EMSC Opportunities for Enhancing Pediatric Emergency Care: Pediatric Readiness Data: An Opportunity to Improve Quality of Care in Your Emergency Department

Moderator: Beth Edgerton, MD, MPH

Presenters:Charles Macias, MD, MPHKatherine Remick, MDEvelyn Lyons, RN, MPH

Date:Wednesday, December 17, 2014

HOUSEKEEPING RULES FOR THE WEB CONFERENCE

Everyone will be muted upon entry.

Please use the chat box (located on the bottom right corner) to ask any questions.

DO NOT PLACE THE PHONE ON HOLD as this will disrupt the webinar.  If you have any technical difficulties, please contact Brandye Williams at BCWillia@childrensnational.org.

As a result of having participated in this webinar, attendees will be able to:

1. Define Quality Improvement and its scope and impact in pediatric emergency care,

2. Distinguish quality assurance from quality improvement,

3. List critical components of the quality improvement process,

4. Illustrate via case presentation a pediatric emergency quality improvement opportunity, and

5. Identify potential quality improvement initiatives via pediatric readiness data. 

ACCREDITATION

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the Indian Health Service (IHS) Clinical Support Center and the EMSC National Resource Center. The IHS Clinical Support Center is accredited by the ACCME to provide continuing medical education for physicians.  The IHS Clinical Support Center designates this live activity for a maximum of 1½ AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. The Indian Health Service Clinical Support Center is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. This activity is designated 1.5 contact hours for nurses.

DISCLAIMER

Accreditation applies solely to this educational activity and does not imply approval or endorsement of any commercial product, services or processes by the CSC, IHS, the federal government, or the accrediting bodies.

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As a provider accredited by ACCME, ANCC, and ACPE, the IHS Clinical Support Center must ensure balance, independence, objectivity, and scientific rigor in its educational activities. Course directors/coordinators, planning committee members, faculty, reviewers and all others who are in a position to control the content of this educational activity are required to disclose all relevant financial relationships with any commercial interest related to the subject matter of the educational activity. Safeguards against commercial bias have been put in place. Faculty will also disclose any off-label and/or investigational use of pharmaceuticals or instruments discussed in their presentation. All those in a position to control the content of this educational activity have completed the disclosure process and have indicated that they do not have any significant financial relationships or affiliations with any manufacturers or commercial products to disclose. There is no commercial interest support for this educational activity.

CE Evaluation and Certificate

Continuing Education guidelines require that the attendance of all who participate be properly documented.  

Those who participate and wish to receive continuing education need to attend the activity in its entirety and complete the online evaluation by December 24, 2014. The online evaluation link will be provided at end of the educational activity by the facilitators. The online link will be available for one week to complete your evaluation. If you need assistance accessing the online evaluation link, or have questions regarding this internet education event please contact Sametria McCammon at (smccammo@childrensnational.org).

Continuing education certificates for doctors and nurses will be automatically generated and emailed to you upon completion of the online evaluation.

TODAY’S PRESENTERS

Charles Macias, MD, MPH, Texas Children’s Hospital

Katherine Remick, MD, Austin-Travis County EMS System and UT Southwestern Austin, Dell Children’s Medical Center

Evelyn Lyons, RN, MPH, Illinois Emergency Medical Services for Children Program, Illinois Department of Public Health

Charles G Macias MD, MPHChief Clinical Systems Integration Officer, Texas Children’s

Director, Evidence Based Outcomes Center and Center for Clinical Effectiveness, Texas Children’/Baylor College of Medicine

Objectives 1.      Define Quality Improvement and its scope and

impact in pediatric emergency care 2.      Distinguish quality assurance from quality

improvement 3.      List critical components of the quality improvement

process 4.      Illustrate via case presentation a pediatric

emergency quality improvement opportunity 5.      Identify potential quality improvement initiatives via

pediatric readiness data 6.      Summary and take home points

Pediatric Emergency Care in the United StatesChildren account for 25 million

visits to emergency departments every year (~25% of all visits)- 80-90% are cared for in

general EDs- 50% of EDs see < 10 pediatric pts/day- <5% require tertiary care- Limited experience with critically ill

children

Quality Improvement and Pediatric Emergency Care

June 15, 2006

Emergency medical care in the United States is on the verge of collapse…

…As a system…it provides care of variable and often unknown quality…

14

Safe Avoid injuries to patients from care intended to help them

Equitable Provide care that does not vary in quality because of personal characteristics

