Srikant B. Iyer

Variation in Growth of Infants with a Single Ventricle

OBJECTIVE The study goal was to evaluate interstage growth variation among sites participating in the National Pediatric Cardiology Quality Improvement Collaborative registry caring for infants with hypoplastic left heart syndrome and to identify nutritional practices common among sites achieving best growth outcomes. STUDY DESIGN This was a retrospective analysis of infants in the registry who had presented due to their superior cavopulmonary connection (SCPC) and whose surgical site had enrolled ≥ 4 eligible patients in the registry. The primary outcome variable was weight-for-age z-score (WAZ) change between Norwood discharge and presentation for SCPC (interstage period). Blinded, structured interviews were performed with each site regarding site-specific nutritional practices. Practices common among sites with positive interstage WAZ changes were identified. RESULTS Sixteen centers enrolled 132 infants from December 2008 through December 2010. Median age at SCPC was 5 months (2.6-12.6), and median interstage WAZ change was -0.29 (-3.2 to 2.3). Significant variation in WAZ changes among sites was demonstrated (P < .001). Sites that used standard feeding evaluation prior to Norwood discharge and that closely monitored for specific weight gain/loss red flags in the interstage period demonstrated significantly better patient growth than those that did not use these practices (P = .002). CONCLUSIONS Considerable variation exists in interstage growth among patients receiving care at these 16 surgical sites. Standardization of interstage nutritional management with focus on best nutritional practices may lead to improved growth in this high-risk population of infants.

Practice Policy and Quality Initiatives: Decreasing Variability in Turnaround Time for Radiographic Studies from the Emergency Department

A study was performed to evaluate use of quality improvement techniques to decrease the variability in turnaround time (TAT) for radiology reports on emergency department (ED) radiographs. An interdepartmental improvement team applied multiple interventions. Statistical process control charts were used to evaluate for improvement in mean TAT for ED radiographs, percentage of ED radiographs read within 35 minutes, and standard deviation of the mean TAT. To determine if the changes in the radiology department had an effect on the ED, the average time from when an ED physician first met with the patient to the time when the final treatment decision was made was also measured. There was a significant improvement in mean TAT for ED radiographs (from 23.9 to 14.6 minutes), percentage of ED radiographs read within 35 minutes (from 82.2% to 92.9%), and standard deviation of the mean TAT (from 22.8 to 12.7). The mean time from when an ED physician first met with the patient to the time a final treatment decision was made decreased from 88.7 to 79.8 minutes. Quality improvement techniques were used to decrease mean TAT and the variability in TAT for ED radiographs. This change was associated with an improvement in ED throughput.

Use of Quality-Improvement Methods to Improve Timeliness of Analgesic Delivery

OBJECTIVES: Despite its high prevalence, pain often is poorly managed in the emergency department. We used improvement science and quality-improvement methods to reduce delays associated with opioid delivery for children presenting to the emergency department with clinically apparent extremity fractures. METHODS: On the basis of a review of the literature, interviews with key stakeholders, expert consensus, and reviews of isolated examples of patients receiving timely analgesics, a multidisciplinary improvement team identified a set of operational factors, or key drivers, believed to be critical to the performance of appropriate initial pain management for children presenting to the emergency department with acute extremity injury. These key drivers focused the development of an intervention. RESULTS: The intervention, termed the orthopedic evaluation process, addressed all 4 identified key drivers simultaneously by standardizing triage decisions, activating necessary health care providers, aligning the care delivery need with necessary resources, and allowing parallel-task completion between physicians and nursing staff. After implementation of this process, 95% of the patients with long-bone extremity fractures treated with intravenous opioids received a first dose within 45 minutes of arrival, compared with a preintervention baseline average of 20%. CONCLUSIONS: By applying quality-improvement and process improvement methodology, we identified key drivers for the rapid delivery of systemic opioids to patients with clinically apparent extremity fractures and significantly improved the timeliness of analgesic delivery for this subgroup of patients.

Reducing the incidence of oxyhaemoglobin desaturation during rapid sequence intubation in a paediatric emergency department

Objectives Rapid sequence intubation (RSI) is the standard for definitive airway management in emergency medicine. In a video-based study of RSI in a paediatric emergency department (ED), we reported a high degree of process variation and frequent adverse effects, including oxyhaemoglobin desaturation (SpO2<90%). This report describes a multidisciplinary initiative to improve the performance and safety of RSI in a paediatric ED. Methods We conducted a local improvement initiative in a high-volume academic paediatric ED. We simultaneously tested: (1) an RSI checklist, (2) a pilot/copilot model for checklist execution, (3) the use of a video laryngoscope and (4) the restriction of laryngoscopy to specific providers. Data were collected primarily by video review during the testing period and the historical period (2009–2010, baseline). We generated statistical process control charts (G-charts) to measure change in the performance of six key processes, attempt failure and the occurrence of oxyhaemoglobin desaturation during RSI. We iteratively revised the four interventions through multiple plan-do-study-act cycles within the Model for Improvement. Results There were 75 cases of RSI during the testing period (July 2012–September 2013). Special cause variation occurred on the G-charts for three of six key processes, attempt failure and desaturation, indicating significant improvement. The frequency of desaturation was 50% lower in the testing period than the historical (16% vs 33%). When all six key processes were performed, only 6% of patients experienced desaturation. Conclusions Following the simultaneous introduction of four interventions in a paediatric ED, RSI was performed more reliably, successfully and safely.

Hospital outcomes associated with guideline-recommended antibiotic therapy for pediatric pneumonia

BACKGROUND Recent national guidelines recommend use of narrow-spectrum antibiotic therapy as empiric treatment for children hospitalized with community-acquired pneumonia (CAP). However, clinical outcomes associated with adoption of this recommendation have not been studied. METHODS This retrospective cohort study included children age 3 months to 18 years, hospitalized with CAP from May 2, 2011 through July 30, 2012. Primary exposure of interest was empiric antibiotic therapy, classified as guideline recommended or not. Primary outcomes were length of stay (LOS), total hospital costs, and inpatient pharmacy costs. Secondary outcomes included broadened antibiotic therapy, emergency department revisits, and readmissions. Multivariable linear regression and Fisher exact test were performed to determine the association of guideline-recommended antibiotic therapy on outcomes. RESULTS Empiric guideline-recommended therapy was prescribed to 168 (76%) of 220 patients. Median hospital LOS was 1.3 days (interquartile range [IQR]: 0.9-1.9 days), median total cost of index hospitalization was

The Effect of Emergency Department Crowding on Reassessment of Children With Critically Abnormal Vital Signs

4097 (IQR:

Behavior changes after minor emergency procedures.

2657-

Assessment of disparities in the use of anxiolysis and sedation among children undergoing laceration repair.

6054), and median inpatient pharmacy cost was

Embedded earrings in children.

91 (IQR:

Using statistical process control to identify early growth failure among infants with hypoplastic left heart syndrome.

40-