Variation in Condition-Specific Readmission Rates Across US Children's Hospitals.

Objective: Despite extensive efforts, overall readmission rates at US children's hospitals have not materially declined over the past decade, raising questions about how to direct future efforts. Using measures of prevalence and performance variation we describe readmission rates by condition and identify priority conditions for future intervention.

Methods: Retrospective cohort study of 49 US children's hospitals in the Pediatric Health Information System in 2017.

STEPP IN: A Multicenter Quality Improvement Collaborative Standardizing Postoperative Handoffs.

Objective: To reduce care failures by 30% through implementation of standardized communication processes for postoperative handoff in NICU patients undergoing surgery over 12 months and sustained over 6 months.

Methods: Nineteen Children's Hospitals Neonatal Consortium centers collaborated in a quality improvement initiative to reduce postoperative care failures in a surgical neonatal setting by decreasing respiratory care failures and all other communication failures. Evidence-based clinical practice recommendations and a collaborative framework supported local teams' implementation of standardized postoperative handoff communication.

Quality Improvement Initiative to Improve Healthcare Providers' Attitudes towards Mothers with Opioid Use Disorder.

Introduction: Individuals with opioid use disorder often report feelings of shame and describe feeling judged negatively. These feelings are especially true for pregnant women with opioid use disorder. The Ohio Perinatal Quality Collaborative conducted a multimodal quality improvement initiative for infants born with Neonatal Abstinence Syndrome (NAS).

Coming Together to Save Babies: Our Institution's Quality Improvement Collaborative to Improve Infant Safe Sleep Practices.

Unlabelled: Many hospitalized infants are not observed in an American Academy of Pediatrics-recommended safe sleep environment, which can translate to unsafe sleep practices at home. We implemented this collaborative to reduce our county's sleep-related death rate by improving infant safe sleep practices in the freestanding children's hospital setting and increasing safe sleep screening and education in our clinics and emergency departments (EDs).

Methods: Physicians from our institution's primary care clinics, EDs, neonatal intensive care units, and general inpatient units created and led multidisciplinary safe sleep teams.

The Diagnostic Error Index: A Quality Improvement Initiative to Identify and Measure Diagnostic Errors.

Objective: To develop a diagnostic error index (DEI) aimed at providing a practical method to identify and measure serious diagnostic errors.

Study Design: A quality improvement (QI) study at a quaternary pediatric medical center. Five well-defined domains identified cases of potential diagnostic errors.

Orchestrated Testing of Formula Type to Reduce Length of Stay in Neonatal Abstinence Syndrome.

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 2 factorial design.

The Vitals Risk Index-Retrospective Performance Analysis of an Automated and Objective Pediatric Early Warning System.

Introduction: Pediatric in-hospital cardiac arrests and emergent transfers to the pediatric intensive care unit (ICU) represent a serious patient safety concern with associated increased morbidity and mortality. Some institutions have turned to the electronic health record and predictive analytics in search of earlier and more accurate detection of patients at risk for decompensation.

Methods: Objective electronic health record data from 2011 to 2017 was utilized to develop an automated early warning system score aimed at identifying hospitalized children at risk of clinical deterioration.

Pediatric Clinician Comfort Discussing Diagnostic Errors for Improving Patient Safety: A Survey.

Introduction: Meaningful conversations about diagnostic errors require safety cultures where clinicians are comfortable discussing errors openly. However, clinician comfort discussing diagnostic errors publicly and barriers to these discussions remain unexplored. We compared clinicians' comfort discussing diagnostic errors to other medical errors and identified barriers to open discussion.

STEPP IN: Working Together to Keep Infants Warm in the Perioperative Period.

Objectives: Reduce postoperative hypothermia by up to 50% over a 12-month period in children's hospital NICUs and identify specific clinical practices that impact success.

Methods: Literature review, expert opinion, and benchmarking were used to develop clinical practice recommendations for maintaining perioperative euthermia that included the following: established euthermia before transport to the operating room (OR), standardized practice for maintaining euthermia on transport to and from the OR, and standardized practice to prevent intraoperative heat loss. Process measures were focused on maintaining euthermia during these time points.

Writing Group Increases Quality Improvement Writing Competency.

Quality improvement (QI) is critically important in current medical practice. Although many QI courses teach improvement science and methods, formal education in writing QI manuscripts for academic journal publication is lacking. The authors developed a QI Writing program, consisting of educational sessions with both coach and peer mentors, to improve comfort and productivity in preparing QI manuscripts for publication.

A diagnostic time-out to improve differential diagnosis in pediatric abdominal pain.

Background: Pediatric abdominal pain is challenging to diagnose and often results in unscheduled return visits to the emergency department. External pressures and diagnostic momentum can impair physicians from thoughtful reflection on the differential diagnosis (DDx). We implemented a diagnostic time-out intervention and created a scoring tool to improve the quality and documentation rates of DDx.

Progress (?) Toward Reducing Pediatric Readmissions.

Many children's hospitals are actively working to reduce readmissions to improve care and avoid financial penalties. We sought to determine if pediatric readmission rates have changed over time. We used data from 66 hospitals in the Inpatient Essentials Database including index hospitalizations from January, 2010 through June, 2016.