Patient-Centered

Provide care that is respectful of and responsive to individual patient preferences, needs, values

Timely Reduce waits and potentially harmful delays for both those who receive and those who give care

Efficient Avoid waste of equipment, supplies, ideas, and energy

Effective Services based on scientific knowledge to all who could benefit (avoid under-use and overuse, respectively)

44,000-98,000 deaths annually in the US due to preventable error

HealthGrades 2007-2009 46% lower risk of a safety

incident at a top hospital 7.3 billion in excess costs

“…Now comes a study in the current issue of the Journal of Patient Safety that says the numbers may be much higher — between 210,000 and 440,000 patients each year who go to the hospital for care suffer some type of preventable harm that contributes to their death, the study says. That would make medical errors the third-leading cause of death in America, behind heart disease, which is the first, and cancer, which is second. “

www.propublica.org, accessed 11/26/2014

Is this pertinent to PEM?

Medical error risk in EM settings Chaotic environments that create latent

environments of risk No prior relationship with families High acuity settings/resuscitations Shift work/handoffs

Pediatrics Weight-based medication/treatments Varied developmental state

Need for Pediatric QI in health care infrastructures

What do we hope to achieve?

There is a limited ability to cut costs in our current paradigm for delivering care.

In an environment where cost, at best, is marginally increasing, healthcare must markedly improve quality.

QualityCostValue =

Why does it matter? A parallel example

RCT of treatment of hypertension on the jobsite (a steel mill) versus referral to the PCP

No difference in compliance between the groups Exploration of factors relating to therapy revealed specific

determinants of the clinical decision to treat some, but not other, hypertensive patients:

1. The level of diastolic blood pressure.2. The patient’s age.3. ????4. The amount of target-organ damage.

A parallel example

RCT of treatment of hypertension on the jobsite (a steel mill) versus referral to the PCP

No difference in compliance between the groups Exploration of factors relating to therapy revealed specific

determinants of the clinical decision to treat some, but not other, hypertensive patients:

1. The level of diastolic blood pressure.2. The patient’s age.3. The year the physician graduated from medical school4. The amount of target-organ damage.

Minimizing variation

Wide variations in practice are often not related to differences among patients

Minimizing variations in practice can improve quality of health care delivery

Variation in clinical practice Variation in beliefs Variation in interpretation of evidence Variation in response when evidence is lacking

Variation in pediatric care models

Option 1: Focus on Outliers – the prescriptive approach

Strategy eliminate the unfavorable tail of the curve (“quality assurance”)

Result The impact is minimal in improving care and the impact on culture from a prescriptive approach has its own untoward outcomes

# of Cases

Excellent Outcomes Poor Outcomes

1.96 std

# of Cases

Mean

Excellent Outcomes Poor Outcomes

1 box = 100 cases in a year

Solutions? traditional approach to quality assurance

22

Excellent Outcomes Poor Outcomes

# of Cases

Mean

1 box = 100 cases in a year

Excellent Outcomes

# of Cases

Poor Outcomes

Option 2: Focus On Inliers – improving quality outcomes across the majority

Strategy Evidence and QI methods applied through EBP clinical standards targets inlier variation and other strategies to improve the routine processes

Result Shifting more cases towards excellent outcomes has much more significant impact. Now your hospital is impacting the majority of the target population

Changing outcomes through QI: changing infrastructures

23

One definition of quality

The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge

K Lohr, N Engl J Med, 1990

Outcomes

Quality

MEASUREMENT

One definition of quality

The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge

K Lohr, N Engl J Med, 1990

Evidence to expertise

Evidence

Physician preferences

Patient values and

preferences

Resource issues

Clinical Decisions

SAEM. Evidence Based Medicine Online Course 2005

Tenets of Quality Improvement1. Evidence-based approaches2. Proactive rather than reactive approach to errors and

inefficiencies3. Safety is a priority4. Errors should be made transparent5. Needs are anticipated- building a high reliability

organization6. Focus improvements within the boundaries of the

infrastructure7. Minimization of wide variations 8. Change should be centered around the

needs of patients

SMART Aim Specific

Single focus directed at that which you are trying to accomplish

Measurable Must have a quantifiable metric

Actionable The end point needs to be defined and within the team’s

control Relevant/Realistic

Is your aim important to your patients, the providers, and the overall goals of the department/hospital

