Multicenter Quality Improvement Initiative Research Articles

Pediatric Ventilator-Associated Events Before and After a Multicenter Quality Improvement Initiative

Pediatric ventilator-associated events (PedVAEs, defined as a sustained worsening in oxygenation after a baseline period of stability or improvement) are useful for surveillance of complications from mechanical ventilation. It is unclear whether interventions to mitigate known risk factors can reduce PedVAE rates. To assess whether adherence to 1 or more test factors in a quality improvement bundle was associated with a reduction in PedVAE rates. This multicenter quality improvement study obtained data from 2017 to 2020 for patients who were mechanically ventilated and cared for in neonatal, pediatric, and cardiac intensive care units (ICUs). These ICUs were located in 95 hospitals participating in the Children's Hospitals' Solutions for Patient Safety (SPS) network in North America. Data analyses were performed between September 2021 and April 2023. A quality improvement bundle consisted of 3 test factors: multidisciplinary apparent cause analysis, daily discussion of extubation readiness, and daily discussion of fluid balance goals. This bundle was distributed to a subgroup of hospitals that volunteered to participate in a collaborative PedVAE prevention initiative under the SPS network guidance in July 2018. Each SPS network hospital submitted monthly PedVAE rates from January 1, 2017, to May 31, 2020, and test factor data were submitted from July 1, 2018, to May 31, 2020. Analyses focused on hospitals that reliably submitted PedVAE rate data, defined as outcomes data submission through May 31, 2020, for at least 80% of the baseline and postbaseline periods. Of the 95 hospitals in the SPS network that reported PedVAE data, 21 were grouped in the Pioneer cohort and 74 in the non-Pioneer cohort. Only 12 hospitals (57%) from the 21 Pioneer hospitals and 33 (45%) from the 74 non-Pioneer hospitals were considered to be reliable reporters of outcome data. Among the 12 hospitals, the PedVAE rate decreased from 1.9 to 1.4 events per 1000 ventilator days (absolute rate difference, -0.6; 95% CI, -0.5 to -0.7; P < .001). No significant change in the PedVAE rate was seen among the 33 hospitals that reliably submitted PedVAE rates but did not implement the bundle. Of the 12 hospitals, 3 that reliably performed daily discussion of extubation readiness had a decrease in PedVAE rate from 2.6 to 1.2 events per 1000 ventilator days (absolute rate difference, -1.4; 95% CI, -1.0 to -1.7; P < .001), whereas the other 9 hospitals that did not implement this discussion did not have a decrease. This study found that a multicenter quality improvement intervention targeting PedVAE risk factors was associated with a substantial reduction in the rate of PedVAEs in hospital ICUs. The findings suggest that ICU teams seeking to reduce PedVAEs incorporate daily discussion of extubation readiness during morning rounds.

Cumulative sum learning curves guiding multicenter multidisciplinary quality improvement of EUS-guided tissue acquisition of solid pancreatic lesions.

Background and study aims In this study, we evaluated the performance of community hospitals involved in the Dutch quality in endosonography team regarding yield of endoscopic ultrasound (EUS)-guided tissue acquisition (TA) of solid pancreatic lesions using cumulative sum (CUSUM) learning curves. The aims were to assess trends in quality over time and explore potential benefits of CUSUM as a feedback-tool. Patients and methods All consecutive EUS-guided TA procedures for solid pancreatic lesions were registered in five community hospitals between 2015 and 2018. CUSUM learning curves were plotted for overall performance and for performance per center. The American Society of Gastrointestinal Endoscopy-defined key performance indicators, rate of adequate sample (RAS), and diagnostic yield of malignancy (DYM) were used for this purpose. Feedback regarding performance was provided on multiple occasions at regional interest group meetings during the study period. Results A total of 431 EUS-guided TA procedures in 403 patients were included in this study. The overall and per center CUSUM curves for RAS improved over time. CUSUM curves for DYM revealed gradual improvement, reaching the predefined performance target (70 %) overall, and in three of five contributing centers in 2018. Analysis of a sudden downslope development in the CUSUM curve of DYM in one center revealed temporary absence of a senior cytopathologist to have had a temporary negative impact on performance. Conclusions CUSUM-derived learning curves allow for assessment of best practices by comparison among peers in a multidisciplinary multicenter quality improvement initiative and proved to be a valuable and easy-to-interpret means to evaluate EUS performance over time.

