Patient Safety Solutions Research Articles

74 Reducing unplanned extubations in a level 3 neonatal intensive care unit - the nuts and bolts of UE bundle implementation

Abstract Background Unplanned extubations (UEs) are preventable adverse events that may lead to short term consequences (e.g. cardiopulmonary collapse) and long term sequelae (e.g. acquired airway injury, brain injury) for patients admitted to the Neonatal Intensive Care Unit (NICU). UE prevention care bundles have been demonstrated to reduce UE rates in NICUs; however, implementation of bundle elements is unit dependent. Objectives To describe the work of a UE Prevention Team in a Level 3 NICU with rising UE rates despite implementation of UE prevention bundle per Children’s Hospital Solutions for Patient Safety (SPS). Design/Methods A neonatologist / respiratory therapist pair was assembled in March 2022 to tackle rising UE rates in a 69 bed NICU. Contributing unit stressors included implementation of a new electronic health record, COVID-19 policies, and nursing shortages. Baseline UE rates were >3x the centerline for SPS network NICUs and likely underreported. Steps undertaken include: 1) daily audit to ensure reporting of all UEs, 2) structured post-event team debriefs, 3) unit education campaign to raise awareness of UE prevention and bundle elements, 4) prominent posting of last UE date and reporting on daily team huddle, 5) rapid UE case reviews and apparent cause analysis with reporting of findings unit-wide, 6) optimize endotracheal tube (ETT) securement methods, 6) enforce T2-T3 ETT tip position, 7) standardize x-ray frequencies and reporting, 8) trial of daily rounds ETT safety checklist. Results From rapid case reviews, apparent causes were determined to be incorrect ETT securement device sizing, taping method prone to loss of tape integrity in high humidity, high ETT positions, and inadequate ETT monitoring during high risk activities other than repositioning (invasive/painful procedures, diaper changes). Post-event structured debriefs and unit-wide vigilance increased reporting of UE events to 100%. UE rates fell from a peak of >4 UEs/month, >2.4/100 ventilation days to 1 UE/month, 0.465/100 ventilation days, a 80% reduction.(Figure 1) Most impactful interventions were standard x-ray reporting template in the electronic health record, reinforcing T2-T3 ETT tip positioning, correcting ETT holder sizing, and change in ETT method (Figure 2). Daily rounds checklist was not effective. UE reductions were achieved without changing patient ratios as nurse staffing shortages continued. Conclusion A nimble systems approach is needed to ensure success in implementation of UE prevention care bundles. Simple changes can be made to decrease UEs, guided by rapid case reviews.

Improving the Accuracy of mmWave Radar for Ethical Patient Monitoring in Mental Health Settings.

Monitoring patient safety in high-risk mental health environments is a challenge for clinical staff. There has been a recent increase in the adoption of contactless sensing solutions for remote patient monitoring. mmWave radar is a technology that has high potential in this field due it its low cost and protection of privacy; however, it is prone to multipath reflections and other sources of environmental noise. This paper discusses some of the challenges in mmWave remote sensing applications for patient safety in mental health wards. In line with these challenges, we propose a novel low-data solution to mitigate the impact of multipath reflections and other sources of noise in mmWave sensing. Our solution uses an unscented Kalman filter for target tracking over time and analyses features of movement to determine whether targets are human or not. We chose a commercial off-the-shelf radar and compared the accuracy and reliability of sensor measurements before and after applying our solution. Our results show a marked decrease in false positives and false negatives during human target tracking, as well as an improvement in spatial location detection in a two-dimensional space. These improvements demonstrate how a simple low-data solution can improve existing mmWave sensors, making them more suitable for patient safety solutions in high-risk environments.

Development and Evaluation of Patient Safety Interventions: Perspectives of Operational Safety Leaders and Patient Safety Organizations.