Time bound Decide on a time period during which this aim can be

accomplished

Quality Improvement Process Aim: Decide what you are trying to accomplish Measures: Determine how to assess

whether change would be an improvement Ideas: Determine what changes should be

made that will result in an improvement Plan-Do-Study-Act (PDSA) cycle

Plan

Do

Study

Act

Langley GJ, Nolan KM, Nolan TW, Normal CL, Provost LP. The Improvement Guide. A Practical Approach to Enhancing Organizational Performance. San Francisco, CA: Jossey-Bass Publishers; 1996.

Various Approaches to Determining Which Changes Will Result in Improvement Brainstorming Process mapping Identify key drivers Fishbone Diagrams (Cause and effect diagrams) Evidence-based medicine (review of the literature) Best practices (successful efforts in other units or

institutions)

Decide Which Change(s) to Implement Choose ideas for change based on approach used to

identify elements most likely to effect outcome Identify leverage points Strategies should be meaningful Change should be important improvement Measurement should be feasible

Quality Improvement Process

Aim: Decide what you are trying to accomplish

Measures: Determine how to assess whether changes would be an improvement

Ideas: Determine what changes should be made that will result in an improvement

Plan-Do-Study-Act

Plan

Do

Study

Act

PDSA Cycle Plan

Determine your aim and how you will measure it Decide which change to make and create a plan for implementation (test

period) Develop a data collection plan

Do Gather data Record observations including unexpected

consequences

Study Compare results to previous performance

Act: Adopt, Adapt, or Abandon Consider need for continued testing Develop a plan for sustainability

Plan

Do

Study

Act

Changes that Result in Process Improvement

Ideas A

ct Plan

Study Do

Act

Plan

Study Do

Act

Plan

Study Do

Improvement

Multiple PDSA cycles can take ideas to improvement

Roadmap for Quality Improvement

Design a PDSA cycle

Implement changes Develop a sustainable plan

Develop a SMART AimIdentify Key

DriversObserve process

Quantify inefficiencies

Choose interventions

Assuring an excellent patient experience

QI education and culture change

Data/predictive analytics: measuring through meaningful metrics

The science

Measurement and analytics

The implementation

ImprovedPopulation

Health

Deployment strategy—Care

Process Teams

Evidence Integrated practice via

guidelines, order sets and measures

Using and innovating best

practices

Pediatric Readiness Data and QI Initiatives

Katherine Remick, MDAssociate Medical Director, Austin-Travis County EMS System

Pediatric Emergency Medicine, Dell Children’s Medical Center

Faculty, UTSW-Austin, Pediatric Emergency Medicine Fellowship

Disclosure

My spouse is a salaried, Manager of Core Labs for transcatheter heart valves at Edwards Lifesciences

Pediatrics 2009; 124(4):1233-43

Guidelines for Care of Children in the ED

Gausche-Hill M, Krug S, and the American Academy of Pediatrics, American College of Emergency Physicians, Emergency Nurses Association

• Recommendations regarding personnel, training, equipment, supplies, medications, support services, quality and process improvement, policies, protocols, and other resources necessary for optimal pediatric care Updated version of 2001 AAP/ACEP joint policy statement Recommendations for patient safety & disaster readiness

added Applicable standard for all EDs with 24/7 physician staffing

• Endorsed by 22 organizations, notable additions: ENA, AAFP, TJC

2009 Guidelines for Care of Children in the Emergency Department

1. Administration and Coordination

2. Physicians, Nurses, and Other Healthcare Providers

3. Quality Improvement

4. Patient Safety

5. Policies, Procedures, and Protocols

6. Support Services

7. Equipment, Supplies, and Medications

National Pediatric Readiness Project

• Based on 2009 Guidelines for Care of Children in the Emergency Department

• Establish a baseline of the nation’s capacity to provide pediatric emergency care in every 24/7 ED

