Kathleen Marie Demmel

Implementation of the Pediatric Early Warning Scoring System on a Pediatric Hematology/Oncology Unit

Despite improved outcomes for pediatric Hematology/Oncology patients over the past 15-20 years, sepsis and other acute events continue to cause serious illness in these children. Implementing a pediatric early warning scoring tool (PEWS) with an associated multi-disciplinary action algorithm in a pediatric Hematology/Oncology unit helped to remove barriers that prevented timely referral of children who are clinically deteriorating and requiring immediate help, enhanced multi-disciplinary team communication, and has led to a more than 3-fold increase in days between codes on the Hematology/Oncology unit.

Increasing Activities of Daily Living Is as Easy as 1-2-3.

Background: Human flora are the most common cause of bacteremia in immunocompromised patients. Activities of daily living (ADL), including oral care and daily chlorhexidine gluconate bathing, can lower the risk of infection. Methods: To address ADL compliance in our pediatric oncology and bone marrow transplant patients, we adopted the ADL 1-2-3 initiative: daily chlorhexidine gluconate bath and linen change, at least 2 activities per day, and oral care 3 times per day. Using the Model for Improvement we created a standardized ADL process that involved all providers. Interventions included addressing ADL 1-2-3 compliance during rounds, establishing accountability in care delivery, an oral care order set and algorithm, daily text message reminders, and physician intervention with noncompliant and high-risk patients. Results: With our interventions, we increased our median compliance with the all-or-none ADL 1-2-3 initiative from 25% to 66% in 90 days. We have sustained our median compliance to 75% sixteen months after implementation. The greatest impact on compliance was seen with text message reminders to staff to complete and document the ADL 1-2-3 components, designated roles and responsibilities, and physician discussion with noncompliant and high-risk patients. Discussion: Oral care algorithm and order set, daily text message reminders, and physician intervention with noncompliant and high-risk patients has improved our compliance. Units where compliance with ADL participation is low can benefit from incorporating elements from this ADL 1-2-3 initiative.

Significant and Sustained Reduction in Chemotherapy Errors Through Improvement Science

PURPOSE A majority of children with cancer are now cured with highly complex chemotherapy regimens incorporating multiple drugs and demanding monitoring schedules. The risk for error is high, and errors can occur at any stage in the process, from order generation to pharmacy formulation to bedside drug administration. Our objective was to describe a program to eliminate errors in chemotherapy use among children. METHODS To increase reporting of chemotherapy errors, we supplemented the hospital reporting system with a new chemotherapy near-miss reporting system. After the model for improvement, we then implemented several interventions, including a daily chemotherapy huddle, improvements to the preparation and delivery of intravenous therapy, headphones for clinicians ordering chemotherapy, and standards for chemotherapy administration throughout the hospital. RESULTS Twenty-two months into the project, we saw a centerline shift in our U chart of chemotherapy errors that reached the patient from a baseline rate of 3.8 to 1.9 per 1,000 doses. This shift has been sustained for > 4 years. In Poisson regression analyses, we found an initial increase in error rates, followed by a significant decline in errors after 16 months of improvement work ( P < .001). CONCLUSION After the model for improvement, our improvement efforts were associated with significant reductions in chemotherapy errors that reached the patient. Key drivers for our success included error vigilance through a huddle, standardization, and minimization of interruptions during ordering.