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Molloy MJ, Morris C, Caldwell A, LaChance D, Woeste L, Lenk MA, Brady PW, Schondelmeyer AC. Increasing the Use of Enteral Antibiotics in Hospitalized Children With Uncomplicated Infections. Pediatrics 2024; 153:e2023062427. [PMID: 38712446 DOI: 10.1542/peds.2023-062427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/06/2024] [Indexed: 05/08/2024] Open
Abstract
BACKGROUND Route of administration is an important component of antimicrobial stewardship. Early transition from intravenous to enteral antibiotics in hospitalized children is associated with fewer catheter-related adverse events, as well as decreased costs and length of stay. Our aim was to increase the percentage of enteral antibiotic doses for hospital medicine patients with uncomplicated common bacterial infections (community-acquired pneumonia, skin and soft tissue infection, urinary tract infection, neck infection) from 50% to 80% in 6 months. METHODS We formed a multidisciplinary team to evaluate key drivers and design plan-do-study-act cycles. Interventions included provider education, structured discussion at existing team huddles, and pocket-sized printed information. Our primary measure was the percentage of antibiotic doses given enterally to patients receiving other enteral medications. Secondary measures included antibiotic cost, number of peripheral intravenous catheters, length of stay, and 7-day readmission. We used statistical process control charts to track our measures. RESULTS Over a 6-month baseline period and 12 months of improvement work, we observed 3183 antibiotic doses (888 in the baseline period, 2295 doses during improvement work). We observed an increase in the percentage of antibiotic doses given enterally per week for eligible patients from 50% to 67%. We observed decreased antibiotic costs and fewer peripheral intravenous catheters per encounter after the interventions. There was no change in length of stay or readmissions. CONCLUSIONS We observed increased enteral antibiotic doses for children hospitalized with common bacterial infections. Interventions targeting culture change and communication were associated with sustained improvement.
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Affiliation(s)
- Matthew J Molloy
- Divisions of Hospital Medicine
- Biomedical Informatics
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Calli Morris
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Alicia Caldwell
- Divisions of Hospital Medicine
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Dennis LaChance
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Laura Woeste
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Mary Anne Lenk
- James M. Anderson Center for Health System Excellence, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Patrick W Brady
- Divisions of Hospital Medicine
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- James M. Anderson Center for Health System Excellence, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Amanda C Schondelmeyer
- Divisions of Hospital Medicine
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- James M. Anderson Center for Health System Excellence, Cincinnati Children's Hospital, Cincinnati, Ohio
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Heiden BT, Subramanian MP, Nava R, Patterson AG, Meyers BF, Puri V, Oncken C, Keith A, Guthrie TJ, Epstein DJ, Lenk MA, Kozower BD. Routine Collection of Patient Reported Outcomes in Thoracic Surgery: A Quality Improvement Study. Ann Thorac Surg 2021; 113:1845-1852. [PMID: 34224723 DOI: 10.1016/j.athoracsur.2021.05.091] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 05/03/2021] [Accepted: 05/31/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patient reported outcomes (PROs) are critical for delivering high quality surgical care yet they are seldom collected in routine clinical practice. The objective of this quality improvement study was to improve routine PROs collection in a thoracic surgery clinic. METHODS Thoracic surgery patients at a single academic institution were prospectively followed from April 2019 to March 2020. The National Institutes of Health (NIH)-validated Patient-Reported Outcomes Measurement Information System (PROMIS) was employed. Using a Model for Improvement design and through multidisciplinary participant observation, multiple plan-do-study-act (PDSA) cycles (an iterative, four-stage model for rapidly testing interventions) were performed to improve routine collection reliability. RESULTS Over the study period, a total of 2,315 patient visits occurred. The baseline PROMIS assessment collection rate was 53%. After convening a multidisciplinary stakeholder team, the key drivers for PROMIS collection were having engaged staff, engaged patients, adequate technological capacity, and adequate time for survey completion (including when to complete the survey during the patient visits). Regular meetings between stakeholders were initiated to promote these key drivers. Several PDSA cycles were then employed to test different interventions, resulting in several positive system shifts as demonstrated on statistical process control (SPC) chart. Adherence to survey collection reached 91% of office visits by approximately 7 months, a 72% relative improvement, which was sustained. CONCLUSIONS Routine collection of PROs, such as PROMIS, are critical for improving thoracic surgical care. Our study shows that reliably collecting these data is possible in a clinical setting with minimal additional hospital resources.
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Affiliation(s)
- Brendan T Heiden
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Melanie P Subramanian
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Ruben Nava
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Alexander G Patterson
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Varun Puri
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Christian Oncken
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Angela Keith
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Tracey J Guthrie
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Deirdre J Epstein
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Mary Anne Lenk
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital, Cincinnati, OH
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO.