The purpose of this study is to understand how patient safety professionals from healthcare facilities and patient safety organizations develop patient safety interventions and the resources used to support intervention development. Semistructured interviews were conducted with patient safety professionals at nine healthcare facilities and nine patient safety organizations. Interview data were qualitatively analyzed, and findings were organized by the following: patient safety solutions and interventions, use of external databases, and evaluation of patient safety solutions. Development of patient safety interventions across healthcare facilities and patient safety organizations was similar and included literature searches, internal brainstorming, and interviews. Nearly all patient safety professionals at healthcare facilities reported contacting colleagues at other healthcare facilities to learn about similar safety issues and potential interventions. Additionally, less than half of patient safety professionals at healthcare facilities and patient safety organizations interviewed report data to publicly available patient safety databases. Finally, most patient safety professionals at healthcare facilities and patient safety organizations stated that they evaluate the effectiveness of patient safety interventions; however, they mentioned methods that may be less rigorous including audits, self-reporting, and subjective judgment. Patient safety professionals often utilize similar methods and resources to develop and evaluate patient safety interventions; however, many of these efforts are not coordinated across healthcare organizations and could benefit from working collectively in a systematic fashion. Additionally, healthcare facilities and patient safety organizations face similar challenges and there are several opportunities for optimization on a national level that may improve patient safety.

Integrating Patient Safety Discussions with First-Year Doctor of Pharmacy Students in a Skills Lab Course.

The patient safety problem has been well established for over 20 years in the United States (U.S.), and there is a recognized focus on ensuring that health professions' trainees receive explicit education in various patient safety principles and practices. While the literature provides examples of different approaches towards patient safety education for pharmacy students, there are few that focus on first-year pharmacy students. This educational observational study describes the implementation and evaluation of two 20 min patient safety learning activities integrated into a required pharmacy skills lab course. The first learning activity utilized a mock prescription and patient safety checklist that had students identify patient safety problems on the prescription, followed by a group discussion of implications for the patient. The second learning activity used images of common safety problems with a facilitated group discussion to have students identify systems-based solutions to those problems. Our study's findings revealed that students were able to identify basic patient safety problems and safety solutions, although some additional foundational information may be needed, particularly for students who may not have pharmacy work experience. Additional research is needed to continue building a literature base on patient safety education approaches, particularly for first-year pharmacy students.

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.

Navigating the Legal and Ethical Terrain of Artificial Intelligence in Enhancing Patient Safety in Nigeria

The emergence of Artificial Intelligence (AI) significantly impacts the understanding of medical errors, minimizes their occurrence, and provides contextual solutions for patient safety in Nigeria.Given the country's expanding population and constrained healthcare resources, the potential significance of AI in enhancing patient safety in Nigeria cannot be overstated. There is a rapid trend to integrate AI into Nigeria's healthcare system, however, this raises concerns about algorithm bias and privacy. This study explores the ethical and legal implications of deploying AI for patient safety in Nigeria and assesses how the existing Nigerian legal frameworks address these concerns. This research shows that although bias and discrimination are generally prohibited by the Constitution of the Federal Republic of Nigeria and other legal instruments, algorithmic bias which arises from the use of AI is not catered for by these laws. In addition, despite current privacy and confidentiality safeguards, AI in healthcare presents unique and novel challenges that the legislation does not yet address. Therefore, developing a new legal and governance structure to address both present and prospective challenges of AI in the health sector is extremely useful.

Peri-operative night-time work of anaesthesiologists: A qualitative study of critical issues and proposals.

Qualitative data on the opinions of anaesthesiologists regarding the impact of peri-operative night-time working conditions on patient safety are lacking. This study aimed to achieve in-depth understanding of anaesthesiologists' perceptions regarding the impact of night-time working conditions on peri-operative patient safety and actions that may be undertaken to mitigate perceived risks. Qualitative analysis of responses to two open-ended questions. Online platform questionnaire promoted by the European Society of Anaesthesiology and Intensive Care (ESAIC). The survey sample consisted of an international cohort of anaesthesiologists. We identified and classified recurrent themes in the responses to questions addressing perceptions regarding (Q1) peri-operative night-time working conditions, which may affect patient safety and (Q2) potential solutions. We analysed 2112 and 2113 responses to Q1 and Q2, respectively. The most frequently reported themes in relation to Q1 were a perceived reduction in professional performance accompanied by concerns regarding the possible consequences of work with fatigue (27%), and poor working conditions at night-time (35%). The most frequently proposed solutions in response to Q2 were a reduction of working hours and avoidance of 24-h shifts (21%), an increase in human resources (14%) and performance of only urgent or emergency surgeries at night (14%). Overall, the surveyed anaesthesiologists believe that workload-to-staff imbalance and excessive working hours were potential bases for increased peri-operative risk for their patients, partly because of fatigue-related medical errors during night-time work. The performance of nonemergency elective surgical cases at night and lack of facilities were among the reported issues and potential targets for improvement measures. Further studies should investigate whether countermeasures can improve patient safety as well as the quality of life of anaesthesia professionals. Regulations to improve homogeneity, safety, and quality of anaesthesia practice at night seem to be urgently needed.

