Prediction of Nonelective Central Venous Catheter Removal in Medically Complex Neonates Introduction: Central venous catheters (CVCs) are essential to neonatal care but associated with significant morbidity. Nonelective CVC removal (NER) is an inadequately studied outcome associated with increased morbidity, infant and family stress, and cost. This study describes prevalence and predictors of NER in infants admitted to a level IV neonatal intensive care unit and NER variation between peripherally inserted central catheters (PICCs), cutdown PICCs, and surgical CVCs. Methods: In this study, we include patient and catheter data for infants admitted to a level IV neonatal intensive care unit (2010–2015). Demographic and clinical characteristics were compared using 1-way analysis of variance (ANOVA), Kruskal-Wallis, and chi-square tests for continuous, non-normally distributed continuous, and categorical variables, respectively. The association between NER due to complication and infant and catheter characteristics was assessed using generalized linear mixed models. Results: Patient and catheter characteristics vary significantly by catheter type. The overall rate of NER is 15% (17% PICCs, 13% cutdown PICCs, and 19% surgical CVCs). The most common indications for NER are catheter breakage, blood stream infection(BSI)/central line-associated blood stream infection(CLABSI), catheter malposition, mechanical obstruction, and extravasation. Birth weight, patient diagnosis, catheter dwell time, and concurrent catheters are associated with increased odds of NER. Conclusions: Patient risk factors and potentially modifiable catheter characteristics, including catheter dwell time and concurrent catheters, are associated with increased NER. As NER is associated with a broad spectrum of adverse outcomes, we propose a quality improvement strategy to risk stratify patients and reduce exposure to high-risk, modifiable catheter characteristics.

Association Between Magnetic Resonance Imaging in Anesthetized Children and Hypothermia Introduction: There is a myriad of factors that can lead to temperature derangements in anesthetized children undergoing magnetic resonance imaging (MRI). Temperature abnormalities in pediatric patients are associated with increased morbidity and mortality. Although some reports have looked at this topic, to our knowledge, no studies have continuously monitored temperature throughout the MRI scan. The purpose of this study is to determine the impact of MRI on body temperature for anesthetized children undergoing MRI using continuous temperature measurement, identify patient risk factors to develop temperature abnormalities, and determine the effect of temperature derangements on perianesthetic complications. Methods: This retrospective, single-center study evaluated 285 pediatric outpatients from January 1, 2018, to March 31, 2018, who were less than 8 years old and underwent anesthesia for an MRI scan. Temperature, postanesthesia care unit length of stay, and demographic data were collected retrospectively using chart review and data extraction from electronic medical records. Statistical analyses included unpaired t test, chi-square test, and simple and multiple linear regressions. Results: Sixty-three percent (179/285) of children in our study had a median temperature less than 36°C during their MRI scan. There were no patients who had a median temperature greater than 38°C during their MRI scan. There were no identifiable patient risk factors for the development of hypothermia. Those who developed hypothermia did not have an increased rate of perianesthetic complications. Conclusion: MRI in anesthetized children is associated with hypothermia but does not correlate with any significant perianesthetic complications.

Keeping Time: Implementing Appointment-based Family-centered Rounds Background: Family-centered rounds (FCRs) provide many benefits over traditional rounds, including higher patient satisfaction, and shared mental models among staff. These benefits can only be achieved when key members of the care team are present and engaged. We aimed to improve patient engagement and satisfaction with our existing bedside rounds by designing a new FCR process. Methods: We conducted a needs assessment and formed a multidisciplinary FCR committee that identified appointment-based family-centered rounds (aFCRs) as a primary intervention. We designed, implemented, and iteratively refined an aFCR process. We tracked process metrics (rounds attendance by key participants), a balancing metric (time per patient), and outcome metrics (patient satisfaction domains) during the intervention and follow-up periods. Results: After implementing aFCR, 65% of patients reported positive experience with rounds and communication. Rounds duration per patient was similar (9 versus 9.4 min). Nurse, subspecialist, and interpreter attendance on rounds was 72%, 60%, and 90%, respectively. We employed a Rounding Coordinator to complete the scheduling and communication required for successful aFCR. Discussion: We successfully improved our rounding processes through the introduction of aFCR with the addition of a rounding coordinator. Our experience demonstrates one method to increase multidisciplinary team member attendance on rounds and patient satisfaction with physician communication in the inpatient setting.