• Voluntary, confidential, and web-based• National assessment

Over 4100 EDs (82.7% response)

National Pediatric Readiness Project• Collaborative QI effort for pediatric care in EDs• Create a foundation for a QI process based on the

2009 Guidelines• Benchmarking to measure improvement over time• Immediate feedback

• Readiness score (compared to similar hospitals)• Gap analysis (of strengths and weaknesses)

Assessment Tool

189 Items on the assessment

82 Items Scored for “Pediatric Readiness”

Perfect Score = 100

6 Major Sections* Coordination (19

pts) Staffing (10 pts) QI/PI (7 pts) Safety (14 pts) Policies (17 pts) Equipment (33

points)

*Modified Delphi Process Used

Benchmarking

National Pediatric Readiness Project: Overall Results

Key Guidelines Recommendations All EDs  Pediatric QI Process 1867 (45.1%)

  Pediatric Disaster Plan 1938 (46.8%)

  Interfacility Transfer Guidelines 1952 (50.0%)

  Interfacility Transfer Agreements 2595 (66.5%)

  Weigh only in Kg 2802 (67.7%)

Physician PECC 1966 (47.5%)

Nurse PECC 2455 (59.3%)

Using Your Gap Analysis to Identify Opportunities for Improvement Specific deficiencies based on 6 major

sections of the 2009 Guidelines Top 3-4 measures most likely to result in

enhanced pediatric readiness

Pediatric Readiness Toolkit

www.pediatricreadiness.org

Pediatric Quality Improvementin Illinois

Evelyn Lyons, RN, MPH

EMSC Manager

Illinois Department of Public Health

Illinois Demographics• Population: 12.9 million

• 5th most populous state• Over 2.7 million <15 y/o

• 637,000 age <3 y/o

• 11 EMS Regions• Provide infrastructure/oversight for

• EMS• EMSC• Trauma

• Hospital Resources• 185 hospitals with Emergency Department’s

• 110 hospitals (60%) participate in Pediatric Facility Recognition program

Pediatric Facility Recognition• Implemented in Illinois in 1998 by the Illinois Department of Public Health (IDPH)

• Initially voluntary process• In 2005, mandatory for EMS System Hospitals

• Tiered recognition - 110 recognized hospitals (60%)• PCCC (Pediatric Critical Care Center) – 10• EDAP (Emergency Department Approved for Pediatrics) – 87• SEDP (Standby Emergency Department Approved for Pediatrics) – 13

• Hospital utilization• In 2013, ~ 1 million ED visits 0-15 y/o

• 78% of visits to a designated PCCC, EDAP, SEDP• 30,000 visits required inpatient admission

• 94% admitted to PCCC, EDAP or SEDP

PCCC, EDAP and SEDP RequirementsRequirements are outlined in State regulations

Facility criteria

Physician, Nursing and Mid-Level Practitioner Qualifications Continuing education Coverage, On-call specialists, response times

Pediatric policies/procedures and treatment guidelines

Interfacility Transfer/Transport

Equipment/supplies/medications

Pediatric disaster preparedness

Pediatric quality improvement

Quality Improvement Requirements Pediatric quality improvement requirements

Multidisciplinary Emergency Department QI Committee/process Documented pediatric monitors must minimally address

Pediatric ED deaths Pediatric interfacility transfers Child abuse and neglect cases Critically ill/injured children in need of stabilization Pediatric strategic priorities of the institution

Pediatric Physician Champion Appointed by ED Medical Director Responsible for oversight, support, review of pediatric quality activities

Pediatric Quality Coordinator Job description includes appropriate allocation of time and resources Works with Pediatric Physician Champion Coordinates data collection/review of indicators/monitors Participates in regional pediatric QI meetings and QI activities

Regional Pediatric Quality Improvement

Examples of Regional Projects

Child Abuse/Neglect Febrile Neonate/Infant Interfacility Transfers Injury Prevention/Safety Equipment Use

in the Trauma Patient Pain Management Pediatric Mental Health Pediatric Mild Traumatic Head Injury Pediatric Sepsis Prehospital Seizure Care

