scholarly journals LO35: A province-wide quality improvement collaborative for treatment of children's pain in Alberta's emergency departments

CJEM ◽  
2020 ◽  
Vol 22 (S1) ◽  
pp. S19-S19
Author(s):  
J. Thull-Freedman ◽  
E. Pols ◽  
A. McFetridge ◽  
S. Libbey ◽  
K. Lonergan ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Length Of Stay ◽  
Pain Score ◽  
Emergency Departments ◽  
Control Charts ◽  
Interrupted Time Series ◽  
Quality Improvement Collaborative ◽  
Topical Anesthetic ◽  
Children's Pain ◽  
Underlying Trend

Background: Pediatric pain is often under-treated in emergency departments (EDs), causing short and long-term harm. In Alberta EDs, children's pain outcomes were unknown. A recent quality improvement collaborative (QIC) led by our team improved children's pain care in 4 urban EDs. We then spread to all EDs in Alberta using the Institute for Healthcare Improvement Framework for Going to Full Scale. Aim Statement: To increase the proportion of children <12 years who receive topical anesthetic before needle procedures from 11% to 50%; and for children <17 years with fractures: to 1) increase the proportion receiving analgesia from 31% to 50%; 2) increase the proportion with pain score documentation from 24% to 50%, and 3) reduce time to analgesia from 60 to 30 minutes, within 1 year. Measures & Design: All 97 EDs in Alberta that treat children were invited. Each was asked to form a project team, attend webinars, develop key driver diagrams and perform PDSA tests of change. Sites were given a monthly list of randomly selected charts for audit and entered data in REDCap for upload to a provincial run chart dashboard. Baseline performance measurement informed aims. Measures included proportion of children <12 years undergoing a lab test who received topical anesthetic, and for children <17 years with fracture, the proportion with a pain score, proportion receiving analgesia and median minutes to analgesia. Length of stay and use of opioids were balancing measures. Control charts were used to detect special cause. Interrupted time series (ITS) was performed to assess significance and trends. Evaluation/Results: 36 sites (37%) participated, including rural and urban sites from all regions. 8417 visits were audited. 23/36 sites completed audits before and after tests of change and were analyzed. Special cause occurred for all aims. The proportion receiving topical anesthetic increased from 11% to 30% (ITS p < 0. 001). For children with fractures, the proportion with pain scores increased from 24% to 34% (ITS p = 0.21, underlying trend present), proportion receiving analgesic medication increased from 31% to 39% (ITS p = 0.41, underlying trend present) and minutes to analgesia decreased from 60 to 28 (ITS p < 0. 01). There was no increase in length of stay or use of opioid medications. Discussion/Impact: A pragmatic approach encouraging locally led change was well-received and key to success. The QIC method shows promise for improving outcomes in diverse EDs across large geographic areas. Next steps include further spread and sustainability measurement.

scholarly journals MP22: Improving treatment of children’s presenting and procedural pain for emergency department visits: a province-wide quality improvement collaborative

CJEM ◽  
2018 ◽  
Vol 20 (S1) ◽  
pp. S48-S48
Author(s):  
J. Thull-Freedman ◽  
E. Pols ◽  
A. McFetridge ◽  
T. Williamson ◽  
S. Libbey ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Pain Score ◽  
Final Analysis ◽  
Interrupted Time Series ◽  
Emergency Department Visits ◽  
Procedural Pain ◽  
Quality Improvement Collaborative ◽  
Topical Anesthetic ◽  
Analgesic Medication ◽  
Children's Pain