Don't Have a Doubt, Get the Catheter Out: A Nurse-Driven CAUTI Prevention Protocol Background: Despite the use of sterile technique for indwelling urinary catheter insertion, as well as use of the defined catheter-associated urinary tract infection (CAUTI) bundle elements per Children’s Hospitals’ Solutions for Patient Safety, the CAUTI rate in the pediatric intensive care unit (PICU) at a free-standing pediatric hospital was increasing. In 2017, the PICU accounted for 87% of the organization’s CAUTIs and 65% of the total indwelling catheter device days. With an important risk factor for CAUTIs being the duration of catheterization, the indication for catheters became an organizational executive priority. Methods: An early 2017 review of the bundle elements identified that the indication for catheterization was not consistently addressed in daily patient rounds. A multidisciplinary project team applying the Plan, Do, Check, Act methodology developed an evidenced-based, nurse-driven indwelling urinary catheter removal protocol. This protocol allows nursing autonomy when removing a catheter by providing clinical indications for catheter use and promoting prompt removal when no longer indicated. Results: Indwelling urinary catheter device days in the PICU decreased by 28% within 6 months of protocol implementation. The PICU CAUTI rate declined from 4.8 (per 1,000 device days) in 2017 to 0.8 in 2018, 1 year after protocol implementation. Conclusions: Providing the bedside nurse with an evidence-based protocol that is driven by specific patient indications and diagnoses allows them to practice autonomously in catheter removal. Prompt removal of indwelling urinary catheters results in decreased device days and decreased incidence of CAUTIs.

Clinical Decision Support to Improve Dosing Weight Use in Infants with Neonatal Abstinence Syndrome Introduction: Opioid abuse in the United States is a public health emergency. From 2000 to 2009, prenatal maternal opiate use increased from 1.19 to 5.63 per 1,000 births, with up to 80% of in utero opioid-exposed infants requiring pharmacotherapy. This study aimed to increase the percentage of neonatal abstinence syndrome (NAS) medication orders based on birth weight (BW) in neonates admitted to a neonatal intensive care unit with a principal diagnosis of NAS from 29% to 90%, within 4 months of project initiation, and to sustain this for 6 months. Methods: This project occurred at an academic medical center with 5,000 deliveries per year and a 49-bed Level III neonatal intensive care unit. We used the Institute for Healthcare Improvement methodology, largely focusing interventions on clinical decision support (CDS) tools. We plotted all measures on Shewhart charts, and Nelson rules differentiated special versus common cause variation. Results: The percent of orders based on BW increased from 29% to 78% after implementing multiple interventions focused primarily on CDS. However, this later decreased to 48% as workarounds began. There was also a significant decrease in the length of stay variability, which persisted throughout the project. Discussion: CDS is a helpful tool to guide prescribing behavior; however, workarounds can negate its usefulness. Standardized use of BW for weight-based NAS medication prescribing can decrease the length of stay variability. Further studies are needed using a human factors approach to minimize workarounds in CDS and potentially decrease the length of stay in neonates with NAS.

Using Resident and Faculty Focus Groups to Obtain Stakeholder Input during the ACGME Self-study Introduction: The Accreditation Council for Graduate Medical Education describes steps to guide programs regarding self-study. The process relies heavily on obtaining stakeholder input to validate findings. Focus groups have been noted to provide input and data not elicited using other methods. Our objective was to show the value of focus groups in obtaining a clear picture of stakeholder priorities as they relate to program aims, opportunities, threats, areas for improvement, and sustainability of improvements. Methods: We conducted a series of focus groups in 2017–2018 at a pediatric residency program with residents and core faculty members. The first session for each group elicited input regarding program aims, opportunities, and threats. The second session focused on evaluating program progress over the past 10 years and identifying strengths and needed areas for improvement. We documented responses obtained during the focus groups and used inductive content analysis methods to identify major themes. We repeated the focus groups every 6 months. Results: We identified 8 program aims and pinpointed opportunities and threats. Areas for improvement were selected and then presented back to the stakeholders who confirmed their appropriateness. Repetition of the focus groups every 6 months facilitated ongoing measurement of progress and promoted the development of multiple plan, do, study, act cycles for areas of improvement. Conclusions: Focus groups are an effective way to initiate the self-study process, examine the program aims, opportunities, and threats, and formulate a detailed improvement plan. They are also useful as part of continual evaluation during a dynamic change process.