Ongoing Oversight Hospital site visits by Illinois Department of Public Health

Conducted every 3-4 years

Assists in assessing compliance with Facility Recognition requirements

Pediatric Physician Champion and Pediatric Quality Coordinator review:

Quality organizational structure and reporting mechanisms Integration of pediatrics into quality improvement processes Medical record review of required monitors: Pediatric ED deaths, Interfacility

transfers, Child abuse and neglect, Critically ill/injured children

Quality improvement documentation undergoes review Monitor tools QI findings/benchmark/trending documentation Loop closure process Multidisciplinary quality meeting minutes Staff meeting minutes

Resources State Committee structure

EMSC Advisory Board Meets quarterly Provides guidance/oversight

Illinois Facility Recognition Committee and Illinois QI Subcommittee

Meet every other month Provide oversight to Facility Recognition

program Recommend changes to Facility

Recognition regulations Responsible for developing quality

improvement and educational resources Reports by each of the eleven Regional

Chairs on their regional QI activities Can access guidance and direction

EMSC Advisory Board

EMSC Facility Recognition Committee

EMSC QI Subcommittee

Example - Statewide Quality Improvement Project

Pediatric Mild Traumatic Head Injury in the Emergency Department Mild head trauma is common CT use increasing with associated risk of radiation induced malignancy

State Facility Recognition Committee and QI Committee Multidisciplinary process Literature search Aim Statement IRB approval Plan/Do/Study/Act process Developed/piloted

Survey Monitor tool

Developed Educational module Educational resources

Statewide Quality Improvement Project

Conducted in 2008 and 2009

AIM Statement To provide safe and effective care for pediatric patients (<15 years) presenting

to the Emergency Department with mild traumatic head injury (GCS > 14) as evidenced by:

Appropriate Assessment Appropriate Management Appropriate Disposition and Discharge Instructions

Each year, participating hospitals Completed a survey Conducted 20 medical record reviews of head injured children

10 records of patients who received a CT scan 10 additional records regardless of diagnostic testing

Project Survey Elements

Policy/guideline/clinical pathway for traumatic head injury Specifically addresses pediatric patient Includes screening for child maltreatment/neglect Identifies specific criteria to determine need for CT

CT scanning practices Presence of in-house CT scanner Typical person responsible for reading CTs (in-house radiology,

consultant services, ED physicians)

Administrative processes Process in place to address/resolve discrepancies between

preliminary and final CT scan findings

Availability of neurological services

Discharge planning Pediatric specific head

injury education Process ensuring

patient/caregiver understands discharge instructions

Quality Improvement Medical record review

process in place Severe or moderate head

injuries (e.g. GCS <13) Mild head injuries (e.g.

GCS 14 or 15) Components assessed in

medical review

Project Survey Components (cont’d)

Patient history Age Mode of arrival Time of injury Mechanism of injury Use of safety equipment (as

applicable)

Project Medical Record Monitor Tool Assessment

◦ Vital signs ◦ Presence of

Scalp abnormality (prior to CT scan) Emesis within last 24 hours Loss of consciousness Other body systems involved Focal neurologic findings/deficits Others

◦ Child abuse screening◦ Neurosurgical consultation

Reassessment and Discharge◦ Neurological reassessment◦ Disposition◦ Discharge instructions

Kuppermann N, et al. Identification of children at very low risk of clinically-important brain injuries after

head trauma: a prospective cohort study.

Lancet 2009; 374: 1160-1170.

25 participating EDs

Prospective cohort study

Analyzed 42,412 children (age 0-17 y/o) presenting to ED within 24 hours of head trauma with GCS scores of 14-15

Aim - identify children at very low risk of clinically-important traumatic brain injuries for whom CT might be unnecessary

Provides data to guide clinical decision making for children presenting with head injury. Suggested algorithm for children <2 years and those age 2 and older with GCS score of 14-15.