Abstract 11384: Discharge and De-Escalation After VAD Implant in Children with Dilated Cardiomyopathy: A Multi-Center Quality Improvement Initiative

Introduction: Children with dilated cardiomyopathy (DCM) are increasingly bridged to heart transplant (Tx) with intracorporeal continuous flow ventricular assist devices (VADs), but there continues to be variability in hospital discharge. We sought to assess the impact of a quality improvement (QI) project promoting hospital discharge in pediatric VAD patients with DCM. Methods: Patients enrolled at sites participating in the Discharge and De-Escalation QI project of the Advanced Cardiac Therapies Improving Outcomes Network (ACTION) registry were eligible. Patients with a HeartWare (HVAD) or HeartMate3 (HM3) VAD, implanted between April 2018 and February 2021, were included. Patient characteristics and outcomes were compared before and after the QI initiative, which targeted team and family expectations, was implemented in November 2019. Results: There were 85 patients (75%) with DCM and/or myocarditis who were included in this study (median age 14 years; median weight 57.1 kg; 67% male). Among 57 patients in the baseline group, 56% (n=32) were discharged with a mean post-implant hospital length of stay (LOS) of 36 days and 44% (n=25) underwent Tx during index VAD admission, with a mean of 52 days on device. There were 28 patients in the intervention group; 64% (n=18) were discharged with a mean LOS of 45 days, while 29% (n=8) patients underwent Tx during index VAD admission, with a mean of 44 hospital days on device. There was no significant difference in the frequency of hospital discharge or in hospital LOS between groups. Conclusions: Pediatric centers discharged just over half of DCM patients supported on an HVAD or HM3, with nearly one third of patients undergoing transplant during the index VAD admission. The QI intervention did not significantly alter the discharge rate. Further work is required to understand practice variation between centers with respect to Tx listing and organ acceptance for children on intracorporeal continuous flow VADs.

HOW MANY PAIN PILLS DO WE PRESCRIBE: A SURVEY OF PARTICIPANTS IN SCORE: A QUALITY IMPROVEMENT INITIATIVE (204)

Objectives:The public health opioid abuse epidemic has led to nationwide interest in judicious use and close monitoring of opioid pain medication. Knee arthroscopy(KA) and anterior cruciate ligament reconstruction(ACLR) are common procedures in adolescent patients for which narcotics have been historically utilized for post-operative pain management. The purpose of this study is to investigate pain management strategies following basic KA or ACLR by pediatric sports surgeons who contribute to a multi-center quality improvement initiative(SCORE).Methods:Surgeon participants in SCORE represent fifteen U.S. institutions from primarily academic teaching hospitals who specialize in pediatric sports medicine. Surgeons contribute all ACLR and other KA-related cases. A RedCap survey was distributed to all SCORE surgeon participants in December 2019. A KA (defined as a knee arthroscopy that does not include a ligament reconstruction or a cartilage procedure other than chondroplasty) represented a less invasive procedure, while the ACLR represented a more invasive procedure. Survey results were collected and analyzed for both practice patterns of regional anesthesia utilization and post-operative narcotic prescribing volumes.Results:Twenty-eight SCORE surgeon participants completed the survey, a 100% response rate. A planned prescription of a mean of 16.4 pain pills (range 0-40 pills) were reported for pain management following a KA, only 32.1% of surgeons reported adjunctive regional anesthesia techniques for this procedure in addition to general anesthesia. Following an ACLR, surgeons reported a planned prescription of a mean 23.8 pain pills (range 0-40 pills) and most (92.3%) reported utilization of regional anesthesia for their peri-operative analgesia strategy. Of those using adjunctive regional anesthesia, significant variability was reported: 30.7% reported indwelling catheter placement for peripheral nerve block following ACLR as opposed to a single shot injection method, and several block locations were reported to be utilized of which adductor canal (67.9%) block was the most common (see Figure 1). For both procedure types, variability in multi-modal pain management was noted, with incomplete adoption of the use of additional non-narcotic medication (acetaminophen, 64.2%; and NSAIDS, 75%). Cryotherapy devices were applied/prescribed in 75.0% of knee arthroscopy procedures and 92.8% of ACLR.Conclusions:Despite evidence for effective adjunctive pain management strategies, incomplete adoption of multi-modal techniques and reliance on narcotic medication remains a significant component of pediatric sports surgical practice; with on average > 15 pills prescribed following these procedures. Opportunities for reducing practice variability, adoption of multi-modal analgesia strategies, and decreasing post-operative narcotic use following common adolescent knee procedures exist for this subset of pediatric sports medicine specialists