Trigger Criteria to Increase Appropriate Palliative Care Consultation in the Neonatal Intensive Care Unit.

Introduction: Pediatric palliative care (PPC) seeks longitudinal relationships with patients facing life-threatening conditions. The majority of pediatric deaths occur within the first year of life, especially neonatal intensive care unit (NICU); however, the consultation by PPC in the NICU is not routine. This project sought to improve the PPC's presence within 1 NICU for patients facing life-limiting conditions through quality improvement techniques.

Using Length of Stay to Understand Patient Flow for Pediatric Inpatients.

Objectives: Develop and test a new metric to assess meaningful variability in inpatient flow.

Methods: Using the pediatric administrative dataset, Pediatric Health Information System, that quantifies the length of stay (LOS) in hours, all inpatient and observation encounters with 21 common diagnoses were included from the calendar year 2013 in 38 pediatric hospitals. Two mutually exclusive composite groups based on diagnosis and presence or absence of an ICU hospitalization termed Acute Care Composite (ACC) and ICU Composite (ICUC), respectively, were created.

Safety II Behavior in a Pediatric Intensive Care Unit.

Unlabelled: : media-1vid110.1542/5763093009001PEDS-VA_2018-0018 BACKGROUND AND OBJECTIVE: Safety I error elimination concepts are focused on retrospectively investigating what went wrong and redesigning system processes and individual behaviors to prevent similar future occurrences. The Safety II approach recognizes complex systems and unpredictable circumstances, mandating flexibility and resilience within systems and among individuals to avoid errors.

Ohio Perinatal Quality Collaborative Improves Care of Neonatal Narcotic Abstinence Syndrome.

Objectives: Neonatal abstinence syndrome (NAS) after an infant's in-utero exposure to opioids has increased dramatically in incidence. No treatment standards exist, leading to substantial variations in practice, degree of opioid exposure, and hospital length of stay.

Methods: The Ohio Perinatal Quality Collaborative conducted an extensive multi-modal quality improvement initiative with the goal to (1) standardize identification, nonpharmacologic and pharmacologic treatment in level-2 and 3 NICUs in Ohio, (2) reduce the use of and length of treatment with opioids, and (3) reduce hospital length of stay in pharmacologically treated newborns with NAS.

Use of quality improvement (QI) methodology to decrease length of stay (LOS) for newborns with uncomplicated gastroschisis.

Purpose: Gastroschisis is a congenital defect of the abdominal wall leading to considerable morbidity and long hospitalizations. The purpose of this study was to use quality improvement methodology to standardize care in the management of gastroschisis that may contribute to length of stay (LOS).

Methods: A gastroschisis quality improvement team established a best-practice protocol in order to decrease LOS in infants with uncomplicated gastroschisis.

Interprofessional QI Training Enhances Competency and QI Productivity Among Graduates: Findings From Nationwide Children's Hospital.

Purpose: Significant resources are expended on quality improvement (QI) training courses. The authors sought to determine whether education provided in QI course training improves self-assessed QI content competence and QI-related productivity among course graduates.

Method: "Quality Improvement Essentials" is a four-month didactic and experiential course designed to prepare multidisciplinary professionals to participate in and lead QI efforts at Nationwide Children's Hospital (NCH).

Hospital-Level Factors Associated with Pediatric Emergency Department Return Visits.

Background: Return visits (RVs) and RVs with admission (RVAs) are commonly used emergency department quality measures. Visit- and patient-level factors, including several social determinants of health, have been associated with RV rates, but hospital-specific factors have not been studied.

Objective: To identify what hospital-level factors correspond with high RV and RVA rates.

A Quality Improvement Initiative to Standardize Use of Inhaled Nitric Oxide in the PICU.

Background: Inhaled nitric oxide (iNO) is a potent pulmonary vasodilator used off-label to treat refractory hypoxemia in the pediatric intensive care unit (PICU). However, clinical practice varies widely, and there is limited evidence to support this expensive therapy. Our objective was to test whether implementation of a clinical guideline for iNO therapy would decrease practice variability, reduce ineffective iNO utilization, and control iNO-related costs.

Children's Hospital Characteristics and Readmission Metrics.

Background And Objective: Like their adult counterparts, pediatric hospitals are increasingly at risk for financial penalties based on readmissions. Limited information is available on how the composition of a hospital's patient population affects performance on this metric and hence affects reimbursement for hospitals providing pediatric care. We sought to determine whether applying different readmission metrics differentially affects hospital performance based on the characteristics of patients a hospital serves.

A Quality Improvement Project to Decrease Human Milk Errors in the NICU.

Backgroud And Objective: Ensuring safe human milk in the NICU is a complex process with many potential points for error, of which one of the most serious is administration of the wrong milk to the wrong infant. Our objective was to describe a quality improvement initiative that was associated with a reduction in human milk administration errors identified over a 6-year period in a typical, large NICU setting.

Methods: We employed a quasi-experimental time series quality improvement initiative by using tools from the model for improvement, Six Sigma methodology, and evidence-based interventions.