Awareness and practice of nine life-saving patient safety solutions among healthcare workers

Millions of people die or are injured each year due to unsafe patient care at a huge human cost. Healthcare workers play a pivotal role in reducing errors, enhancing safety, and ensuring high-quality patient care. There are a number of ways in which patient safety can deteriorate in healthcare. Some important factors include a lack of patient safety research, inadequate training of healthcare professionals, and lack of patient safety guidelines in hospitals. There are nine life-saving patient safety solutions that, combined, can have an immediate, significant, and measurable impact. It is critical that healthcare workers are aware of the nine life-saving patient safety solutions and adopt them into their daily practice. Patient safety is one of the most important characteristics of good care, measured by clinically effective care. It is primarily the safety of patients in hospitals but also covers the continuum of care. Can it be implemented in non-institutional care? Adopting each of these solutions will not only reduce many common medical errors such as medication and medication errors, surgical site infections, bed sores, and hospital-acquired delirium, but will also significantly meet most international quality standards.

Artificial intelligence and remote patient monitoring in US healthcare market: a literature review

ABSTRACT Background: Artificial intelligence (AI) enables remote patient monitoring (RPM) which reduces costs by triaging patients to optimize hospitalization and avoid complications. The FDA regulates AI in medical devices and aims to ensure patient safety, effectiveness, and transparent AI solutions. Objectives: Identify and summarize FDA approved RPM devices to provide information for the US medical device industry based on previous approvals and the markets’ needs. Methods: We searched publicly available databases on FDA-approved RPM devices. Selection criteria were established to classify a solution as AI. Technical information was analyzed on pre-identified 16 parameters for the qualified solutions. Results: A total of 47 RPM devices were reviewed, among which 12.8% were classified as a De Novo product and the remaining devices fell under the 510(K) FDA category. The cardiovascular (74%) AI RPM solutions dominated the US market, followed by ECG-based arrhythmia detection algorithms (59.4%), and Hemodynamics and Vital Sign monitoring algorithms (21.9%). The trend observed in the FDA rejected devices was their inability to be classified into clinically relevant categories (Criteria 2 and 3). Conclusion: The market needs more innovative RPM solutions under the De Novo category, as there are very few. The transparency is low on the technical aspect of AI algorithms. The market needs AI algorithms that can effectively classify patients rather than merely improve device functionality.

Association between Electronic Health Record Implementations and Hospital-Acquired Conditions in Pediatric Hospitals.

Implementing an electronic health record (EHR) is one of the most disruptive operational tasks a health system can undergo. Despite anecdotal reports of adverse events around the time of EHR implementations, there is limited corroborating research, particularly in pediatrics. We utilized data from Solutions for Patient Safety (SPS), a network of 145+ children's hospitals that share data and protocols to reduce harm in pediatric care delivery, to study the impact of EHR implementations on patient safety. Determine if there is an association between the time immediately surrounding an EHR implementation and hospital-acquired conditions (HACs) rates in pediatrics. A survey of information technology leaders at pediatric institutions identified EHR implementations occurring between 2012 and 2022. This list was cross-referenced with the SPS database to create an anonymized dataset of 27 sites comprising monthly HAC and care bundle compliance rates in the 7 months preceding and succeeding the transition. Six HACs were analyzed: central-line associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), adverse drug events, surgical site infections (SSIs), pressure injuries (PIs), and falls, in addition to four associated care bundle compliance rates: CLABSI and CAUTI maintenance bundles, SSI bundle, and PI bundle. To determine if there was a statistically significant association with EHR implementation, the observation period was divided into three eras: "before" (months -7 to -3), "during" (months -2 to +2), and "after" go-live (months +3 to +7). Average monthly HAC and bundle compliance rates were calculated across eras. Paired t-tests were performed to compare rates between the eras. No statistically significant increase in HAC rates or decrease in bundle compliance rates was observed across the EHR implementation eras. This multisite study detected no significant increase in HACs and no decrease in preventive care bundle compliance in the months surrounding an EHR implementation.

Reducing paediatric unintended extubation: A standardized bundle approach.