PECARN Publication

Suggested CT Algorithm for Mild Traumatic Head Injury (GCS 14 or 15) Age 0-23 Months

GCS=14

Or

Other signs of altered mental status (any of the following): - agitation - somnolence - repetitive questioning - slow response to verbal communication

Or

Palpable skull fracture

CT Recommended Yes

4.4% risk of clinically important TBI

No

Occipital or parietal or temporal scalp hematoma

Or

History of LOC >= 5 seconds

Or

Severe mechanism of injury (any of the following): - Motor vehicle crash (MVC) with patient ejection - MVC with death of another passenger - MVC with rollover - Pedestrian or bicyclist without helmet struck by a

motorized vehicle - Falls of more than 0.9 m (3 feet) - Head struck by a high-impact object

Or

Not acting normally per parent

No

CT generally not recommended The risk of clinically important TBI for these patients is exceedingly low, generally lower than the risk of CT-induced malignancies.

< 0.02% risk of clinically important TBI

Yes

Observation versus CT on the basis of other clinical factors including:

- Physician experience - Multiple versus isolated findings

(Patients with certain isolated findings such as isolated LOC, isolated headache, isolated vomiting, and certain types of isolated scalp hematomas in infants older than 3 months have a substantially lower than 1% risk of clinically important TBI)

- Worsening symptoms or signs during or after emergency department observation

- Age <= 3 months higher risk - Parental preference

0.9% risk of clinically important TBI

Based on Figure 3 of Kuppermann, et al, Identification of children at very low risk of clinically important brain injuries after head trauma: a prospective cohort study, Lancet, 2009 Oct 3;374(9696):1160-70.

http://www.luhs.org/emsc

http://www.luhs.org/emsc

Suggested CT Algorithm for Mild Traumatic Head Injury (GCS 14 or 15) Age 2-17 Years

GCS=14

Or

Other signs of altered mental status (any of the following): - agitation - somnolence - repetitive questioning - slow response to verbal communication

Or

Signs of basilar skull fracture

CT Recommended Yes

4.3% risk of clinically important TBI

No

History of LOC

Or

History of vomiting

Or

Severe mechanism of injury (any of the following): - Motor vehicle crash (MVC) with patient ejection - MVC with death of another passenger - MVC with rollover - Pedestrian or bicyclist without helmet struck by a

motorized vehicle - Falls of more than 1.5 m (5 feet) - Head struck by a high-impact object

Or

Severe headache

No

CT generally not recommended The risk of clinically important TBI for these patients is exceedingly low, generally lower than the risk of CT-induced malignancies.

< 0.05% risk of clinically important TBI

Yes

Observation versus CT on the basis of other clinical factors including:

- Physician experience - Multiple versus isolated findings

(Patients with certain isolated findings such as isolated LOC, isolated headache, isolated vomiting, and certain types of isolated scalp hematomas in infants older than 3 months have a substantially lower than 1% risk of clinically important TBI)

- Worsening symptoms or signs during or after emergency department observation

- Parental preference

0.9% risk of clinically important TBI

Based on Figure 3 of Kuppermann, et al, Identification of children at very low risk of clinically important brain injuries after head trauma: a prospective cohort study, Lancet, 2009 Oct 3;374(9696):1160-70.

http://www.luhs.org/emsc

IL EMSC Educational Module (excerpt)Pediatric Mild Traumatic Head Injury

Patient /Parent Education

Response 112 hospitals responded in 2008 99 hospitals responded in 2009

Highlighted findings include: 57% respondents reported taking action (i.e. providing education or

revising documentation) as a result of participation in the statewide QI monitor. Over half of hospitals (52%) reported taking action related to their CT scanning practices based on participation in this project.

Slight increase in percentage of facilities with a policy, guideline or clinical pathway for traumatic head injury (increase from 28% in 2008 to 31% in 2009)

Policies that specifically addressed pediatrics increased from 42% in 2008 to 59% in 2009

Policies that include a process for screening for signs of child maltreatment/neglect increased from 58% in 2008 to 62% in 2009

Highlights: Survey

During a two-year timeframe (2008-2009), over 6800 medical records were reviewed by participating hospitals. 113 participating hospitals in 2008 114 participating hospitals in 2009

Record review focused on infants age 0–23 months and children age 2–15 y/o.

Roll-out of the educational module and guidance from PECARN researcher occurred between the 2008 and 2009 data collection cycles.

