A Quality Improvement Initiative to Reduce Hospitalizations for Low-risk Diabetic Ketoacidosis

Use of a Clinical Guideline and Orderset to Reduce Hospital Admissions for Croup

BACKGROUND

Studies have found infrequent interventions after croup admission. Our objectives were to achieve 25% reduction in (1) admission rate and (2) neck radiograph utilization among patients presenting to the emergency department.

METHODS

At our tertiary children's hospital, we implemented clustered interventions including education, guideline, and orderset integration. We included patients 3 months to 8 years old with an emergency department, observation, or inpatient encounter for croup. We excluded patients with direct or ICU admissions, complex chronic conditions, or concurrent asthma, pneumonia, or bronchiolitis. We reviewed a random sample of 60% of encounters from baseline (October 1, 2017 to September 30, 2019) and implementation (October 1, 2019 to September 30, 2020) periods. We conducted a posthoc analysis from October 1, 2017 to December 1, 2021 to assess sustainment during coronavirus disease 2019. Interrupted time series analysis was used to evaluate changes in outcome, process, and balancing measures.

RESULTS

There were 2906 (2123 baseline and 783 implementation) encounters included. Extrapolating preintervention trend estimates, the baseline admission rate of 8.7% decreased to 5.5% postintervention (relative decrease 37% [95% confidence interval: 8 to 66]) and sustained over 26 months after implementation. Admission rate in patients receiving 2 or fewer racemic epinephrine was significantly lower in implementation (1.7%) compared with baseline (6.3%), relative decrease of 72% (95% confidence interval: 68 to 88). There were no significant changes in neck radiographs, length of stay, or revisits.

CONCLUSIONS

Croup quality improvement interventions were associated with a significant decrease in hospital admissions with no increase in revisits.

Resource utilization and outcomes among children risk stratified by pediatric appendicitis risk calculator at a tertiary pediatric center

OBJECTIVES

Appendicitis is a common pediatric condition requiring surgery. The pediatric appendicitis risk calculator (pARC) was recently developed to guide clinical care. The objective of this study is to describe resource utilization and clinical outcomes among children with appendix ultrasound (US) scans risk stratified by pARC score.

METHODS

Prospective enrolled observational cohort single-center study of children aged 5-18, who had an US for suspected appendicitis. We estimated the rate of appendicitis, rate of equivocal US scans, and resource utilization by pARC score strata. Total adjusted charges were determined for low-risk pARC patients compared to discharged emergency department (ED) patients with abdominal pain and complete blood count (CBC) obtained without advanced abdominal imaging.

RESULTS

Over the 13-month study period, 407 children were enrolled. The overall rate of appendicitis was 33.4%, and 199 (49%) were male. The observed rate of appendicitis was 3.3% in those with a pARC score of <15% and 96.8% in those with a pARC score of ≥85%. Of enrolled patients, 152 (37.3%) had a pARC score <15%. Of those with a pARC score of <15%, the negative appendectomy rate was 28.6%, and the rate of equivocal US was 49.3%. The rate of CT scans and hospitalizations was 19% and 23%, respectively. Median total charges for patients with pARC <15% with usual care were $3756. Median total charges for patients presenting to the ED with abdominal pain who had a CBC but no advanced abdominal imaging performed was $2484, indicating a potential savings of $1272 per patient.

CONCLUSIONS

There is a high rate of resource utilization among patients who are low appendicitis risk by pARC score. Outcome variation by pARC scores presents future opportunity to selectively reduce resource utilization in pediatric patients.

A Quality Improvement Initiative to Improve Attention-Deficit/Hyperactivity Disorder Follow-Up Rates Using School-Based Telemedicine

OBJECTIVE

Patients with a new diagnosis of attention-deficit/hyperactivity disorder (ADHD) who are prescribed stimulant medication need regular follow-up. Guidelines recommend follow-up within 30 days of stimulant initiation or change but this goal is seldom achieved. This quality improvement (QI) study in an urban academic outpatient practice aimed to: 1) assess whether use of school-based telemedicine increases rates of follow-up within 30 days and decreases the number of days to follow-up for ADHD, and 2) compare rates of 30-day follow-up via in-person vs telemedicine visits.

METHODS

We performed three Plan-Do-Study-Act cycles over a 12-month period: QI interventions included clinic wide education, paper prompts for clinicians, and creation of a database to track ADHD patients. We measured days from the index visit to the follow-up visit, and the mode of both visits (in-person or telemedicine). Data were collected for 6 months pre-intervention and 12 months post-intervention.

RESULTS

Follow-up within 30 days increased from 19% (of 191 visits) to 33% (of 661 visits) (P < .001). The time to follow-up decreased from 67 to 34 days (P < .001). Follow up visits by telemedicine were more also more likely to be within 30 days (62% vs. 32%, P < .001).

DISCUSSION

A QI intervention for ADHD care increased rates of follow-up within 30 days, particularly when telemedicine was used, and decreased the number of days to follow-up. This intervention could serve as a model to improve follow-up for ADHD in other settings.

What Gets Measured Gets Improved-Setting Standards and Accreditation for Quality Improvement for Diabetes Services in Australia

The purpose of this article is to illustrate that setting standards of care is the cornerstone for excellence in diabetes management. This is underpinned by 3 activities: a standards and accreditation process, an audit and benchmarking program and a linked quality improvement plan. While there are many examples of local auditing and quality improvement programs, there are very few that are at a national level. The National Association of Diabetes Centres (NADC) was formed by the Australian Diabetes Society and the Australian Diabetes Educators Association to set standards of diabetes care in Australia. A rigorous accreditation process was put in place to recognize primary, secondary, and tertiary level diabetes centers that meet these standards. The NADC accreditation process is underpinned by a quality improvement plan, which must be submitted for accreditation to be granted and is informed by the Australian National Diabetes Audit (ANDA). ANDA is conducted annually to gather information about treatments, complications, self-care practices and quality of life outcomes and provides a national as well as an individual report to the participating center that is used to benchmark against other like centers. The ANDA reports are important to inform national policy and advocacy for diabetes care and to also provide information for quality improvement purposes for the individual participating center. We believe that the NADC Standards and Accreditation can be an exemplar for other countries to adapt and adopt to standardize diabetes care at the highest level.