Introduction: Pediatric pain is often under-treated in emergency departments (EDs), which is known to cause short and long-term harm. A recent quality improvement collaborative (QIC) was successful in improving treatment of children’s pain across 4 EDs in our city. A new QIC was then formed among EDs across our province to improve treatment of presenting and procedural pain. Aims were to improve the proportion of children <12 years of age who receive topical anesthetic before needle procedures from 13% to 50%; and for children <17 years of age with fractures: to 1) improve the proportion who receive analgesic medication from 35% to 50%; 2) improve the proportion who have a documented pain score from 23% to 50%, and 3) reduce median time to analgesia from 59 minutes to 30 minutes, within 1 year. Methods: Invitations to participate in the QIC were sent to all 113 EDs in the province that treat children and had not participated in the previous QIC. Each site was asked to form a project team, participate in monthly webinars, develop key driver diagrams and project aims, undertake PDSA tests of change, and audit charts to assess performance. Sites are given a list of 20 randomly selected charts per month for audit. Audit data was entered into REDCap and uploaded to a provincial run chart dashboard. All participating sites received a “comfort kit” consisting of distraction items for children as well as educational materials. Measures of presenting pain included proportion of children <17 years with a diagnosis of fracture who have a documented pain score, proportion who receive an analgesic medication, and minutes to analgesia. The measure for procedural pain was the proportion of children <12 years who receive topical anesthetic prior to a needle procedure for a laboratory test. Length of stay for pediatric patients and all patients were balancing measures. Run charts were used to detect special cause. Difference in proportions were compared using 2. Final analysis will include interrupted time series. Results: 34 of 113 invited sites (30%) agreed to participate, including rural and regional representation from all geographic zones; 4222 visits since June 2016 were analyzed. Implementation began June 2017. Comparing the first 4 months following implementation to the preceding year, the proportion of children receiving topical anesthetic prior to needles increased from 13% to 25% (p<0.001). For children with fractures, the proportion with pain scores increased from 23% to 35% (p<0.001), proportion receiving analgesic medication increased from 35% to 42% (p<0.001), and median minutes to analgesia decreased from 59 to 43. Insufficient time points at this stage preclude identification of special cause. Conclusion: This province-wide QIC has already resulted in significant progress toward aims during the first 4 months of implementation. The QIC approach shows promise for improving pain outcomes in children visiting diverse EDs across a province.

Length of Stay per Total Body Surface Area Burn Relative to Mechanism: A Pediatric Injury Quality Improvement Collaborative (PIQIC) Study

2021 ◽  
Author(s):  
Kelli N Patterson ◽  
Amanda Onwuka ◽  
Kyle Z Horvath ◽  
Renata Fabia ◽  
Sheila Giles ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Length Of Stay ◽  
Surface Area ◽  
Body Surface Area ◽  
Body Surface ◽  
Total Body Surface Area ◽  
Common Mechanism ◽  
Quality Improvement Collaborative ◽  
Pediatric Injury ◽  
Total Body

Abstract Studies on length of stay (LOS) per total body surface area (TBSA) burn in pediatric patients are often limited to single institutions and are grouped in ranges of TBSA burn which lacks specific detail to counsel patients and families. A LOS to TBSA burn ratio of 1 has been widely accepted but not validated with multi-institution data. The objective of this study is to describe the current relationship of LOS per TBSA burn and LOS per TBSA burn relative to burn mechanism with the use of multi-institutional data. Data from the Pediatric Injury Quality Improvement Collaborative (PIQIC) were obtained for patients across five pediatric burn centers from July 2018-September 2020. LOS per TBSA burn ratios were calculated. Descriptive statistics and generalized linear regression which modeled characteristics associated with LOS per TBSA ratio are described. Among the 1267 pediatric burn patients, the most common mechanism was scald (64%), followed by contact (17%) and flame (13%). The average LOS/TBSA burn ratio across all cases was 1.2 (SD 2.1). In adjusted models, scald burns and chemical burns had similar LOS/TBSA burn ratios of 0.8 and 0.9, respectively, while all other burns had a significantly higher LOS/TBSA burn ratio (p&lt;0.0001). LOS/TBSA burn ratios were similar across races, although Hispanics had a slightly higher ratio at 1.4 days. These data establish a multi-institution LOS per TBSA ratio across PIQIC centers and demonstrate significant variation in the LOS per TBSA burn relative to the burn mechanism sustained.