Medical Record Review Process

By the end of the project, notable findings include:

Increased awareness of history taking that included documenting: Similar recurrent head injury Scalp abnormality present (prior to CT imaging) Safety equipment usage

Neurological reassessment improved

Child abuse screening improved significantly between 2008 and 2009 (p<0.0001). Of particular note were increases reported in specific regions (significant improvements p<0.05):

Region 1 (36% to 57%) Region 4 (49% to 71%) Region 5 (63% to 73%) Region 8 (52% to 70%)

Subsequent analysis of Statewide Emergency Department data Suggests hospital participation in facility recognition was associated with lower

head CT usage in the ED

Highlights: Medical Record Review

Next Steps

Katherine Remick, MDAssociate Medical Director, Austin-Travis County EMS System

Pediatric Emergency Medicine, Dell Children’s Medical Center

Faculty, UTSW-Austin, Pediatric Emergency Medicine Fellowship

Components that can benefit from QI efforts Local infrastructure Variation in care

Multidisciplinary team approach Pediatric Quality Coordinator Pediatric Physician Champion

Combine performance feedback with clinical practice guidelines/education

Collaborative and multi-center initiatives Support benchmarking Engage community hospitals Create a larger system of care

Summary: QI lessons learned

Areas of Focus for Quality Improvement in Your ED

Family-centered/patient-centered care Cost Patient safety Best practices Efficiency

Top 15 Performance Measures in Pediatric Emergency Care*

   

System-Based Measures  

Patient Triage Measurement of weight in kilograms for patients under 18 years of age

  Method to identify age-based abnormal pediatric vital signs

Infrastructure and PersonnelPresence of all recommended pediatric equipment in the emergency department

  Presence of physician and nurse coordinators for pediatric emergency care

Patient-Centered Care Patient and/or caregiver understanding of discharge instructions

Emergency Department Flow Door-to-Provider time

  Total length of stay

Pain Management Pain assessment and reassessment for children with acute fractures

Quality and Safety Number of return visits within 48 hours resulting in hospitalization

  Medication error rates

   

Disease Specific Measures  

Trauma Use of head CT in children with minor head trauma

  Protocol for suspected child maltreatment

Respiratory Diseases Administration of systemic steroids for pediatric asthma exacerbations

  Use of an evidence-based guideline to manage bronchiolitis

Infectious Diseases Use of antibiotics in children with suspected viral illness*Based on the work of Alessandrini et al, 2011

The Business of QI: How to be an Effective Liaison Identify a team

Hospital/Administrative leadershipTechnical expertiseDay-to-day clinical leadership

Regular meetings and updates

Data Extraction

Identify a performance measure Data collection planning:

Specific data points Sources of information Timeline

Standardize the process Decide frequency of data measurement

Depends on area of focus

Data Analysis

Give validity to the data extraction processStandardizedThoroughSufficient

Quantify the impact of your QI efforts Demonstrate improved performance

Compare results to initial goals

Performance Management

Establish standards within your institution Define specific measures

InfrastructureServicesOutcomes

Measure and report on progress Ongoing QI program

Developing a Message for Leadership Demonstrate the value of the QI process

Financial incentives Quality of care

Minimize variation Improve overall efficiency and safety Utilize best practices Patient-centered

Accreditation Recognition as a regional expert and/or Patient-

Centered Medical Home

Assuring an excellent patient experience

QI education and culture change

Data/predictive analytics: measuring through meaningful metrics

The science

Measurement and analytics

The implementation

ImprovedPopulation

Health

Deployment strategy—Care

Process Teams

Evidence Integrated practice via

guidelines, order sets and measures

Using and innovating best

practices

Pediatric Readiness Toolkit

www.pediatricreadiness.org

Questions and Discussion

CE Evaluation and Certificate

Continuing Education guidelines require that the attendance of all who participate be properly documented.  Those who participate and wish to receive continuing education need to attend the activity in its entirety and complete the online evaluation by December 24, 2014. The online link will be available for one week to complete your evaluation.

The link to complete your online evaluation is: http://emscnrc.org/Events/Webinar_Evaluation.aspx (Note that you can only gain access to the page by copying and pasting the URL into your browser. )

If you need assistance accessing the online evaluation link, please contact Sametria McCammon (smccammo@childrensnational.org). Your Continuing Education certificate will be automatically generated and emailed to you upon completion of the online evaluation.

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