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Waak M, Harnischfeger J, Ferguson A, Gibbons K, Nguyen KH, Long D. Every child, every day, back to play: the PICUstars protocol - implementation of a nurse-led PICU liberation program. BMC Pediatr 2022; 22:279. [PMID: 35562671 PMCID: PMC9102243 DOI: 10.1186/s12887-022-03232-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 03/21/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND As admissions to paediatric intensive care units (PICU) rise and mortality rates decline, the focus is shifting from survival to quality of survivorship. There is paucity of internationally accepted guidelines to manage complications like over-sedation, delirium, and immobility in the paediatric setting. These have a strong adverse impact on PICU recovery including healthcare costs and long-term functional disability. The A2F bundle (ABCDEF), or ICU Liberation, was developed to operationalise the multiple evidence-based guidelines addressing ICU-related complications and has been shown to improve clinical outcomes and health-care related costs in adult studies. However, there is little data on the effect of ICU Liberation bundle implementation in PICU. METHODS PICU-STARS will be a single centre before-and-after after trial and implementation study. It is designed to evaluate if the multidimensional, nurse-led ICU Liberation model of care can be applied to the PICU and if it is successful in minimising PICU-related problems in a mixed quaternary PICU. In a prospective baseline measurement, the present practises of care in the PICU will be assessed in order to inform the adaptation and implementation of the PICU Liberation bundle. To assess feasibility, implementation outcomes, and intervention effectiveness, the implementation team will use the Consolidated Framework for Implementation Research (CIFR) and process assessment (mixed methods). The implementation process will be evaluated over time, with focus groups, interviews, questionnaires, and observations used to provide formative feedback. Over time, the barriers and enablers for successful implementation will be analysed, with recommendations based on "lessons learned." All outcomes will be reported using standard descriptive statistics and analytical techniques, with appropriate allowance for patient differentials in severity and relevant characteristics. DISCUSSION The results will inform the fine-tune of the Liberation bundle adaptation and implementation process. The expected primary output is a detailed adaptation and implementation guideline, including clinical resources (and investment) required, to adopt PICU-STARS in other children's hospitals. PATIENT AND PUBLIC INVOLVEMENT STATEMENT The authors thank the PICU education and Liberation Implementation team, and our patients and families for their inspiration and valuable comments on protocol drafts. Results will be made available to critical care survivors, their caregivers, relevant societies, and other researchers. TRIAL REGISTRATION ACTRN, ACTRN382863 . Registered 19/10/2021 - Retrospectively registered. STUDY STATUS recruiting.
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Affiliation(s)
- M Waak
- Child Health Research Centre, The University of Queensland, 62 Graham Street, South Brisbane, Queensland, 4101, Australia. .,Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, Australia.
| | - J Harnischfeger
- Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, Australia
| | - A Ferguson
- Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, Australia
| | - K Gibbons
- Child Health Research Centre, The University of Queensland, 62 Graham Street, South Brisbane, Queensland, 4101, Australia
| | - K H Nguyen
- Centre for Applied Health Economics, School of Medicine and Griffith Health Institute, Griffith University, Brisbane, QLD, 4131, Australia.,Centre for Health Service Research, Faculty of Medicine, University of Queensland, QLD, Herston, 4006, Australia
| | - D Long
- Child Health Research Centre, The University of Queensland, 62 Graham Street, South Brisbane, Queensland, 4101, Australia.,Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, Australia.,School of Nursing, Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, QLD, Australia
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2
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Vacher A, El Mhamdi S, d'Hollander A, Izotte M, Auroy Y, Michel P, Quenon JL. Impact of an Original Methodological Tool on the Identification of Corrective and Preventive Actions After Root Cause Analysis of Adverse Events in Health Care Facilities: Results of a Randomized Controlled Trial. J Patient Saf 2021; 17:483-489. [PMID: 29116954 DOI: 10.1097/pts.0000000000000437] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The aim of the study was to assess the effectiveness of a new methodological tool for the identification of corrective and preventive actions (CAPAs) after root cause analysis of health care-related adverse events. METHODS From January to June 2010, we conducted a randomized controlled trial involving risk managers from 111 health care facilities of the Aquitaine Regional Center for Quality and Safety in Health Care (France). Fifty-six risk managers, randomly assigned to two groups (intervention and control), identified CAPAs in response to two sequentially presented adverse event scenarios. For the baseline measure, both groups used their usual adverse event management tools to identify CAPAs in each scenario. For the experimental measure, the control group continued using their usual tools, whereas the intervention group used a new tool involving a systemic approach for CAPA identification. The main outcome measure was the number of CAPAs the participants identified that matched a criterion standard established by eight experts. RESULTS Baseline mean number of identified CAPAs did not differ between the two groups (P = 0.83). For the experimental measure, significantly more CAPAs (P = 0.001) were identified by the intervention group (mean [SD] = 4.6 [1.7]) than by the control group (mean [SD] = 2.8 [1.2]). CONCLUSIONS For the two scenarios tested, more relevant CAPAs were identified with the new tool than with usual tools. Further research is needed to assess the effectiveness of the new tool for other types of adverse events and its impact on patient safety.
