Quality Improvement Methodologies: Principles and Applications in the Pediatric Emergency Department

Evaluation of the WHO standards to assess quality of care for children with acute respiratory infections: findings of a baseline multicentre assessment (CHOICE) in Italy

BACKGROUND

Experience is lacking on the implementation of the WHO standards for improving the quality of care (QOC) for children at facility level. We describe the use of 10 prioritised WHO standard-based quality measures to assess provision of care for children with acute respiratory infections (ARI) in Italy.

METHODS

In a multicentre observational study across 11 emergency departments with different characteristics, we collected 10 WHO standard-based quality measures related to case management of children with ARI and no emergency/priority signs. Univariate and multivariate analyses were conducted.

RESULTS

Data from 3145 children were collected. Major differences in QOC across facilities were observed: documentation of saturation level and respiratory rate varied from 34.3% to 100% and from 10.7% to 62.7%, respectively (p<0.001); antibiotic prescription rates ranged from 22.6% to 80.0% (p<0.001), with significant differences in the pattern of prescribed antibiotic; hospitalisations rates ranged between 2.3% and 30.6% (p<0.001). When corrected for children's individual sociodemographic and clinical characteristics, the variable more consistently associated with each analysed outcome was the individual facility where the child was managed. Higher rates of antibiotics prescription (+33.1%, p<0.001) and hospitalisation (+24.7%, p<0.001) were observed for facilities in Southern Italy, while university centres were associated with lower hospitalisation rates (-13.1%, p<0.001), independently from children's characteristics.

CONCLUSIONS

The use of 10 WHO standard-based measures can help quickly assess QOC for children with ARI. There is an urgent need to invest more in implementation research to identify sustainable and effective interventions to ensure that all children receive high QOC.

Development and implementation of a medication reconciliation during pediatric transitions of care in a public hospital

OBJECTIVES

To generate effective changes in the work processes of an institution, such as hospitals, strategies are needed for the implementation of services. These should be based on the needs of the practice scenario and evidence that may develop programs applied to the routine of health care. This study aimed to implement medication reconciliation (MR) at the transition of care in the pediatric department of a public hospital located in Northeast Brazil.

SETTING

A step-by-step approach was adopted to implement MR in the studied hospital and conducted from March 2019 to December 2019.

PRACTICE INNOVATION

The implementation of MR used the "Model for Improvement" framework. The processes were built and tested in the Plan-Do-Study-Act (PDSA) cycles. Children admitted to the hospital's pediatrics department were included in the study. The objective of the PDSA cycles was to reach 75% of the patients included, with the service performed in at least one transition of care episode.

EVALUATION

This study used the following indicators: number of steps performed, number of discrepancies identified, and resolution of discrepancies. Descriptive statistical analysis was performed for all variables.

RESULTS

In the first cycle, all patients (n = 34) had the best possible medication history (BPMH) completed, and 26.4% went through all the MR stages. Seventy-two discrepancies were identified and 90.3% of them were resolved. In the second cycle, all patients (n = 35) had the BPMH completed, and 20% went through all the stages. A total of 32 discrepancies were identified and 96.8% of them were resolved. In the third cycle, all patients (n = 30) had the BPMH completed, and 56.6% of patients went through all the stages. Twenty-four discrepancies were identified and resolved.

CONCLUSION

The use of the "Model for Improvement" framework effectively contributed to the implementation of the service according to the characteristics of the studied hospital.

Multidisciplinary Kaizen Event to Improve Adherence to a Sepsis Clinical Care Guideline

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Introduction:

Since 2015, the Ann and Robert H. Lurie Children’s Hospital Emergency Department (ED) has improved the recognition and treatment of pediatric sepsis and septic shock. Despite existing clinical care guidelines, the ED had not yet achieved the Surviving Sepsis Campaign timeliness goals for fluid and antibiotic administration.

Methods:

The team conducted a multidisciplinary Kaizen event to evaluate clinical workflows and identify opportunities to improve sepsis care adherence. Using rigorous quality improvement methodology, frontline providers mapped workflows to identify barriers and prioritize emerging solutions.

Results:

Thirty-seven staff members across 17 disciplines participated. Nurses and physicians identified communication gaps at pathway initiation. Access to supplies, inadequate task delegation, and a lack of urgency for a subset of pathway patients delayed treatment. Prioritized interventions included scripted communication tools, a delineated response plan, and standardized reassessment processes. Revisions to the key driver diagram were made after the improvement event, guiding future plan-do-study-act cycles.

