Quality Improvement Studies in Pediatric Critical Care Medicine

Developing a Sustainable Quality Improvement Program in an Academic Center: The Experience of an Adolescent Unit

Introduction

Successful quality improvement (QI) efforts use a comprehensive, institutional QI framework and professional development, but literature describing implementing QI frameworks in Adolescent Medicine practices is sparse. We aimed to implement and increase the number of formally structured QI projects (primary aim) and the number of projects achieving a centerline (CL) shift (secondary aim) in our hospital's Adolescent Medicine Clinic.

Methods

We used formal QI methodology to improve health outcomes by increasing the number of faculty with formalized QI education, creating interdisciplinary QI teams, and improving staff motivation. QI education was mandatory for Adolescent Medicine fellows and pediatric residents and encouraged for faculty and staff. The Divisional QI leadership team attended monthly meetings to review key driver diagrams, run and control charts, and receive intervention updates. All providers and staff received monthly updates, and the Hospital Quality and Safety Committee received biannual updates. We used run charts to share progress with primary and secondary aims.

Results

Since Q3 2014, the Adolescent Medicine team consistently achieved the primary aim of having 5 active projects in process, with 9 projects from Q1 2018-Q4 2020. For the secondary aim, a target of 50% of active QI projects attaining a sustained centerline shift was achieved in Q2 2018 and maintained in 16 of 20 quarters since.

Conclusions

Clinicians can use QI methodology to improve health outcomes while facilitating professional development. For this initiative to succeed, institutional leadership must provide an infrastructure prioritizing meaningful QI involvement.

Implementation Science Research in Pediatric Critical Care Medicine

OBJECTIVES

Delay or failure to consistently adopt evidence-based or consensus-based best practices into routine clinical care is common, including for patients in the PICU. PICU patients can fail to receive potentially beneficial diagnostic or therapeutic interventions, worsening the burden of illness and injury during critical illness. Implementation science (IS) has emerged to systematically address this problem, but its use of in the PICU has been limited to date. We therefore present a conceptual and methodologic overview of IS for the pediatric intensivist.

DESIGN

The members of Excellence in Pediatric Implementation Science (ECLIPSE; part of the Pediatric Acute Lung Injury and Sepsis Investigators Network) represent multi-institutional expertise in the use of IS in the PICU. This narrative review reflects the collective knowledge and perspective of the ECLIPSE group about why IS can benefit PICU patients, how to distinguish IS from quality improvement (QI), and how to evaluate an IS article.

RESULTS

IS requires a shift in one's thinking, away from questions and outcomes that define traditional clinical or translational research, including QI. Instead, in the IS rather than the QI literature, the terminology, definitions, and language differs by specifically focusing on relative importance of generalizable knowledge, as well as aspects of study design, scale, and timeframe over which the investigations occur.

CONCLUSIONS

Research in pediatric critical care practice must acknowledge the limitations and potential for patient harm that may result from a failure to implement evidence-based or professionals' consensus-based practices. IS represents an innovative, pragmatic, and increasingly popular approach that our field must readily embrace in order to improve our ability to care for critically ill children.

Quality measurement and surveillance platforms in critically ill children: A scoping review

BACKGROUND/AIM

The objective of this study was to describe current surveillance platforms which support routine quality measurement in paediatric critical care.

METHOD

Scoping review. The search strategy consisted of a traditional database and grey literature search as well as expert consultation. Surveillance platforms were eligible for inclusion if they collected measures of quality in critically ill children.

RESULTS

The search strategy identified 21 surveillance platforms, collecting 57 unique outcome (70%), process (23%), and structural (7%) quality measures. Hospital-associated infections were the most commonly collected outcome measure across all platforms (n = 11; 52%). In general, case definitions were not harmonised across platforms, with the exception of nationally mandated hospital-associated infections (e.g., central line-associated blood stream infection). Data collection relied on manual coding. Platforms typically did not provide an evidence-based rationale for measures collected, with no identifiable reports of co-designed, consensus-derived measures or consumer involvement in measure selection or prioritisation.

CONCLUSIONS

Quality measurement in critically ill children lacks uniformity in definition which limits local and international benchmarking. Current surveillance activities for critically ill children focus heavily on outcome measurement, with process, structural, and patient-reported measures largely overlooked. Long-term outcome measures were not routinely collected. Harmonisation of paediatric intensive care unit quality measures is needed and can be achieved using prioritisation and consensus/co-design methods.