Applying the Chronic Care Model to Improve Care and Outcomes at a Pediatric Medical Center

Health outcomes measurement and organizational readiness support quality improvement: a systematic review

BACKGROUND

Using outcome measures to advance healthcare continues to be of widespread interest. The goal is to summarize the results of studies which use outcome measures from clinical registries to implement and monitor QI initiatives. The second objective is to identify a) facilitators and/or barriers that contribute to the realization of QI efforts, and b) how outcomes are being used as a catalyst to change outcomes over time.

METHODS

We searched the PubMed, EMBASE and Cochrane databases for relevant articles published between January 1995 and March 2017. We used a standardized data abstraction form. Studies were included when the following three criteria were fulfilled: 1) they relied on structural data collection, 2) when a structural and comprehensive QI intervention had been implemented and evaluated, and 3) impact on improving clinical and/or patient-reported outcomes was described. Data on QI strategies, QI initiatives and the impact on outcomes was extracted using standardized assessment tools.

RESULTS

We included 21 articles, of which eight showed statistically significant improvements on outcomes using data from clinical registries. Out of these eight studies, the Chronic Care Model, IT application as feedback, benchmarking and the Collaborative Care Model were used as QI methods. Encouraging trends in realizing improved outcomes through QI initiatives were observed, ranging from improving teamwork, implementation of clinical guidelines, implementation of physician alerts and development of a decision support system. Facilitators for implementing QI initiatives included a high quality database, audits, frequent reporting and feedback, patient involvement, communication, standardization, engagement, and leadership.

CONCLUSION

This review suggests that outcomes collected in clinical registries are supportive to realize QI initiatives. Organizational readiness and an active approach are key in achieving improved outcomes.

Hospital clinical pathways for children affected by juvenile idiopathic arthritis

Background

Juvenile idiopathic arthritis (JIA) is the most common pediatric chronic rheumatic disease, which requires constant follow-up over the years, due to relapses during its progression. To maintain a good quality of life, it is important to limit admissions as far as possible. With the development of a Diagnostic Therapeutic Assistance Pathway (DTAP), we aim to select patients with suitable clinical conditions to be moved from routine hospital management to day care or outpatient treatment, evaluating the number of patients to whom this would apply.

Methods

Monocentric study regarding admissions for JIA between 2014 and 2016 in a Pediatric Unit of a university hospital in Milan. Through an analysis of the medical records, relevant information was extracted and collected in a Microsoft™ Excel database; starting from the data collected during the first year, a DTAP was prepared for patients with active arthritis and appropriate clinical conditions.

Results

The study includes data from 223 JIA hospitalization cases involving 127 patients. Applying DTAP criteria, 32% patients would have avoided admissions and 23% would have been admitted less frequently. The data concerning the activities of the Unit for JIA patients showed a relevant drop in the number of hospitalizations since 2015, from 89 in 2014 to 66 and 68 in 2015 and 2016 respectively.

Conclusion

The opportunity offered by DTAP, has suggested feasible changes in hospitalization management and it’s use would promote the possibility of treating the children without hospitalization, or minimizing it. In conclusion DTAP application is a priority for the continuous improvement of clinical practice and quality of life for patients and their families.

Managing paediatric bleeding disorder patients undergoing surgical procedures: Leveraging the electronic medical record

INTRODUCTION

Individuals with bleeding disorders have a high risk of bleeding complications with surgical procedures. Careful planning and management of peri-operative treatment is vital for their safety. Yet, inter-provider communication and communication between patients/families and providers is not reliable.

AIM

Our haemophilia treatment centre (HTC) created a care gap report that used the electronic medical record to inform our team when patients with bleeding disorders were scheduled for procedures.

METHODS

An electronic medical record-based patient registry was linked to the hospital's surgical schedule and a report was run daily by HTC staff for the upcoming 14 days. We determined the number of surgeries scheduled for patients with a bleeding disorder without the knowledge of the HTC, identified by the care gap report during the 6 months prior to and 2 years after implementing the report.

RESULTS

Had the report been in effect 6 months prior, the majority of surgery cases would have been detected and planned for an average of 10 days prior to the procedure. Following implementation, the report identified 62 of 225 surgeries on patients with known bleeding disorders where the HTC did not have prior communication from the patient/family or surgical team.

CONCLUSION

This surgery care gap report provides the date and time of procedures on bleeding disorder patients without relying on contact from patients/families or the surgical team. Its use has resulted in an improved peri-operative process for patients with bleeding disorders undergoing surgical procedures and potentially prevented surgery cancellations.