Unintended extubation (UE) is a serious risk associated with endotracheal intubation. In the paediatric population, UE can lead to significant patient harm. On average, each UE increases ICU and hospital length of stay by 5.5 and 6.5 days respectively and costs an additional $36 000. The international benchmark rate of UE for quality analysis cited in the literature is <1 per 100 ventilator days. The United States organization Solutions for Patient Safety (SPS) developed and introduced a bundle to reduce UE with a goal of ≤0.95 per 100 ventilator days. The aim of this quality improvement project was to determine the baseline rate of UE in a 20-bed mixed medical/surgical PICU in the Pacific Northwest of the United States, implement the SPS bundle for UE prevention, and assess adherence to the bundle, and subsequent rate of UE. The IHI Model for Improvement Plan-Do-Study-Act (PDSA) was used to guide the development, implementation, and assessment of the SPS UE Bundle standardizing the management of endotracheal tubes. Adherence to the bundle was measured through peer-to-peer audits. Rates of adherence and UE were monitored on line charts. Baseline rate of UE was 1.83 per 100 ventilator days; 23 weeks post implementation of the bundle the rate of UE was reduced to 0.38 UE per 100 ventilator days, F(7, 9)=4.685, p=0.027. The mean bundle adherence was 92%. This quality improvement initiative confirms that high adherence to the SPS UE Bundle may significantly reduce rates of UE in PICU settings. Use of the SPS evidence-based discrete UE bundle and high adherence to the bundle can standardize practise and may reduce unintended extubation in the paediatric population.

Association Between Hospital-Acquired Harm Outcomes and Membership in a National Patient Safety Collaborative

Hospital engagement networks supported by the US Centers for Medicare & Medicaid Services Partnership for Patients program have reported significant reductions in hospital-acquired harm, but methodological limitations and lack of peer review have led to persistent questions about the effectiveness of this approach. To evaluate associations between membership in Children's Hospitals' Solutions for Patient Safety (SPS), a federally funded hospital engagement network, and hospital-acquired harm using standardized definitions and secular trend adjustment. This prospective hospital cohort study included 99 children's hospitals. Using interrupted time series analyses with staggered intervention introduction, immediate and postimplementation changes in hospital-acquired harm rates were analyzed, with adjustment for preexisting secular trends. Outcomes were further evaluated by early-adopting (n = 73) and late-adopting (n = 26) cohorts. Hospitals implemented harm prevention bundles, reported outcomes and bundle compliance using standard definitions to the network monthly, participated in learning events, and implemented a broad safety culture program. Hospitals received regular reports on their comparative performance. Outcomes for 8 hospital-acquired conditions were evaluated over 1 year before and 3 years after intervention. In total, 99 hospitals met the inclusion criteria and were included in the analysis. A total of 73 were considered part of the early-adopting cohort (joined between 2012-2013) and 26 were considered part of the late-adopting cohort (joined between 2014-2016). A total of 42 hospitals were freestanding children's hospitals, and 57 were children's hospitals within hospital or health systems. The implementation of SPS was associated with an improvement in hospital-acquired condition rates in 3 of the 8 conditions after accounting for secular trends. Membership in the SPS was associated with an immediate reduction in central catheter-associated bloodstream infections (coefficient = -0.152; 95% CI, -0.213 to -0.019) and falls of moderate or greater severity (coefficient = -0.331; 95% CI, -0.594 to -0.069). The implementation of the SPS was associated with a reduction in the monthly rate of adverse drug events (coefficient = -0.021; 95% CI, -0.034 to -0.008) in the post-SPS period. The study team observed larger decreases for the early-adopting cohort compared with the late-adopting cohort. Through the application of rigorous methods (standard definitions and longitudinal time series analysis with adjustment for secular trends), this study provides a more thorough analysis of the association between the Partnership for Patients hospital engagement network model and reductions in hospital-acquired conditions. These findings strengthen previous claims of an association between this model and improvement. However, inconsistent observations across hospital-acquired conditions when adjusted for secular trends suggests that some caution regarding attributing all effects observed to this model is warranted.