108 Length of Stay per Total Body Surface Area Relative to Burn Mechanism: A Pediatric Injury Quality Improvement Collaborative (PIQIC) Study

2021 ◽  
Vol 42 (Supplement_1) ◽  
pp. S72-S73
Author(s):  
Kelli N Patterson ◽  
Kyle Horvath ◽  
Amanda Onwuka ◽  
Renata Fabia ◽  
Sheila Giles ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Length Of Stay ◽  
Surface Area ◽  
Body Surface Area ◽  
Body Surface ◽  
Total Body Surface Area ◽  
Quality Improvement Collaborative ◽  
Burn Care ◽  
Pediatric Injury ◽  
Total Body

Abstract Introduction Studies on length of stay (LOS) per total body surface area (TBSA) burn in pediatric patients have been performed at single institutions and based on ranges of TBSA burn. A LOS to TBSA burn ratio of 1:1 has also been widely accepted but not confirmed over time across numerous institutions. The objective of this study was to use multi-institutional pediatric burn data to describe benchmarks associated with LOS per TBSA burn. Methods Data from the Pediatric Injury Quality Improvement Collaborative (PIQIC) were obtained for 1004 patients (n=1004) treated at five pediatric burn centers from July 2018-March 2020. LOS/TBSA burn ratios were calculated for each site. LOS/TBSA burn by institution and mechanism were analyzed. Generalized linear regression models were used to model the effect of hospital and burn mechanism on the LOS/TBSA ratio. Results Among the 1004 injuries, the most common burn mechanism was by scald (64%), followed by contact (16%) and flame (13%). The average LOS/TBSA burn ratio across all cases was 1.3 days (SD 2.2). Flame burns had a higher LOS/TBSA burn ratio than scald burns with a mean LOS/TBSA burn of 1.63 compared to 0.84. In adjusted models, scald burns, and chemical burns had the lowest LOS/TBSA burn ratio and electrical and friction burns had the highest LOS/TBSA burn ratio. The LOS/TBSA burn ratio was comparable across hospitals after adjustment for mechanism, with just Hospital 4 having a lower average LOS/TBSA burn of 0.49 days. Conclusions These data establish a multi-institutional ratio for the overall performance in LOS for pediatric burn patients. A LOS per TBSA ratio of about 1 was observed across PIQIC centers, except for a lower ratio at one center. Additionally, it provides evidence on the variance in LOS per TBSA burn relative to the sustained burn mechanism. Further collaborative data analysis will allow us to recognize specific patterns and outcomes in pediatric burn care, which is essential for the implementation of quality improvement standards.

scholarly journals Improving adherence to guideline recommendations in dementia care through establishing a quality improvement collaborative of agents of change: an interrupted time series study

2020 ◽  
Vol 1 (1) ◽  
Author(s):  
Kate Laver ◽  
Monica Cations ◽  
Gorjana Radisic ◽  
Lenore de la Perrelle ◽  
Richard Woodman ◽  
...  
Keyword(s):  
Time Series ◽  
Quality Improvement ◽  
Health Professionals ◽  
Interrupted Time Series ◽  
Aged Care ◽  
Dementia Care ◽  
Trial Registration ◽  
Guideline Recommendation ◽  
Quality Improvement Collaborative ◽  
People With Dementia

Abstract Background Non-pharmacological interventions including physical activity programmes, occupational therapy and caregiver education programmes have been shown to lead to better outcomes for people with dementia and their care partners. Yet, there are gaps between what is recommended in guidelines and what happens in practice. The aim of this study was to bring together clinicians working in dementia care and establish a quality improvement collaborative. The aim of the quality improvement collaborative was to increase self-reported guideline adherence to three guideline recommendations. Methods Interrupted time series. We recruited health professionals from community, hospital and aged care settings across Australia to join the collaborative. Members of the collaborative participated in a start-up meeting, completed an online learning course with clinical and quality improvement content, formed a quality improvement plan which was reviewed by a team of experts, received feedback following an audit of their current practice and were able to share experiences with their peers. The primary outcome was self-reported adherence to their guideline recommendation of interest which was measured using checklists. Data were collected monthly over a period of 18 months, and the study used an interrupted time series design and multilevel Poisson regression analysis to evaluate changes in self-reported adherence. Results A total of 45 health professionals (78% therapists) from different sites joined the collaborative and 28 completed all requirements. Data from 1717 checklists were included in the analyses. Over the duration of the project, there was a significant increase in clinician self-reported adherence to guideline recommendations with a 42.1% immediate increase in adherence (incidence rate ratio = 1.42; 95% confidence interval = 1.08–1.87; p = 0.012). Conclusion Health professionals working with people with dementia are interested in and willing to join a quality improvement collaborative with the goal of improving non-pharmacological aspects of care. Participation in the collaborative improved the quality of care for people with dementia as measured through self-reported adherence to guideline recommendations. Although there are challenges in implementation of guideline recommendations within dementia care, the quality improvement collaborative method was considered successful. A strength was that it equipped and empowered clinicians to lead improvement activities and allowed for heterogeneity in terms of service and setting. Trial registration ACTRN12618000268246

