BACKGROUND AND OBJECTIVES:
Viral respiratory infections are common in children, and practice guidelines do not recommend routine testing for typical viral illnesses. Despite results often not impacting care, nasopharyngeal swabs for viral testing are frequently performed and are an uncomfortable procedure. The aim of this initiative was to decrease unnecessary respiratory viral testing (RVT) in the emergency department (ED) and the pediatric medicine wards (PMWs) by 50% and 25%, respectively, over 36 months.
METHODS:
An expert panel reviewed published guidelines and appropriate evidence to formulate an RVT pathway using plan-do-study-act cycles. A multifaceted improvement strategy was developed that included implementing 2 newer, more effective tests when testing was deemed necessary; electronic order modifications with force functions; audit and feedback; and education. By using statistical process control charts, the outcomes analyzed were the percentage of RVT ordered in the ED and the rate of RVT ordered on the PMWs. Balancing measures included return visits leading to admission and inpatient viral nosocomial outbreaks.
RESULTS:
The RVT rate decreased from a mean of 3.0% to 0.5% of ED visits and from 44.3 to 30.1 per 1000 patient days on the PMWs and was sustained throughout the study. Even when accounting for the new rapid influenza test available in the ED, a 50% decrease in overall ED RVT was still achieved without any significant impact on return visits leading to admission or inpatient nosocomial infections.
CONCLUSIONS:
Through implementation of a standardized, electronically integrated RVT pathway, a decrease in unnecessary RVT was successfully achieved. Audit and feedback, reminders, and biannual education all supported long-term sustainability of this initiative.
BackgroundAbscesses are a common reason for ED visits. While many are drained in the ED, some require drainage in the operating room (OR). We observed that a higher percentage of patients at our institution in Columbus, Ohio, were admitted to the hospital with abscesses for incision and drainage (I&D) in the OR than other institutions, including paediatric institutions. Our aim was to decrease hospitalisations for abscess management.MethodsA multidisciplinary team convened to decrease hospitalisation for patients with abscesses and completed multiple ‘Plan-Do-Study-Act’ cycles, including increasing I&Ds performed in the ED. Other interventions included implementation of a clinical pathway, training of procedure technicians (PT), updating the electronic medical record (EMR), credentialing advanced practice nurses in sedation and individual follow-up with providers for admitted patients. Data were analysed using statistical process control charts. Gross average charges were assessed.ResultsAdmissions for I&D decreased from 26.3% to 13.7%. Abscess drainage in the ED improved from 79.3% to 96.5%. Mean length of stay decreased from 19.5 to 11.5 hours for all patients. Patients sedated increased from 3.3% to 18.2%. The number of repeat I&Ds within 30 days decreased from 4.3% to 1.7%.ConclusionWe decreased hospitalisations for abscess I&D by using quality improvement methodology. The most influential intervention was an initiative to increase I&Ds performed in the ED. Additional interventions included expanded training of PTs, implementation of a clinical pathway, updating the EMR, improving interdepartmental communication and increasing sedation providers.
BACKGROUND
In September 2017, the American Academy of Pediatrics issued guidance recommending hepatitis B vaccine be administered to well newborns with birth weight ≥2000 g within 24 hours after birth. At that time, ∼85% of well newborns were vaccinated before discharge at our center; however, only 35% were vaccinated within 24 hours after birth. Our aim was to vaccinate 70% of eligible newborns within 24 hours after birth by June 2018 while maintaining the overall rate of vaccination.
METHODS
A multidisciplinary improvement team analyzed existing vaccine administration processes in the well-newborn nursery. From October 2017 to January 2018, changes were made to activation of vaccine orders and to obtaining and documenting the consent processes. Vaccine administration was bundled with routine care given ≤24 hours after birth, and parent scripting was changed from offering vaccine as an option to stating it as a recommendation. From November 2016 to June 2019, we determined the overall rate and timing of vaccination using statistical process control methods.
RESULTS
Among 10 887 eligible infants, the proportion administered hepatitis B vaccine ≤24 hours after birth increased from 35.5% to 78.8% after process changes with special-cause variation on process control charts. Proportion of infants receiving vaccine any time before discharge also increased from 86.5% to 92.3%.
CONCLUSIONS
Specific process changes allowed our birth center to comply with the recommended timing for hepatitis B vaccination of ≤24 hours after birth among eligible newborns.
In this chapter, readers are given step-by-step instructions on how to access the software necessary to use SSD for R. They are also presented with a brief overview of the capabilities of the SSD for R package. These include basic graphing functions, descriptive statistics, many effect size functions, autocorrelation, regression, statistical process control charts, hypothesis testing, and functions associated with analyzing group data. In combination, R, RStudio, and SSD for R, all of which are freely available, provide a robust way to analyze single-system research data. This chapter demonstrates how to download the necessary software and provides an overview of the visual and statistical capability available with SSD for R.
Avoiding routine, repetitive inpatient laboratory testing is a Choosing Wisely® recommendation, with benefits that may be even more pronounced in the setting of the COVID-19 pandemic, considering the need to limit unnecessary exposure, use of personal protective equipment, and laboratory resources. However, the COVID-19 pandemic presented a unique challenge: how to efficiently develop and standardize care for a disease process that had yet to be fully characterized. This article describes the development of a local committee to critically review evidence-based practices, reach consensus, and guide practice patterns, with the aim of delivering high-value care. Following the local introduction of recommendations and electronic health record order sets, non-critically-ill COVID-19 patients at our hospital had more inpatient days where they did not receive laboratory tests, achieving sustained special cause variation on statistical process control charts. The principles of Choosing Wisely® can be applied even within novel and rapidly evolving situations.
Objective: To evaluate the monthly rates of hospitalizations for childhood diarrhea in macro-regions of Araçatuba, Marília and Presidente Prudente, SP, between 2019 -June Between June 2009. Methods: The average rates and their standard deviations for admission of diarrhea in the target population were obtained from DATASUS and standardized for cases x 100,000 inhabitants. Confidence limits were established, occurrences above confidence limits were considered epidemic events. The normality of the data and serial autocorrelation were tested using the Shapiro-Wilk and Durbin-Watson method. Results: All methods detected epidemic occurrences in the three regions. Araçatuba and Marília, the peaks were concentrated in the first half of the decade and Presidente Prudente, close to the middle. The CUSUM method was more sensitive to detect epidemic periods, however the normality data and assumptions have been violated by serial autocorrelation in a few months. The EWMA method was considered the most appropriate. Conclusions: Statistical process control charts can be used to monitor and compare disease incidence between different regions.
Statistical control charts to assess the incidence of presumably infectious diarrhea reported between 2009 and 2019 in children under 4 years of age in the macro regions of Araçatuba, Marília and Presidente Prudente, São Paulo, Brazil.