Quality Improvement Project in Congenital Cardiothoracic Surgery Patients: Reducing Surgical Site Infections Background: Healthcare-associated infections are a major focus for quality improvement in hospitals today. Surgical site infections (SSIs), a postoperative complication in cardiac surgery, are associated with increased morbidity, mortality, hospital length of stay, and financial burden. Methods: A recent increase in cardiothoracic surgery SSIs (CT-SSIs) at our institution instigated a multidisciplinary team to explore infection prevention, bundle element compliance, and to identify interventions to reduce the CT-SSI rate. Key interventions included preoperative screening and decolonization of methicillin-sensitive Staphylococcus aureus and methicillin-resistant S. aureus with repeated intranasal applications of mupirocin, universal skin prep with chlorhexidine for all patients, and additional antibiotic dosing upon initiating cardiopulmonary bypass. Results: In 2014, the CT-SSI rate at our institution was 1.9/100 cases, which increased during the “intervention period” to 3.6 infections/100 cases in 2015 (16 total infections). Postinterventions, the CT-SSI rate decreased to 0.3 infections/100 cases (2 total infections), which was significantly lower than our baseline before the spike in infection rate. Conclusions: A comprehensive interdisciplinary approach with multiple interventions was successful in significantly reducing the CT-SSI rate in cardiothoracic surgery at a tertiary care pediatric hospital.

Prevent Safety Threats in New Construction through Integration of Simulation and FMEA Introduction: The built environment may impact safety and decisions made during the design phases can have unintended downstream effects that lead to patient harm. These flaws within the system are latent safety threats (LSTs). Simulation-based clinical systems testing (SbCST) provides a clinical context to examine the environment for safety threats postconstruction. Integration of Failure Mode Effect Analysis (FMEA) with SbCST provides a framework to identify, categorize, and prioritize LSTs before patient exposure. Methods: We implemented SbCST in a newly constructed pediatric subspecialty outpatient center before opening. We used in-situ simulations to evaluate both routine and high-risk clinical scenarios pertinent to each clinical area. FMEA was used as a methodology to assign risk, prioritize, and categorize LSTs identified during the simulation. Results: Over 3 months, we conducted 31 simulated scenarios for 15 distinct subspecialty clinics involving 150 participants and 151 observers. We identified a total of 334 LSTs from 15 distinct clinics. LSTs were further classified into process/workflow, facility, resource, or clinical performance issues. Conclusions: Integration of SbCST and FMEA risk assessment is effective in evaluating a new space for safety threats, workflow, and process inefficiencies in the postconstruction environment, providing a framework for prioritizing issues with the greatest risk for harm.

Accelerating Initiation of Adequate Antimicrobial Therapy Using Real-Time Decision Support and Microarray Testing Introduction: Bloodstream infections (BSI) represent a common cause of sepsis and mortality in children. Early and adequate empirical antimicrobial therapy is a critical component of successful treatment of BSI. Rapid PCR-based diagnostic technologies, such as nucleic acid microarrays, can decrease the time needed to identify pathogens and antimicrobial resistance and have the potential to ensure patients are started on adequate antibiotics as early as possible. However, without appropriate processes to support timely and targeted interpretation of these results, these advantages may not be realized in practice. Methods: Our Antimicrobial Stewardship Program (ASP) implemented a quality improvement initiative using the Institute for Healthcare Improvement’s Model for Improvement to decrease the time between a nucleic acid microarray result for Gram-positive bacteremia and the time a patient was placed on adequate antimicrobial therapy. The primary effective intervention was a near real-time notification system to the managing physicians of inadequate antimicrobial therapy via a call from the ASP team. Results: Following the intervention, the average time to adequate antimicrobial therapy in patients with Gram-positive BSI and inadequate coverage decreased from 38 hours with the nucleic acid microarray result alone to 4.7 hours when results were combined with an ASP clinical decision support intervention, an 87% reduction. Conclusions: The positive effects of rapid-detection technologies to improve patient care are enhanced when combined with clinical decision support tools that can target inadequate antimicrobial treatments in near real time.

Personal Phone Calls Lead to Decreased Rates of Missed Appointments in an Adolescent/Young Adult Practice Introduction: Nationally, hospital practice missed appointment rates are high. Our goal was to reduce the rate of missed appointments in an Adolescent/Young Adult Practice through quality improvement methods. Methods: During the 12-month intervention period, administrative staff called patients the day before their primary or specialty care appointments to remind them of the date, time, and location, as well as patients who did not attend their appointments to ask about the reason for their missed appointment. We implemented Plan-Do-Study-Act interventions and analyzed data to compare missed appointment rates between the 12 months before and after February 1, 2017, the project intervention date. Results: Results showed significant reductions in the missed appointment rate for the Adolescent/Young Adult Practice. A control chart showed a shift in the mean overall percent of completed appointments from 76.7% to 79.2%. The most common reasons for missed appointments included forgetting (39.2%), conflicts with work/school (11.0%), or emailing the provider without contacting administrative staff (7.8%). There were significant reductions in missed appointment rates for both males and females as well as patients who were ≥20 years old, identified English or Spanish as their primary language, had public or private insurance, identified as Black or Hispanic, or did or did not require an interpreter. Conclusion: These data show that targeted interventions such as personalized reminder calls can be effective in reducing patient missed appointment rates in Adolescent/Young Adult Practices.