Assessment of an Unplanned Extubation Bundle to Reduce Unplanned Extubations in Critically Ill Neonates, Infants, and Children

Unplanned extubations (UEs) in children contribute to significant morbidity and mortality, with an arbitrary benchmark target of less than 1 UE per 100 ventilator days. However, there have been no multicenter initiatives to reduce these events. To determine if a multicenter quality improvement initiative targeting all intubated neonatal and pediatric patients is associated with a reduction in UEs and morbidity associated with UE events. This multicenter quality improvement initiative enrolled patients from pediatric, neonatal, and cardiac intensive care units (ICUs) in 43 participating children's hospitals from March 2016 to December 2018. All patients with an endotracheal tube requiring mechanical ventilation were included in the study. Participating hospitals implemented a quality improvement bundle to reduce UEs, which included standardized anatomic reference points and securement methods, protocol for high-risk situations, and multidisciplinary apparent cause analyses. The main outcome measures for this study included bundle compliance with each factor tested and UE rates on the center level and on the cohort level. Among the 43 children's hospitals, the quality improvement initiative was associated with an aggregate 24.1% reduction in UE events, from a baseline rate of 1.135 UEs per 100 ventilator days to 0.862 UEs per 100 ventilator days. Across ICU settings studied, the pediatric ICU and neonatal ICU demonstrated centerline shifts, with an absolute reduction in events of 20.6% (from a baseline rate of 0.729 UEs per 100 ventilator days to 0.579 UEs per 100 ventilator days) and 17.6% (from a baseline rate of 1.555 UEs per 100 ventilator days to 1.282 UEs per 100 ventilator days), respectively. Most UEs required reintubation within 1 hour (mean of 120 of 206 events per month [58.3%]), followed by UEs that did not require reintubation (mean of 78 of 206 events per month [37.9%]) and UEs that resulted in cardiovascular collapse (mean of 8 of 206 events per month [3.9%]). Cardiovascular collapse events represented the most significant consequence of UE studied, and the collaborative reduced these UE events by 36.6%, from a study baseline rate of 0.041 UEs per 100 ventilator days to 0.026 UEs per 100 ventilator days. This multicenter quality improvement initiative was associated with a reduction in UEs across different pediatric populations in diverse settings. A significant reduction in event rate and rate of harm (cardiovascular collapse) was observed, which was sustained over the time course of the intervention. This quality improvement process and UE bundle may be considered standard of care for pediatric hospitals in the future.