Abstract 12605: Center Variability in Timing of Stage 2 Palliation and Association With Interstage Mortality: A Report From the National Pediatric Cardiology Quality Improvement Collaborative

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Garick Hill ◽  
Nancy Rudd ◽  
Nancy Ghanayem ◽  
David Hehir ◽  
Peter Bartz
Keyword(s):  
Quality Improvement ◽  
Length Of Stay ◽  
Pediatric Cardiology ◽  
Severity Of Illness ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Optimal Timing ◽  
Quality Improvement Collaborative ◽  
Interstage Mortality ◽  
The Impact

Introduction: The interstage period from discharge following stage 1 palliation (S1P) until stage 2 palliation (S2P) remains high risk. Significant variability between institutions exists around the timing of S2P. We sought to describe the variability in a multi-institution cohort and assess its association with interstage mortality. Methods: The National Pediatric Cardiology Quality Improvement Collaborative registry, with data from 52 centers, was queried. Patients undergoing a hybrid S1P, transplanted prior to S2P, lost to follow up prior to S2P or deemed not candidates for S2P were excluded. Only centers with 10 or greater patients meeting eligibility were included to reduce the impact of outliers. Centers were divided based on median age at S2P into early (n=15) and late (n=16) centers using a cutoff of 153 days. Groups were compared using Chi-squared or Wilcoxon rank sum test. Results: The final cohort included 789 patients from 31 centers. Center specific median age at S2P varied from 109 to 214 days, with a center mean of 158 ± 27 days. At S1P, the late centers had a higher prevalence of preoperative ventilation (34.7% vs. 26.9%, p=0.02) and longer average post-S1P duration of intubation (14.4 ± 19.7 vs. 10.2 ± 11.4 days, p<0.001) and S1P hospital length of stay (48.5 ± 30.4 vs. 38.5 ± 22.3 days, p<0.0001). Interstage mortality was significantly higher in centers performing late vs. early S2P (9.9% vs. 5.7%, p=0.03). Interstage event rate (late: 8.2 vs. early: 5.8 deaths per 10000 interstage days) was not different by group (p=0.26), but interstage duration was significantly longer (133.9 ± 71.5 vs. 103.4 ± 37.8 days, p<0.0001) in the late group. Survival to hospital discharge (98.9% in both groups, p>0.98) and hospital length of stay following S2P (late: 15.6 ± 22.3 vs. early: 13.7 ± 22.4, p=0.68) were similar between groups. Conclusions: In a large multi-institution collaborative, the median age at S2P varies between centers. Centers performing S2P at a later median age have higher interstage mortality. This may be in part due to a higher severity of illness, reflected by higher S1P morbidity in this group. Although optimal timing of S2P remains unclear, centers performing early S2P did not experience worse S2P outcomes, and experienced less interstage mortality.

scholarly journals Examining the pace of change in contraceptive practices in abortion services – a follow-up case study of a quality improvement collaborative

2020 ◽  
Vol 20 (1) ◽  
Author(s):  
Helena Kilander ◽  
Jan Brynhildsen ◽  
Siw Alehagen ◽  
Johan Thor
Keyword(s):  
Professional Development ◽  
Quality Improvement ◽  
Control Charts ◽  
User Involvement ◽  
Statistical Control ◽  
Quality Improvement Collaborative ◽  
Contraceptive Services ◽  
Post Abortion

