Schaffzin JK, Harte L, Marquette S, Zieker K, Wooton S, Walsh K, Newland JG. Surgical Site Infection Reduction by the Solutions for Patient Safety Hospital Engagement Network. Pediatrics. 2015 Nov;136(5):e1353-60.
National standards for surgical site prevention do not exist in pediatric settings. We sought to reduce harm due to surgical site infections by implementation a prevention bundle through the Children’s Hospitals Solutions for Patient Safety Network (SPS). SPS is a network of over 100 children’s hospitals working together to eliminate harm to children caused by healthcare. The recommended bundle elements encompassed proper preoperative bathing, intraoperative skin antisepsis, and antibiotic delivery; hospitals measured and reported reliability of adherence to bundle elements. We focused our improvement work on spinal fusion, neurosurgical ventricular shunt, or cardiothoracic surgery in which the chest was fully closed in the operating room. Reports of a statistically significant 21% reduction in SSI rates across network hospitals, from a mean baseline rate of 2.5 surgical site infections per 100 procedures to a mean rate of 1.8 surgical site infections per 100 procedures. There was a reduced rate sustained for 15 months. Adoption of a SSI prevention bundle with concomitant reliability measurement reduced the network surgical site infection rate. Linking reliability measurement to standardization at an institutional level may lead to safer care.
Goudie A, Dynan L, Brady PW, Fieldston E, Brilli RJ, Walsh KE. Costs of Venous Thromboembolism, Catheter-Associated Urinary Tract Infection, and Pressure Ulcer. Pediatrics. 2015 Sep;136(3):432-9.
Before this publication, there was no published data to estimate costs of venous thromboembolism, catheter associated urinary tract infection, and pressure ulcer for children. We found that patients with venous thromboembolism had eight more inpatient days and $27,686 excess costs compared to matched controls. Patients with catheter associated urinary tract infection had two more inpatient days and $7,200 excess costs compared to matched controls. For both of these conditions these differences from matched controls were statistically significant. We were unable to find an adequate number of matches for our pressure ulcer population to identify statistically significant differences in these patients. The extended lengths of stay for these patients highlights the substantial morbidity of these potentially preventable events. Accurate cost data are critical to health systems seeking to create a business case for initiatives to reduce these harms in hospitalized children.
Marsolo K, Margolis PA, Forrest CB, Colletti RB, Hutton JJ. A Digital Architecture for a Network-Based Learning Health System: Integrating Chronic Care Management, Quality Improvement, and Research. EGEMS (Wash DC). 2015 Aug 17;3(1):1168.
The use data from the EHR to inform the cycle of clinical care, improvement and research is a goal of learning health systems. However, the concept of a broadly distributed EHR-based Learning Health System remains aspirational. This stems in part from two technical challenges: designing information systems that need to support clinical care, research, and QI activities concurrently, and having to fulfill the needs of users dispersed geographically and across multiple organizations. In addition to the technical challenges, there are numerous societal and scientific barriers to overcome, such as achieving alignment among stakeholders and handling the difference in operational time scales. As a result, most efforts have focused on optimizing systems to support the use of EHR data either for research or for clinical care and QI. This article describes how the vision of a learning health system is achieved in a ‘proof of concept’ project with the ImproveCareNow Network to automate analytic and chronic care reports, create an application for storing protected health information and tracking patient consent, and deploy a cohort identification tool to support the use of data to support the development of studies and hypothesis generation.
Kashikar-Zuck S, Carle A, Barnett K, Goldschneider KR, Sherry DD, Mara CA, Cunningham N, Farrell J, Tress J, DeWitt EM.Longitudinal evaluation of patient-reported outcomes measurement information systems measures in pediatric chronic pain. Pain. 2016 Feb;157(2):339-47.
Patient centered research depends in part on successfully including the patient’s voice and perspective on their own health and health related outcomes. Scientifically established patient reported outcomes (PRO) measures are one of the key methods for meeting this need. Our paper established the construct validity and responsiveness to change for seven Patient-Reported Outcomes Measurement Information System (PROMIS) measures among children with pediatric chronic pain. We used parallel process longitudinal growth models, a type of structural equation model, to examine responsiveness to change and construct validity across PROMIS and “legacy” measures simultaneously. This was the first application of parallel process longitudinal growth models in the academic medicine literature and allowed us to demonstrate responsiveness to change and construct validity in ways that more traditional methods don’t allow.
Johnson DP, Lind C, Parker SE, Beuschel C, VanVliet S, Nichols J, Rauch CA, Lee B, Muething SE. Toward High-Value Care: A Quality Improvement Initiative to Reduce Unnecessary Repeat Complete Blood Counts and Basic Metabolic Panels on a Pediatric Hospitalist Service. Hosp Pediatr. 2016 Jan;6(1):1-8.
This work is a direct result of the lead author participating in Cincinnati Children's Hospital Medical Center's external I2S2 class. Cincinnati Children's faculty mentored Dr. Johnson's class project. The improvement work occurred at Vanderbilt, and demonstrated how standardization resulted in decreased cost to the patient without deterioration in other quality outcomes. This work is generalizable across inpatient care, and expected to accelerate appropriate standardization to reduce unwarranted variation. This is an excellent example of inter-organization collaboration.