A multicenter quality improvement initiative on the impact of pharmacists’ postdischarge follow-up to reduce medication-related acute care episodes

This multicenter quality improvement initiative aims to measure and quantify pharmacists' impact on reducing medication-related acute care episodes (MACEs) for high-risk patients at an increased risk for readmission due to drug-related problems (DRPs). This was a prospective, multicenter quality improvement initiative conducted at 9 academic medical centers. Each participant implemented a standardized methodology for evaluating MACE likelihood to demonstrate the impact of pharmacist postdischarge follow-up (PDFU). The primary outcome was MACEs prevented, and the secondary outcome was DRPs identified and resolved by pharmacists. During PDFU, pharmacists were responsible for identification and resolution of DRPs, and cases were reviewed by physicians to confirm whether potential MACEs were prevented. A total of 840 patients were contacted by 9 participating academic medical centers during a 6-week data collection period. Of these, 328 cases were identified as MACEs prevented during PDFU by pharmacists, and physician reviewers confirmed that pharmacist identification of DRPs during PDFU prevented 27.9% of readmissions. Pharmacist identified 959 DRPs, 2.8% (27) of which were identified as potentially life threatening. Potentially serious or significant DRPs made up 56.6% (543) of the DRPs, and 40.6% (389) were identified as having a low capacity for harm. The results demonstrate that PDFU of high-risk patients reduces DRPs and prevents MACEs based on physician confirmation. Implementation of MACE methodology provides health-system pharmacy departments the ability to demonstrate pharmacists' value in transitions of care and assist in expanding pharmacist services.

A prospective multi-center quality improvement initiative (NINJA) indicates a reduction in nephrotoxic acute kidney injury in hospitalized children

Nephrotoxic medication (NTMx) exposure is a common cause of acute kidney injury (AKI) in hospitalized children. The Nephrotoxic Injury Negated by Just-in time Action (NINJA) program decreased NTMx associated AKI (NTMx-AKI) by 62% at one center. To further test the program, we incorporated NINJA across nine centers with the goal of reducing NTMx exposure and, consequently, AKI rates across these centers. NINJA screens all non-critically ill hospitalized patients for high NTMx exposure (over three medications on the same day or an intravenous aminoglycoside over three consecutive days), and then recommends obtaining a daily serum creatinine level in exposed patients for the duration of, and two days after, exposure ending. Additionally, substitution of equally efficacious but less nephrotoxic medications for exposed patients starting the day of exposure was recommended when possible. The main outcome was AKI as defined by the Kidney Disease Improving Global Outcomes (KDIGO) serum creatinine criteria (increase of 50% or 0.3 mg/dl over baseline). The primary outcome measure was AKI episodes per 1000 patient-days. Improvement was defined by statistical process control methodology and confirmed by Autoregressive Integrated Moving Average (ARIMA) modeling. Eight consecutive bi-weekly measure rates in the same direction from the established baseline qualified as special cause change for special process control. We observed a significant and sustained 23.8% decrease in NTMx-AKI rates by statistical process control analysis and by ARIMA modeling; similar to those of the pilot single center. Thus, we have successfully applied the NINJA program to multiple pediatric institutions yielding decreased AKI rates.

Reduction in coronary artery bypass grafting surgery mortality and morbidity during a 3-year multicenter quality improvement project

ObjectiveRisk-adjusted operative mortality is a key quality measure for isolated coronary artery bypass grafting. Through a multicenter quality improvement initiative, we sought to improve this measure at 14 surgical programs within a large and geographically dispersed health care system. MethodsObserved mortality and combined mortality/morbidity rates for isolated coronary artery bypass grafting were collected from January 2014 to June 2017. Expected mortality and mortality/morbidity rates were determined using the Society of Thoracic Surgeons risk models. The observed/expected ratios during the baseline (2014) and final 12-month outcome period were compared. The quality improvement intervention was multifaceted and surgeon led, and consisted of (1) regular sharing of unblinded data, (2) standardized quality improvement processes, (3) regular system-wide quality improvement meetings, (4) annual observed/expected mortality targets, (5) identification of underperforming institutions and creation of nonpunitive quality improvement action plans, and (6) implementation of checklists to drive perioperative care standardization. ResultsThe observed/expected ratio of mortality was 1.19 during the baseline period and decreased to 0.59 for the outcome period (P = .004) without a change in expected mortality or case volume. The observed/expected ratio decreased for mortality/morbidity, and mortality without antecedent morbidity was almost eliminated. ConclusionsA significant and clinically meaningful 50% reduction in the observed/expected ratio for isolated coronary artery bypass grafting mortality was observed during a multifaceted quality improvement initiative across a large multicenter health care system. Morbidity also decreased. Keys to success included surgeon leadership and engagement, frequent unblinded data sharing, development of standardized quality improvement processes, improvement and standardization of care delivery, setting of quality improvement targets, and a shared vision for improved patient outcomes.

