Pediatric Quality & Safety

BACKGROUND: Toddler's fractures are one of the most common orthopedic injuries in young walking-age children. They are defined as nondisplaced spiral-type metaphyseal fractures involving only the tibia without any injury to the fibula and are inherently stable. We aimed to use quality improvement methodology to increase the proportion of patients with toddler's fractures treated without cast immobilization at a large tertiary referral pediatric orthopedic center from a baseline of 45...

BACKGROUND: Pediatric patients require central venous catheters to maintain adequate hydration, nutritional status, and delivery of life-saving medications in the pediatric intensive care unit. Although central venous catheters provide critical medical therapies, their use increases the risk of severe infection, morbidity, and mortality. Adopting an evidence-based central line-associated bloodstream infection (CLABSI) bundle to guide nursing practice can decrease and sustain low CLABSI rates, but reliable and consistent implementation is challenging...

BACKGROUND: Osteopenia of prematurity (OOP) is often a silent disease in the neonatal intensive care unit (NICU). Despite its association with increased neonatal morbidity, such as fractures, wide variation exists in screening, diagnostic, and management practices. We sought to decrease the rate of OOP-related fractures in our level IV NICU by 20% within 1 year. METHODS: A multidisciplinary quality improvement team identified inconsistent screening, diagnosis, and management of OOP, as well as handling of at-risk patients, as primary drivers for OOP-related fractures...

BACKGROUND: Current national guidelines recommend against chest X-rays (CXRs) for patients with acute asthma exacerbation (AAE). The overuse of CXRs in AAE has become a concern, prompting the need for a quality improvement (QI) project to decrease CXR usage through guideline-based interventions. We aimed to reduce the percentage of CXRs not adhering to national guidelines obtained for pediatric patients presenting to the Emergency Department (ED) with AAE by 50% within 12 months of project initiation...

INTRODUCTION: Children born prematurely are at increased risk for autism spectrum disorder (ASD). ASD can be diagnosed between 18 and 24 months of age, but access barriers and medical complexity can delay diagnosis. ASD screening was implemented in a high-risk infant follow-up program using QI methodology. The project aimed to screen 60% of children and refer 90% of those with positive screens. METHODS: The team developed a standardized workflow to administer the M-CHAT-R/F to HRIF patients between the ages of 16-22 months...

INTRODUCTION: Patient portal enrollment following pediatric emergency department (ED) visits allows access to critical results, physician documentation, and telehealth follow-up options. Despite these advantages, there are many challenges to portal invitation and enrollment. Our primary objective was to improve patient portal enrollment rates for discharged pediatric ED patients. METHODS: A multidisciplinary team of staff from two ED sites developed successful portal enrollment interventions through sequential Plan-Do-Study-Act cycles from October 2020 to October 2021...

BACKGROUND: Surge demands for annual influenza vaccines challenge healthcare systems. Mass immunizations differ from the traditional care model. The coronavirus 2019 (COVID-19) pandemic challenged current care models with amplified demand and infection risks while challenging the organization to create new and improve existing processes. METHODS: Using the Model for Improvement, the team set out to (1) safely meet a surge in vaccination demand and (2) adopt pandemic-driven innovations into routine immunization practice...

BACKGROUND: Cancer is associated with increased venous thromboembolism in children. Risk factors for venous thromboembolism in this cohort include using central venous catheters, mass effect from underlying malignancy, chemotherapy, and surgery. Anticoagulation management in this cohort is challenging, given recurrent episodes of thrombocytopenia, the need for invasive procedures, and coagulopathy. A quality improvement (QI) initiative was developed to improve hematology consultation services and provide documentation of an individualized anticoagulation care plan for this high-risk cohort...

BACKGROUND: Mediastinal masses in children with cancer present unique challenges, including the risk of respiratory and hemodynamic compromise due to the complex anatomy of the mediastinum. Multidisciplinary communication is often a challenge in the management of these patients. After a series of patients with mediastinal masses were admitted to Riley Hospital for Children Pediatric Intensive Care Unit, the time from presentation to biopsy and pathology was greater than expected. We aimed to reduce the time to biopsy by 25% and demonstrate improved multidisciplinary communication within 6 months of protocol implementation for patients presenting to Riley Hospital for Children Emergency Department with an anterior mediastinal mass...

