUC criteria for each TTE. check details Participants met quarterly to evaluate outcome, process, and balancing measures, intervention effectiveness, and to identify and mitigate barriers.

Twenty-two pediatric cardiologists participated. TTE appropriateness level before (n = 216) and after (n = 557) intervention was high. There was no significant difference in mean baseline and post-intervention AUC score (7.42 ± 1.87 versus 7.16 ± 2.87,
= 0.1), nor in TTE sensitivity (27% versus 25%,
> 0.1) as a balancing measure. Among baseline studies, 81% were "appropriate," and 6% "rarely appropriate." Among post-intervention studies, 76% were "appropriate," and 11% "rarely appropriate." Barriers identified to implementing AUC include TTE indications not specified by current AUC, expectations of referring provider or parent to perform TTE, consistent provider application of AUC, and ability of AUC to capture comprehensive clinical judgment.

Although the mean AUC appropriateness level was high, we were able to identify significant barriers to the implementation of AUC. Future efforts should focus on the reduction of "rarely appropriate" TTE ordering.
Although the mean AUC appropriateness level was high, we were able to identify significant barriers to the implementation of AUC. Future efforts should focus on the reduction of "rarely appropriate" TTE ordering.
Infants in neonatal intensive care units require painful and noxious stimuli as part of their care. Judicious use of analgesic medications, including opioids, is necessary. However, these medications have long- and short-term side effects, including potential neurotoxicity. This quality improvement project's primary aim was to decrease opioid exposure by 33% in the first 14 days of life for infants less than 1,250 g at birth within 12 months.

A multidisciplinary care team used
methodology to identify root causes of the quality gap including (1) inconsistent reporting of objective pain scales; (2) variable provider prescribing patterns; and (3) variable provider bedside assessment of pain. These root causes were addressed by two interventions (1) standardized reporting of the premature infant pain profile scores and (2) implementation of an analgesia management pathway.

Mean opioid exposure, measured in morphine equivalents, in infants less than 1,250 g at birth during their first 14 days of life decreased from 0.64 mg/kg/d (95% confidence interval 0.41-0.87) at baseline to 0.08 mg/kg/d (95% confidence interval 0.03-0.13) during the postintervention period (
< 0.001). There was no statistical difference in rates of days to full feedings, unintentional extubations, or central line removals between epochs.

Following the implementation of consistent pain score reporting and an analgesia management pathway, opioid exposure in the first 14 days of life for infants less than 1,250 g was significantly reduced by 88%, exceeding the project aim.
Following the implementation of consistent pain score reporting and an analgesia management pathway, opioid exposure in the first 14 days of life for infants less than 1,250 g was significantly reduced by 88%, exceeding the project aim.
Continuous positive airway pressure (CPAP) and surfactant both improve outcomes for premature infants with respiratory distress syndrome. However, prolonged trials of CPAP, as well as observation periods after intubation, may delay the administration of surfactant. Late surfactant treatment likely increases the incidence of bronchopulmonary dysplasia, which leads to significant morbidity and healthcare utilization.

We aimed to decrease time from meeting standard criteria (start of a continuous run of F
O
> 40% or P
CO
> 65 for >90 min) to intubation, and from intubation to surfactant administration, for infants <1,500 g or younger than 32 weeks gestation. Retrospective data collection from the electronic medical record assessed those process measures as the primary endpoints. Balancing measures were the adverse outcomes of asymmetric lung disease, the inappropriate position of the endotracheal tube, or pneumothorax on the first x-ray (within 24 h) after surfactant.

Mean time to intubatthe engagement of medical staff. Timely intubation and surfactant may decrease bronchopulmonary dysplasia.
Delays in the operating room (OR) can lead to increased hospital costs as well as patient and provider dissatisfaction. Starting the first case on time in the OR can potentially prevent subsequent delays. We designed a quality improvement project to improve the first case on-time starts in the pediatric OR at a tertiary care children's hospital.

Following the collection of baseline data, we formed an interdisciplinary team. We analyzed the causes of delay and used the Six Sigma methodology of Define, Measure, Analyze, Improve, and Control. We identified key drivers and implemented several low-cost interventions using Plan-Do-Study-Act cycles. Major interventions included preoperative care coordination, strategic staggering of OR cases, and introduction of "Wow Bucks" incentives. We monitored start times and the delay in minutes for all first cases weekly. The OR minutes saved per week were calculated and used to estimate cost savings.

We studied a total of 1981 first-start cases from May 2018 to October 2019. The first case on-time starts improved from 62% to 77% over the study period. There was a significant improvement in total minutes delayed for all the first cases from 197.9 minutes per week down to 133 minutes per week (
< 0.05). Estimated cost savings were $4,023 per week due to improved OR utilization.

A multidisciplinary collaborative team approach using quality improvement tools can improve on-time starts in the pediatric OR.
A multidisciplinary collaborative team approach using quality improvement tools can improve on-time starts in the pediatric OR.
Overutilization of point-of-care (POC) testing may reduce the overall value of care due to high-cost cartridges, need for staff training, and quality assurance requirements.

The Diagnostic Stewardship group at Cincinnati Children's Hospital Medical Center assembled a multidisciplinary team to reduce the use of POC blood gas testing by 20% in the pediatric intensive care unit (PICU). Key drivers of test overutilization included poor knowledge of cost, concern with testing turnaround time, and a lack of a standard definition of when a POC test was appropriate. We calculated weekly the outcome measure of POC blood gas tests per PICU patient-day and a balancing measure of blood gas result turnaround time using data extracted from the electronic medical record. Interventions focused on staff education, the establishment of a standard practice guideline for the use of POC testing, and improving turnaround time for laboratory blood gas testing.

Over the baseline period starting July 2016, a median of 0.94 POC blood gas tests per PICU patient-day was ordered.
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