Adverse events and their risk factors 90 days after cervical spine surgery: analysis from the Michigan Spine Surgery Improvement Collaborative.

The Michigan Spine Surgery Improvement Collaborative (MSSIC) is a statewide, multicenter quality improvement initiative. Using MSSIC data, the authors sought to identify 90-day adverse events and their associated risk factors (RFs) after cervical spine surgery. A total of 8236 cervical spine surgery cases were analyzed. Multivariable generalized estimating equation regression models were constructed to identify RFs for adverse events; variables tested included age, sex, diabetes mellitus, disc herniation, foraminal stenosis, central stenosis, American Society of Anesthesiologists Physical Classification System (ASA) class > II, myelopathy, private insurance, anterior versus posterior approach, revision procedures, number of surgical levels, length of procedure, blood loss, preoperative ambulation, ambulation day of surgery, length of hospital stay, and discharge disposition. Ninety days after cervical spine surgery, adverse events identified included radicular findings (11.6%), readmission (7.7%), dysphagia requiring dietary modification (feeding tube or nothing by mouth [NPO]) (6.4%), urinary retention (4.7%), urinary tract infection (2.2%), surgical site hematoma (1.1%), surgical site infection (0.9%), deep vein thrombosis (0.7%), pulmonary embolism (0.5%), neurogenic bowel/bladder (0.4%), myelopathy (0.4%), myocardial infarction (0.4%), wound dehiscence (0.2%), claudication (0.2%), and ileus (0.2%). RFs for dysphagia included anterior approach (p < 0.001), fusion procedures (p = 0.030), multiple-level surgery when considering anterior procedures only (p = 0.037), and surgery duration (p = 0.002). RFs for readmission included ASA class > II (p < 0.001), while preoperative ambulation (p = 0.001) and private insurance (p < 0.001) were protective. RFs for urinary retention included increasing age (p < 0.001) and male sex (p < 0.001), while anterior-approach surgery (p < 0.001), preoperative ambulation (p = 0.001), and ambulation day of surgery (p = 0.001) were protective. Preoperative ambulation (p = 0.010) and anterior approach (p = 0.002) were protective of radicular findings. A multivariate analysis from a large, multicenter, prospective database identified the common adverse events after cervical spine surgery, along with their associated RFs. This information can lead to more informed surgeons and patients. The authors found that early mobilization after cervical spine surgery has the potential to significantly decrease adverse events.

Common Challenges to Effective ABCDEF Bundle Implementation: The ICU Liberation Campaign Experience.

Although growing evidence supports the safety and effectiveness of the ABCDEF bundle (A, assess, prevent, and manage pain; B, both spontaneous awakening and spontaneous breathing trials; C, choice of analgesic and sedation; D, delirium: assess, prevent, and manage; E, early mobility and exercise; and F, family engagement and empowerment), intensive care unit providers often struggle with how to reliably and consistently incorporate this interprofessional, evidence-based intervention into everyday clinical practice. Recently, the Society of Critical Care Medicine completed the ICU Liberation ABCDEF Bundle Improvement Collaborative, a 20-month, nationwide, multicenter quality improvement initiative that formalized dissemination and implementation strategies and tracked key performance metrics to overcome barriers to ABCDEF bundle adoption. The purpose of this article is to discuss some of the most challenging implementation issues that Collaborative teams experienced, and to provide some practical advice from leading experts on ways to overcome these barriers.