BACKGROUND: Informed consent is necessary to preserve patient autonomy and shared decision-making, yet compliant consent documentation is suboptimal in the intensive care unit (ICU). We aimed to increase compliance with bundled consent documentation, which provides consent for a predefined set of common procedures in the neonatal ICU from 0% to 50% over 1 year. METHODS: We used the Plan-Do-Study-Act model for quality improvement. Interventions included education and performance awareness, delineation of the preferred consenting process, consent form revision, overlay tool creation, and clinical decision support (CDS) alert use within the electronic health record...

BACKGROUND: We developed a multidisciplinary antimicrobial stewardship team to optimize antimicrobial use within the Pediatric Cardiac Intensive Care Unit. A quality improvement initiative was conducted to decrease unnecessary broad-spectrum antibiotic use by 20%, with sustained change over 12 months. METHODS: We conducted this quality improvement initiative within a quaternary care center. PDSA cycles focused on antibiotic overuse, provider education, and practice standardization...

BACKGROUND: Clinical pathways standardize healthcare utilization, but their impact on healthcare equity is poorly understood. This study aims to measure the effect of a bronchiolitis pathway on management decisions by preferred language for care. METHODS: We included all emergency department encounters for patients aged 1-12 months with bronchiolitis from 1/1/2010 to 10/31/2020. The prepathway period ended 10/31/2011, and the postpathway period was 1/1/2012-10/31/2020...

INTRODUCTION: Poor adherence to medication regimens accounts for the substantial worsening of disease, death, and increased healthcare costs of approximately $100 billion annually in the United States. Patients participating in medication synchronization had 3.4 to 6.1 times increased odds of adherence, depending on the drug class. Abundant literature supports medication synchronization within the adult population. This IRB-exempt, prospective quality improvement project is an example of implementing and assessing medication synchronization inclusive of the pediatric setting...

INTRODUCTION: Patients following the Fontan procedure have a physiology that results in prolonged pleural effusion, often delaying hospital discharge. The hospital length of stay (LOS) of patients following the Fontan procedure at our institution was significantly longer than the Society of Thoracic Surgery benchmark. This quality improvement project aimed to decrease hospital LOS in patients following the Fontan procedure from a baseline of 23 days to 7 days by January 1, 2021, and sustain indefinitely...

INTRODUCTION: Spinal anesthesia has a long history as an effective and safe technique to avoid general anesthesia in infants undergoing surgery. However, spinal anesthesia was rarely used as the primary anesthetic in this population at our institution. This healthcare improvement initiative aimed to increase the percentage of successful spinal placements as the primary anesthetic in infants undergoing circumcision, open orchidopexy, or hernia repair from 11% to 50% by December 31, 2019, and sustain that rate for 6 months...

INTRODUCTION: Despite the updated American Academy of Pediatrics recommendation for universal administration of the hepatitis B vaccine for newborns, delays in routine prophylaxis are common in the Neonatal Intensive Care Unit (NICU). Delayed immunization can increase perinatal acquisition risks and lead to subsequent delays in routine childhood immunization. This study aimed to increase the on-time administration of the birth dose of the hepatitis B vaccine from 46% to ≥70% at a level III and level IV NICU within the same health system...

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INTRODUCTION: Emergency transfers are associated with increased inpatient pediatric mortality. Therefore, interventions to improve system-level situational awareness were utilized to decrease a subset of emergency transfers that occurred within four hours of admission to an inpatient medical-surgical unit called very rapid emergency transfers (VRET). Specifically, we aimed to increase the days between VRET from non-ICU inpatient units from every 10 days to every 25 days over 1 year. METHODS: Using the Model for Improvement, we developed an interdisciplinary team to reduce VRET...

INTRODUCTION: Uncomplicated urinary tract infections (uUTIs) are among the more common pediatric bacterial infections. Despite their prevalence, significant variability exists in the treatment duration and antibiotic selection for uUTI. Our first aim was to improve adherence to a three-day course of antibiotic treatment for uUTI in children over 24 months old. Our second aim was to increase the selection of cephalexin in this population. METHODS: We conducted a single-center quality improvement study from March 2021 to March 2022...

INTRODUCTION: The limited data indicate that pediatric medical errors in the outpatient setting, including at home, are common. This study is the first step of our Ambulatory Pediatric Patient Safety Learning Lab to address medication errors and treatment delays among children with T1D in the outpatient setting. We aimed to identify failures and potential solutions associated with medication errors and treatment delays among outpatient children with T1D. METHODS: A transdisciplinary team of parents, safety researchers, and clinicians used Systems Engineering Initiative for Patient Safety (SEIPS) based process mapping of data we collected through in-home medication review, observation of administration, chart reviews, parent surveys, and failure modes and effects analysis (FMEA)...