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Affiliation(s)
- Anthony Vacher
- From the Institut de Recherche Biomédicale des Armées [French Armed Forces Biomedical Research Institute], Unité Sécurité des Systèmes à Risques, Brétigny sur Orge, France
| | | | - Alain d'Hollander
- Anesthesiology Department, Geneva University Hospitals, Geneva, Switzerland
| | - Marion Izotte
- Comité de Coordination de l'Evaluation Clinique et de la Qualité en Aquitaine (CCECQA) [Aquitaine Regional Centre for Quality and Safety in Health Care], Hôpital Xavier Arnozan, Pessac, France
| | | | | | - Jean-Luc Quenon
- Comité de Coordination de l'Evaluation Clinique et de la Qualité en Aquitaine (CCECQA) [Aquitaine Regional Centre for Quality and Safety in Health Care], Hôpital Xavier Arnozan, Pessac, France
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Osorio SN, Gage S, Mallory L, Soung P, Satty A, Abramson EL, Provost L, Cooperberg D. Factorial Analysis Quantifies the Effects of Pediatric Discharge Bundle on Hospital Readmission. Pediatrics 2021; 148:peds.2021-049926. [PMID: 34593650 DOI: 10.1542/peds.2021-049926] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/24/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Factorial design of a natural experiment was used to quantify the benefit of individual and combined bundle elements from a 4-element discharge transition bundle (checklist, teach-back, handoff to outpatient providers, and postdischarge phone call) on 30-day readmission rates (RRs). METHODS A 24 factorial design matrix of 4 bundle element combinations was developed by using patient data (N = 7725) collected from January 2014 to December 2017 from 4 hospitals. Patients were classified into 3 clinical risk groups (CRGs): no chronic disease (CRG1), single chronic condition (CRG2), and complex chronic condition (CRG3). Estimated main effects of each bundle element and their interactions were evaluated by using Study-It software. Because of variation in subgroup size, important effects from the factorial analysis were determined by using weighted effect estimates. RESULTS RR in CRG1 was 3.5% (n = 4003), 4.1% in CRG2 (n = 1936), and 17.6% in CRG3 (n = 1786). Across the 3 CRGs, the number of subjects in the factorial groupings ranged from 16 to 674. The single most effective element in reducing RR was the checklist in CRG1 and CRG2 (reducing RR by 1.3% and 3.0%) and teach-back in CRG3 (by 4.7%) The combination of teach-back plus a checklist had the greatest effect on reducing RR in CRG3 by 5.3%. CONCLUSIONS The effect of bundle elements varied across risk groups, indicating that transition needs may vary on the basis of population. The combined use of teach-back plus a checklist had the greatest impact on reducing RR for medically complex patients.