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Ghafoor S, Fan K, Williams S, Brown A, Bowman S, Pettit KL, Gorantla S, Quillivan R, Schwartzberg S, Curry A, Parkhurst L, James M, Smith J, Canavera K, Elliott A, Frett M, Trone D, Butrum-Sullivan J, Barger C, Lorino M, Mazur J, Dodson M, Melancon M, Hall LA, Rains J, Avent Y, Burlison J, Wang F, Pan H, Lenk MA, Morrison RR, Kudchadkar SR. Beginning Restorative Activities Very Early: Implementation of an Early Mobility Initiative in a Pediatric Onco-Critical Care Unit. Front Oncol 2021; 11:645716. [PMID: 33763377 PMCID: PMC7982584 DOI: 10.3389/fonc.2021.645716] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 02/01/2021] [Indexed: 12/23/2022] Open
Abstract
Introduction Children with underlying oncologic and hematologic diseases who require critical care services have unique risk factors for developing functional impairments from pediatric post-intensive care syndrome (PICS-p). Early mobilization and rehabilitation programs offer a promising approach for mitigating the effects of PICS-p in oncology patients but have not yet been studied in this high-risk population. Methods We describe the development and feasibility of implementing an early mobility quality improvement initiative in a dedicated pediatric onco-critical care unit. Our primary outcomes include the percentage of patients with consults for rehabilitation services within 72 h of admission, the percentage of patients who are mobilized within 72 h of admission, and the percentage of patients with a positive delirium screen after 48 h of admission. Results Between January 2019 and June 2020, we significantly increased the proportion of patients with consults ordered for rehabilitation services within 72 h of admission from 25 to 56% (p<0.001), increased the percentage of patients who were mobilized within 72 h of admission to the intensive care unit from 21 to 30% (p=0.02), and observed a decrease in patients with positive delirium screens from 43 to 37% (p=0.46). The early mobility initiative was not associated with an increase in unplanned extubations, unintentional removal of central venous catheters, or injury to patient or staff. Conclusions Our experience supports the safety and feasibility of early mobility initiatives in pediatric onco-critical care. Additional evaluation is needed to determine the effects of early mobilization on patient outcomes.
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Affiliation(s)
- Saad Ghafoor
- Division of Critical Care Medicine, Department of Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Kimberly Fan
- Department of Pediatric Critical Care, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Sarah Williams
- Division of Critical Care Medicine, Department of Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Amanda Brown
- Division of Critical Care Medicine, Department of Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Sarah Bowman
- Division of Critical Care Medicine, Department of Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Kenneth L Pettit
- Office of Quality and Patient Care, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Shilpa Gorantla
- Office of Quality and Patient Care, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Rebecca Quillivan
- Office of Quality and Patient Care, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Sarah Schwartzberg
- Department of Rehabilitation Services, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Amanda Curry
- Department of Rehabilitation Services, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Lucy Parkhurst
- Department of Rehabilitation Services, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Marshay James
- Division of Critical Care Medicine, Department of Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Jennifer Smith
- Department of Child Life, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Kristin Canavera
- Department of Psychology, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Andrew Elliott
- Division of Psychiatry, Department of Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Michael Frett
- Division of Anesthesiology, Department of Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Deni Trone
- Department of Pharmaceutical Services, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Jacqueline Butrum-Sullivan
- Department Critical Care/Pulmonary Medicine-Respiratory Therapy, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Cynthia Barger
- Department of Inpatient Units-Nursing, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Mary Lorino
- Department of Inpatient Units-Nursing, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Jennifer Mazur
- Department of Nursing Administration- Nursing Education, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Mandi Dodson
- Department of Nursing Administration- Nursing Education, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Morgan Melancon
- Department of Nursing Administration- Nursing Education, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Leigh Anne Hall
- Department of Inpatient Units-Nursing, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Jason Rains
- Department Critical Care/Pulmonary Medicine-Respiratory Therapy, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Yvonne Avent
- Division of Critical Care Medicine, Department of Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Jonathan Burlison
- Department of Pharmaceutical Sciences- Patient Safety, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Fang Wang
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Haitao Pan
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Mary Anne Lenk
- Department of Quality Improvement Education and Training, Cincinnati Children's Hospital- James M. Anderson Center for Health Systems Excellence, Cincinnati, OH, United States
| | - R Ray Morrison
- Division of Critical Care Medicine, Department of Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Sapna R Kudchadkar
- Departments of Anesthesiology and Critical Care Medicine, Pediatrics and Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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