Early results of a French care-related adverse events database in radiology

PurposeThe purpose of this study was to report the initial results of the declaration of care-related adverse events (CRAEs) in radiology in the French National Authority for Health (HAS) database for accreditation of radiological medical teams. Materials and methodsBetween October 2018 and December 2020, 48 radiological teams (32 teams in 2019 and 16 teams in 2020; 471 registered radiologists) signed up to the team accreditation process, a system supported by the HAS. Reports of the CRAEs in radiology started in September 2019 after the team registration phase. ResultsAmong the 89 CRAEs reported, 28 (31%) were targeted as interventional radiology, 27 (30%) as linked to contrast media and 11 (12%) as related to MRI care; the 23 other CRAEs reported included five defaults in the transmission of requests or results, five delays in diagnosis or treatment, four patient-identity monitoring events, four diagnostic radiology complications, four radiation protection events and one patient information problem. The severity was rated as “minor” for 53% of CRAEs and as “serious to critical” or “catastrophic” for 8% and 9% of CRAEs, respectively. They were preventable or probably preventable in 84% of all events. ConclusionThese early results of this nation-wide CRAEs declaration database show the diversity of all CRAEs and their causes in radiological practice in France, and provide a global vision of areas for improvement of the quality of care in radiology. This should convince other radiologists to declare CRAEs and allow, in time, the production of recommendations and patient safety solutions as to limit the risks associated with radiological care.

988 A Quality Improvement Project; Improving the Quality and Safety of Handover During COVID-19

AimThe World Health Organisation (WHO) positions effective handover, in its top five patient safety solutions. During our District Hospital Trust’s COVID-19 response, an unprecedented reorganisation of all teams occurred. All surgical and medical speciality junior doctors were re-deployed and split into 4 zones to cover the hospital. In this quality improvement project (QIP), we sought to understand our trainees’ thoughts on this new multi-zonal handover process and aimed to identify risk-reduction measures to aid better patient care.MethodThe opinions of trainees on the new handover system were obtained using an online Likert scale survey. Following the responses, a new morning and night handover proforma was developed. This was used trust-wide and a post-intervention repeat survey was conducted to assess the new changes.ResultsThe primary survey received 31 responses with feedback illustrating mixed effectiveness of the existing handover process. Free text comments highlighted issues surrounding “safety”, “poor organisation”, “poor continuity of care” with one serious incident reported. Post-intervention of a new handover proforma, a repeat online survey received 25 responses. Results were significantly more positive with >84% of responses being in the “strongly agree to agree” category, including for “continuity of care”, “organisation”, and “safety”.ConclusionsThis QIP illustrates a good example of a low-cost intervention to create a better handover system and aid hospitals during time of crises. For us, it managed to reform the handover process and ultimately improved our patient care. Forthcoming, we would like to create a national best practice guide for effective handover.

Addressing and Recognizing Pediatric Inpatient Aggression Utilizing an Interprofessional Quality Team Approach

In Brief Children’s Hospitals’ Solutions for Patient Safety (SPS) is a network of over 140 children’s hospitals who share the vision of working together to eliminate serious harm across all pediatric hospitals. The SPS network is built on the fundamental belief that by sharing successes and failures transparently and learning from one another, children’s hospitals can achieve their goals more effectively and quickly than working alone. Each year, SPS hosts National Learning Sessions to which members are invited to submit abstracts describing relevant safety research or improvement work. The following abstracts were among the top submitted for the SPS Spring 2021 National Learning Session.

Standardization of Care is Key: Reducing CLABSI in Pediatric Patients

In Brief Children’s Hospitals’ Solutions for Patient Safety (SPS) is a network of over 140 children’s hospitals who share the vision of working together to eliminate serious harm across all pediatric hospitals. The SPS network is built on the fundamental belief that by sharing successes and failures transparently and learning from one another, children’s hospitals can achieve their goals more effectively and quickly than working alone. Each year, SPS hosts National Learning Sessions to which members are invited to submit abstracts describing relevant safety research or improvement work. The following abstracts were among the top submitted for the SPS Spring 2021 National Learning Session.

Reduction of CLABSIs at Riley NICU: It Takes a Village and a Continuous QI Process!

In Brief Children’s Hospitals’ Solutions for Patient Safety (SPS) is a network of over 140 children’s hospitals who share the vision of working together to eliminate serious harm across all pediatric hospitals. The SPS network is built on the fundamental belief that by sharing successes and failures transparently and learning from one another, children’s hospitals can achieve their goals more effectively and quickly than working alone. Each year, SPS hosts National Learning Sessions to which members are invited to submit abstracts describing relevant safety research or improvement work. The following abstracts were among the top submitted for the SPS Spring 2021 National Learning Session.