Fungal peritonitis in the Standardizing Care to Improve Outcomes in Pediatric End Stage Renal Disease (SCOPE) Collaborative.

Fungal peritonitis is a serious complication among peritoneal dialysis (PD) patients. The Standardizing Care to Improve Outcomes in Pediatric End Stage Renal Disease (SCOPE) Collaborative is a North American multicenter quality improvement initiative with the primary aim to reduce catheter-related infections in children on chronic dialysis. To describe the epidemiology of fungal peritonitis and outcomes of affected patients among pediatric subjects receiving chronic PD and enrolled in SCOPE. Data pertaining to PD characteristics, peritonitis episodes and patient outcome were collected between October 2011 and September 2015 from 30 pediatric dialysis centers participating in the SCOPE collaborative. Peritonitis-related data were stratified by etiology, fungal versus bacterial/culture-negative peritonitis. Differences among groups were assessed by Chi-square analysis. Of 994 patients enrolled in the registry, there were 511 peritonitis episodes of which 41 (8.0%) were fungal. Thirty-six individual patients with 39 unique catheters accounted for the fungal peritonitis episodes. Twenty-three (59%) of the episodes occurred in patients aged < 2years (p= 0.03). Fungal peritonitis was the initial episode of peritonitis in 48.8% of affected patients, and only 17.1% of these patients had had a previous peritonitis episode within 30days of the fungal infection. Insertion of the PD catheter at < 2years of age was associated with an adjusted odds ratio of 2.8 (95% confidence interval 1.24, 6.31) for development of fungal peritonitis compared to older children (p= 0.01). Fungal peritonitis was associated with an increased rate of hospitalization (80.5 vs. 63.4%; p= 0.03), increased length of hospitalization (median of 8 vs. 5days; p< 0.001) and increased rates of catheter removal (84.6 vs 26.9%; p= 0.001) and technique failure (68.3 vs. 8%; p= 0.001) compared to other causes of peritonitis. Fungal infections were responsible for 8.0% of peritonitis episodes in the SCOPE collaborative, with the majority of fungal peritonitis episodes occurring in children aged < 2years. Although no risk factors for infection other than young age were identified, fungal peritonitis was associated with an increased risk of hospitalization, longer hospital stay and an increased frequency of technique failure.

Implementing the PEP uP Protocol in Critical Care Units in Canada

Previous studies have documented widespread iatrogenic underfeeding in intensive care unit (ICU) patients. In an experimental setting, we demonstrated the safety and efficacy of a novel enteral feeding protocol designed to overcome the main barriers to adequate delivery of enteral nutrition (EN), the Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol (PEP uP protocol). The purpose of this article is to describe our experience with implementing this feeding protocol under "real-world" settings in Canada. This study is a multicenter quality improvement initiative with a concurrent control group. Selected ICUs implemented the PEP uP protocol, and nutrition practices and outcomes were compared with a concurrent control group of ICUs. In 2013, of the 24 ICUs from Canada that participated in the International Nutrition Survey, 8 implemented the PEP uP protocol and the remaining 16 served as concurrent control sites. Patients at PEP uP sites received 60.1% of their prescribed energy requirements from EN compared with 49.9% in patients from control hospitals (P = .02). In addition, patients in PEP uP protocol sites received more protein from EN (61.0% vs 49.7% of prescribed amounts; P = .01), were more likely to receive protein supplements (71.8% vs 47.7%; P = .01), and were more likely to receive >80% of their protein requirements by day 3 (46.1% vs 29.3%; P = .05) compared with patients in control hospitals. In the real-life setting, the PEP uP protocol can improve the delivery of EN to critically ill patients.

175 Identification of Actionable Items for Systems Improvement Through Patient Safety Executive Walkrounds in a Pediatric Hospital (USA)

Background: This institution is participating in a multi-center quality improvement initiative, Executive Walkrounds (EW), designed to provide hospital staff with a forum to communicate safety concerns to leadership. We developed a method to transform these concerns into actions and facilitate follow-up.