Conclusions:

Frontline provider participation in the Kaizen event uncovered barriers to care and identified the root causes of ineffective communication and system process inefficiencies. Engaging key stakeholders from multiple care areas in a candid context was a novel approach to process improvement within our department. The Kaizen methodology is fundamental to developing sustainable quality improvement practices, creating momentum for a continuous improvement culture to engrain quality improvement in practice. The success of Kaizen will shape the format of future ED improvement projects.

Prevalence of medication discrepancies in pediatric patients transferred between hospital wards

Background Children are more susceptible to harm from medication errors and adverse drug reactions when compared to adults. Such events may occur from medication discrepancies while transitioning patients throughout the healthcare system. Contributing factors include medication discontinuity and lack of information by the healthcare team. Objective To analyze the prevalence of medication discrepancies in transition points of care in a pediatric department. Setting Pediatric department of a public hospital in Northeast Brazil. Method A cross-sectional study was carried out from August 2017 to March 2018. Data collection consisted of the following steps: collection of sociodemographic data, clinical interview with the patient's caregiver, registration of patient prescriptions, and evaluation of medical records. Medication discrepancies were classified as intentional and unintentional. The unintentional medication discrepancies were classified as omission of medication, therapeutic duplicity, and differences in dose, frequency, or route of administration. Main outcomes measure Discrepancy profile identified at admission, internal transfer and hospital discharge. Results Among the 114 patients included in the study, 85 (74.5%) patients had at least one unintentional medication discrepancy, of which 16 (14.0%) patients presented medication discrepancies at hospital admission, 42 (36.8%) patients at internal transfer, and 52 (45.6%) patients during discharge. Omission of medication represented 20 (74.1%) errors at admission, 26 (37.7%) errors at internal transfer, and 80 (100.0%) errors at hospital discharge. Conclusions The main transition points of care where unintentional discrepancies occurred in the studied pediatric department were at internal transfer and hospital discharge, with omission being the most common type of unintentional discrepancy.

Roles of Registered Nurses in Pediatric Preventive Care Delivery: A Pilot Study on Between-office Variation and Within-office Role Overlap

PURPOSE

Registered nurses (RN) participate in delivery of routine pediatric preventive care. This pilot study characterized variation in RN roles and overlap with other team roles.

METHODS

We conducted a pilot cross-sectional survey of RNs from an urban/suburban pediatric primary care network. RNs described tasks during preventive visits and other staff completing similar tasks. Health system data characterized office staffing, volume, and patient population. We assessed whether role overlap and time on key tasks was associated with office characteristics or staffing ratios.

RESULTS

Twenty-three offices reported a mean ratio of RNs to physicians and nurse practitioners of 0.99 (range 0.62-1.33). Of tasks RNs completed during preventive care, health education overlapped most with physician/nurse practitioner roles (17 sites with overlap) and rooming patients overlapped most with medical assistant roles (20 sites with overlap). Across sites, RNs spent 9% of time on health education and 26% on rooming. Offices with more role overlap between RNs and physicians/nurse practitioners had higher RN to physician/nurse practitioner ratios (1.13 versus 0.86, t-test p-value 0.002). There was no association between role overlap and other office characteristics, or between RN time on key tasks and staffing ratios.

CONCLUSIONS

RN staffing ratios varied twofold across offices. RNs spent more time on tasks that overlapped with medical assistant roles than tasks that overlapped with physician/nurse practitioner roles.

PRACTICE IMPLICATIONS

Opportunities exist to optimize RN pediatric primary care roles, for example by delegating certain tasks. Optimization may reduce costs, while improving quality, patient experience, and staff satisfaction.

Methodological Approaches to Support Process Improvement in Emergency Departments: A Systematic Review

The most commonly used techniques for addressing each Emergency Department (ED) problem (overcrowding, prolonged waiting time, extended length of stay, excessive patient flow time, and high left-without-being-seen (LWBS) rates) were specified to provide healthcare managers and researchers with a useful framework for effectively solving these operational deficiencies. Finally, we identified the existing research tendencies and highlighted opportunities for future work. We implemented the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology to undertake a review including scholarly articles published between April 1993 and October 2019. The selected papers were categorized considering the leading ED problems and publication year. Two hundred and three (203) papers distributed in 120 journals were found to meet the inclusion criteria. Furthermore, computer simulation and lean manufacturing were concluded to be the most prominent approaches for addressing the leading operational problems in EDs. In future interventions, ED administrators and researchers are widely advised to combine Operations Research (OR) methods, quality-based techniques, and data-driven approaches for upgrading the performance of EDs. On a different tack, more interventions are required for tackling overcrowding and high left-without-being-seen rates.