A Quality Improvement Bundle to Reduce Ambulatory CLABSI: The Importance of a Multidisciplinary Team

In Brief Children’s Hospitals’ Solutions for Patient Safety (SPS) is a network of over 140 children’s hospitals who share the vision of working together to eliminate serious harm across all pediatric hospitals. The SPS network is built on the fundamental belief that by sharing successes and failures transparently and learning from one another, children’s hospitals can achieve their goals more effectively and quickly than working alone. Each year, SPS hosts National Learning Sessions to which members are invited to submit abstracts describing relevant safety research or improvement work. The following abstracts were among the top submitted for the SPS Spring 2021 National Learning Session.

Racial Disparities in Hospital-acquired Conditions among Pediatric Patients

In Brief Children’s Hospitals’ Solutions for Patient Safety (SPS) is a network of over 140 children’s hospitals who share the vision of working together to eliminate serious harm across all pediatric hospitals. The SPS network is built on the fundamental belief that by sharing successes and failures transparently and learning from one another, children’s hospitals can achieve their goals more effectively and quickly than working alone. Each year, SPS hosts National Learning Sessions to which members are invited to submit abstracts describing relevant safety research or improvement work. The following abstracts were among the top submitted for the SPS Spring 2021 National Learning Session.

Implementation of Electronic Health Record Tools for Prevention of Venous Thromboembolism in Hospitalized Children with Cancer and Blood Disorders

▪IntroductionVenous thromboembolism (VTE) is the 2nd most common hospital acquired condition at our pediatric hospital. Children with cancer and blood disorders have acquired prothrombotic risk factors. As part of a quality improvement (QI) initiative to decrease VTE in hospitalized children with cancer and blood disorders, we implemented VTE risk assessment, prevention, and documentation tools within the Electronic Health Record (EHR). The baseline documented screening prior to the tool was 0% and sequential compression device (SCD) and prophylactic anticoagulation were rarely prescribed. The primary outcome was percentage of patients with documented screening.MethodsA VTE risk assessment tool, including the Braden Q activity score (score <3 is defined as chair or bedridden) and clinical risk factors, was developed based on published literature, clinical practice guidelines, local experience, and recommendations from the Children's Hospitals' Solutions for Patient Safety. Patients were categorized as LOW, MODERATE, or HIGH risk for VTE and risk-based recommendations for VTE prevention were provided. MODERATE risk was defined as Braden Q activity score <3 plus 0-1 other risk factors; SCD were recommended if not contraindicated. HIGH risk was defined as central venous catheter (CVC) in place and/or Braden Q activity score <3 plus 2 or more other risk factors; SCD and prophylactic anticoagulation were recommended if no contraindications. Patients are eligible for risk assessment if they are 10-17.99 years and admitted to the hematology/oncology unit at Rady Children's Hospital San Diego for >24 hours.ResultsBetween March 1 to May 31, 2017, 57 unique patients had a total of 107 admissions, and VTE risk assessment was completed for 102 admissions (95.3%), see Table 1. Members of the VTE Prevention Taskforce reviewed the accuracy of the risk assessments. Four LOW risk patients were reclassified as HIGH risk and 1 MODERATE risk patient was reclassified as HIGH risk. One HIGH risk patients with new diagnosis of VTE had therapeutic anticoagulation ordered and SCD placed on the unaffected lower extremity. Three MODERATE risk patients had SCD placed. Two patients who were initially classified as LOW risk during hospitalization were subsequently diagnosed with CVC related upper extremity deep vein thrombosis (DVT) after hospital discharge. New risk factors at the time of DVT diagnosis were obesity in one patient and recent asparaginase treatment in the other.Tools which positively impacted adherence with the risk assessment are a Best Practice Advisory (BPA) which fired for medical providers when an eligible patient was admitted, a BPA which fired once the risk category was assigned, a VTE Registry which included all eligible patients, and a VTE Quality Measure Screen which the VTE Prevention Champion used to identify patients who had not been screened and those who were identified at HIGH and MODERATE risk. Medical decision making was documented with a VTE risk assessment note located in the Admission Navigator.ConclusionsWe effectively implemented VTE risk assessment, prevention, and documentation tools in the EHR. Additional QI cycles are required to determine the optimal VTE risk assessment, to improve accuracy of screening, and to increase adherence with recommended interventions to decrease VTE. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.