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Affiliation(s)
- Snezana Nena Osorio
- Department of Pediatrics, Weill Cornell Medical College and New York Presbyterian Hospital, New York, New York
| | - Sandra Gage
- Department of Pediatrics, Medical College of Wisconsin and Children's Hospital of Wisconsin, Milwaukee, Wisconsin.,Department of Child Health, College of Medicine-Phoenix, University of Arizona and Phoenix Children's Hospital, Phoenix, Arizona
| | - Leah Mallory
- Department of Pediatrics, School of Medicine, Tufts University and The Barbara Bush Children's Hospital, Portland, Maine
| | - Paula Soung
- Department of Pediatrics, Medical College of Wisconsin and Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Alexandra Satty
- Department of Pediatrics, Weill Cornell Medical College and New York Presbyterian Hospital, New York, New York
| | - Erika L Abramson
- Department of Pediatrics, Weill Cornell Medical College and New York Presbyterian Hospital, New York, New York
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Kaplan HC, Kuhnell P, Walsh MC, Crowley M, McClead R, Wexelblatt S, Ford S, Provost LP, Lannon C, Macaluso M. Orchestrated Testing of Formula Type to Reduce Length of Stay in Neonatal Abstinence Syndrome. Pediatrics 2020; 146:peds.2019-0914. [PMID: 32913133 DOI: 10.1542/peds.2019-0914] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/15/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Despite the standardization of care, formula feeding varied across sites of the Ohio Perinatal Quality Collaborative (OPQC). We used orchestrated testing (OT) to learn from this variation and improve nonpharmacologic care of infants with neonatal abstinence syndrome (NAS) requiring pharmacologic treatment in Ohio. METHODS To test the impact of formula on length of stay (LOS), treatment failure, and weight loss among infants hospitalized with NAS, we compared caloric content (high versus standard) and lactose content (low versus standard) using a 22 factorial design. During October 2015 to June 2016, OPQC sites joined 1 of 4 OT groups. We used response plots to examine the effect of each factor and control charts to track formula use and LOS. We used the OT results to revise the nonpharmacologic bundle and implemented it during 2017. RESULTS Forty-seven sites caring for 546 NAS infants self-selected into the 4 OT groups. Response plots revealed the benefit of high-calorie formula (HCF) on weight loss, treatment failure, and LOS. The nonpharmacologic treatment bundle was updated to recommend HCF when breastfeeding was not possible. During implementation, HCF use increased, and LOS decreased from 17.1 to 16.4 days across the OPQC. CONCLUSIONS OT revealed that HCF was associated with shorter LOS in OPQC sites. Implementation of a revised nonpharmacologic care bundle was followed by additional LOS improvement in Ohio. Despite some challenges in the implementation of OT, our findings support its usefulness for learning in improvement networks.
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Affiliation(s)
- Heather C Kaplan
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio; .,Perinatal Institute.,James M. Anderson Center for Health Systems Excellence, and
| | - Pierce Kuhnell
- Division of Epidemiology and Biostatistics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Michele C Walsh
- Division of Neonatology, Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, Ohio.,Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio
| | - Moira Crowley
- Division of Neonatology, Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, Ohio.,Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio
| | - Richard McClead
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio; and
| | - Scott Wexelblatt
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.,Perinatal Institute
| | - Susan Ford
- Division of Neonatology, Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | | | - Carole Lannon
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.,James M. Anderson Center for Health Systems Excellence, and
| | - Maurizio Macaluso
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.,Division of Epidemiology and Biostatistics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Pallotto EK, Piazza AJ, Smith JR, Grover TR, Chuo J, Provost L, Mingrone T, Holston M, Moran S, Morelli L, Zaniletti I, Brozanski B. Sustaining SLUG Bug CLABSI Reduction: Does Sterile Tubing Change Technique Really Work? Pediatrics 2017; 140:peds.2016-3178. [PMID: 28951441 DOI: 10.1542/peds.2016-3178] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/19/2017] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To evaluate the ability to sustain and further reduce central line-associated bloodstream infection (CLABSI) rates in NICUs participating in a multicenter CLABSI reduction collaborative and to assess the impact of the sterile tubing change (TC) technique as an important component in CLABSI reduction. METHODS A multi-institutional quality improvement collaborative lowered CLABSI rates in level IV NICUs over a 12-month period. During the 19-month sustain phase, centers were encouraged to monitor and report compliance measures but were only required to report the primary outcome measure of the CLABSI rate. Four participating centers adopted the sterile TC technique during the sustain phase as part of a local Plan-Do-Study-Act cycle. RESULTS The average aggregate baseline NICU CLABSI rate of 1.076 CLABSIs per 1000 line days was sustained for 19 months across 17 level IV NICUs from January 2013 to July 2014. Four centers transitioning from the clean to the sterile TC technique during the sustain phase had a 64% decrease in CLABSI rates from the baseline (1.59 CLABSIs per 1000 line days to 0.57 CLABSIs per 1000 line days). CONCLUSIONS Sustaining low CLABSI rates in a multicenter collaborative is feasible with team engagement and ongoing collaboration. With these results, we further demonstrate the positive impact of the sterile TC technique in CLABSI reduction efforts.
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Affiliation(s)
- Eugenia K Pallotto
- Division of Neonatology, Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri;
| | - Anthony J Piazza
- Department of Pediatrics, Emory University - Children's Healthcare of Atlanta at Egleston, Atlanta, Georgia
| | - Joan R Smith
- Department of Pediatrics, St Louis Children's Hospital, St Louis, Missouri
| | - Theresa R Grover
- Department of Pediatrics, Children's Hospital Colorado, Aurora, Colorado
| | - John Chuo
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Teresa Mingrone
- Department of Pediatrics, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Margaret Holston
- Department of Neonatology, Nationwide Children's Hospital, Columbus, Ohio; and
| | | | | | | | | | | | - Beverly Brozanski
- Department of Pediatrics, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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