Abstract Background Among all women who experienced an abortion in Sweden 2017, 45% had previously underwent at least one abortion. This phenomenon of increasing rates of repeat abortions stimulated efforts to improve contraceptive services through a Quality Improvement Collaborative (QIC) with user involvement. The participating teams had difficulty in coordinating access post-abortion to the most effective contraception, Long-acting reversible contraception (LARC), during the eight-month QIC. This prompted questions about the pace of change in contraceptive services post-abortion. The aim of the study is to evaluate the evolution and impact of QIC changes regarding patient outcomes, system performance and professional development over 12 months after a QIC designed to enhance contraceptive services in the context of abortion. Methods This follow-up case study involves three multi-professional teams from abortion services at three hospitals in Sweden, which participated in a QIC during 2017. We integrated qualitative data on the evolution of changes and quantitative data regarding the monthly proportion of women initiating LARC, analysed in statistical control charts from before the QIC up until 12 months after its conclusion. Results Teams A and B increased the average proportion of women who initiated LARC within 30 days post abortion in the 12 months after the QIC; Team A 16–25%; Team B 20–34%. Team C achieved more than 50% in individual months but not consistently in the Post-QIC period. Elusive during the QIC, they now could offer timely appointments for women to initiate LARC more frequently. Team members reported continued focus on how to create trustful relationships when counseling women. They described improved teamwork, leadership support and impact on organizing appointments for initiating LARC following the QIC. Conclusions QIC teams further improved women’s timely access to LARC post abortion through continued changes in services 12 months after the QIC, demonstrating that the 8-month QIC was too short for all changes to materialize. Teams simultaneously improved women’s reproductive health, health services, and professional development.

Abstract 13342: Increasing Use of the Right Ventricle to Pulmonary Artery Shunt for Stage 1 Palliation: A Report From the National Pediatric Cardiology Quality Improvement Collaborative

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Garick Hill ◽  
Haleh Heydarian ◽  
Elisa Marcuccio ◽  
Brooke Tepe ◽  
Laurel H Stein ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Length Of Stay ◽  
Pulmonary Artery ◽  
Right Ventricle ◽  
Pediatric Cardiology ◽  
Hybrid Procedure ◽  
Quality Improvement Collaborative ◽  
Factors Influencing ◽  
Stage 1 ◽  
Over Time

Introduction: Stage 1 palliation (S1P) of single ventricle heart defects with aortic hypoplasia consists of either the Norwood operation with a modified Blalock-Taussig shunt (MBTS) or a right ventricle-to-pulmonary artery shunt (RVPAS), or a hybrid procedure. Changes in national trends over time and factors influencing surgical approach remain unclear. Hypothesis: There has been an increase in national use of the RVPAS for S1P. Methods: Data from the National Pediatric Cardiology Quality Improvement Collaborative (NPC-QIC) phase 1 (6/2008-8/2016) and phase 2 (8/2016-9/2019) databases were used. S1P type was evaluated by year of operation. Factors influencing the choice of MBTS versus RVPAS, as well as length of stay after S1P and mortality prior to Stage 2 palliation (S2P) between shunt types, were evaluated. Sites were stratified by the number of patients in the database per year as small (<5), medium (<10) and large (≥10) centers. Results: The combined database included 3335 eligible patients; 1,028 (30.8%) with MBTS, 1,989 (59.7%) with RVPAS, and 318 (9.5%) with hybrid procedure. Overall, of 62 centers, 14.6% of S1P were at small centers (n=26), 40.6% at medium centers (n=24), and 44.7% at large centers (n=12). There was an increase in RVPAS use over time (p=0.02). In multivariable analysis, increasing hospital volume (OR 1.2 [95% CI 1.1-1.4], p=0.003) and absence of other organ system anomalies (OR 1.5 [95% CI 1.0-2.2], p=0.049) were associated with MBTS use over RVPAS. Median length of stay after S1P with MBTS was longer than with RVPAS (31 [95% CI 20-49] vs 29 [95% CI 19-47] days, p=0.054) and mortality was higher prior to S2P (12.3% vs 9.6%, p=0.03). Conclusions: Use of RVPAS with S1P has increased over time with a decrease in MBTS use and unchanged hybrid frequency. MBTS is used more commonly in centers with higher volume and in patients without other anomalies but is associated with longer post-op hospitalization and lower transplant-free survival to stage 2 palliation.

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