Nationwide Children's Hospital Approved Maintenance of Certification (MOC) Projects

Ambulatory

• Adult Cystic Fibrosis Sleep Health
• Improving the Systems to Detect and Address Hypertension in Children and Adults
• Increase Obesity Diagnosis in Nationwide Children's Hospital Primary Care Center
• Increasing use of Asthma Action Plan in the Pediatric Pulmonary Clinic
• Interferon-gamma release assay testing for tuberculosis (TB) and effect on completion of therapy for latent tuberculosis infection (LTBI) in children
• Improvement of Diabetes Sick Day Management Skills

Emergency Department

• Child Abuse Screening Tool
• Decreasing the blood culture contamination rate
• Fever/Neutropenia - Time to Antibiotics Reduction
• Reducing Staff Exposures to Pertussis

Inpatient

• Accurate Insulin Dosage
• Decrease ALOS for infants admitted to the Nationwide Children's main campus NICU
• Decrease hospital acquired respiratory infection in mechanically ventilated patients
• Reduce Adverse Drug Events
• Reduce the Unplanned Extubation rate

Surgery

• Reduce Surgical Site Infections
• Surgical Hypothermia Incidence Reduction Project
• Improving on Time Anticonvulsant Administration During the Home to Hospital Transition Through the Surgical Unit

Accurate Insulin Dosage

Insulin is included on the Institute for Safe Medication Practices List of High-Alert Medications. Medications appearing on this list represent increased risk of causing significant harm if used in error. After looking at the different causes for insulin errors at Nationwide Children’s, it was discovered that 60% of the errors occurred during the prescribing process. This project seeks to implement safeguards to reduce the risk of errors associated with insulin and increase the average number of day’s in-between insulin events.

Project Leader: David Repaske, MD

Adult Cystic Fibrosis Sleep Health

Cystic fibrosis, CF is a complex disease, requiring intensive management, in which early death is due to lung failure in > 95% of patients. Those patients with lower lung function, FEV1 ≤ 50 % predicted are at risk for hypoxia and sleep disturbances. These may adversely affect health and function and may negatively impact the patient’s clinical course, quality of life and even transplant candidacy. The aim of this project is to increase rate of sleep evaluations in CF patients with lower lung function (FEV1 ≤ 50%).

Project Leader: Karen McCoy, MD

Child Abuse Screening Tool

Limited research exists on the use of screening tools to identify physical abuse and the effect of such tools on the demographics of patients assessed for abuse and the rate of reporting to child protective service (CPS). An electronic health record-based four question screening tool was initiated in the Emergency Department (ED) that automatically initiates a Child Assessment Team (CAT) consultation for any patient less than five years old admitted with an injury that occurred in the home.

The tool was implemented in July 2011. Compliance with the tool is monitored on a monthly basis as a trauma performance indicator. Poor compliance rates potentially increase the risk of not identifying a child who requires subspecialty evaluation for suspected abuse, and places the child at risk for further harm and/or death.

Project Leader: Kathy Nuss, MD

Decrease ALOS for infants admitted to the NCH main campus NICU

Unnecessary and prolonged hospitalization exposes neonates to preventable harm such as hospital acquired infections, pressure ulcers, and medication errors. Prolonged hospitalization in the NICU also has an adverse effect on parents, siblings, and other family members. Moreover, prolonged hospitalization contributes to excessive healthcare costs. Thus, optimizing patient care services to reduce unnecessary hospitalization is an important quality initiative that will decrease preventable harm, reduce hospital costs and improve parent satisfaction.

Project Leader: Richard McClead, MD

Decrease hospital acquired respiratory infection in mechanically ventilated patients

This project seeks to improve oral care in intubated patient in Pediatric Intensive Care Unit (PICU) utilizing the IHI Model in a cooperative environment with a multidisciplinary team approach.

• Ventilator Associated Pneumonia (VAP) is one of the leading causes of death due to health care associated infection in ICUs.
• VAP occurs in 9-28% of mechanically ventilated patients.
• Centers for Disease Control and prevention (CDC) recommend the development and implementation of a comprehensive strategy for preventing VAP.

Project Leader: Onsy S. Ayad, MD

Decreasing the blood culture contamination rate in the ED

Blood cultures are drawn in pediatric patients to identify bacteremia and sepsis. Results of the cultures are used to direct therapy. Sometimes, a blood culture grows a contaminant. Unfortunately it is very difficult or impossible to differentiate initial growth of a skin contaminant such as staph epidermidis from a pathogen such as staph aureus. The potential of contaminants leads to longer hospital stays, unnecessary antibiotic therapy, and additional laboratory testing. As a result, the cost of blood culture contamination incurred by a hospital is many times that incurred by the laboratory. These patients need rechecks, repeat blood draws and sometimes antibiotic therapy for a few days until infection can be differentiated from contamination. Decreasing the number of false positive blood cultures should decrease the number of revisits and admissions for false positive cultures, decrease antibiotic administration for false positive cultures, decrease the number phone calls to families, and increase the positive predictive value of blood culture growth.

Project Leader: Jeremy Larson, MD

Fever/Neutropenia - Time to Antibiotics Reduction

Children with oncology diagnoses are at high risk for life-threatening infections. Neutropenia is disorder causing an abnormally low level of white blood cells (WBCs) produced in the bone marrow that fights bacteria. If a patient with a diagnosis of Neutropenia arrives to the Emergency Department with a fever then immediate treatment must be administered. Presence of a fever may be the only indication of a severe underlying infection, because typically signs and symptoms of inflammation are lacking. Due to the lack of neutrophils patients are at risk for rapid progression of aggressive bacterial infections. National Guidelines suggest initiating treatment with broad-spectrum empiric antibiotics to the patient within 2 hours of presentation to the Emergency Department. Risks of not following the guidelines include high morbidity, potential for sepsis and high mortality. This project seeks to implement best practice diagnostic methods, treatments and to mitigate the risk for failure of coordination of care that could lead to these critically ill patients falling through the slats in a busy Emergency Department.

Project Leader: Kathy Nuss, MD

Improvement of Diabetes Sick Day Management Skills

Diabetes mellitus is a chronic illness requiring learning of diabetes management skills. These skills are taught and learnt from the multidisciplinary diabetes care team comprised of an M.D., CDE, nurses, and RDs at diagnosis, and are reinforced at subsequent clinic visits on an ongoing basis. Successful learning of these skills is therefore the key to successful diabetes management. Diabetes programs have education materials and teaching techniques that they utilize to impart these diabetes management skills.

Project Leader: Manmohan Kamboj, MD

Improving on Time Anticonvulsant Administration During the Home to Hospital Transition Through the Surgical Unit

Transitions in care are known to be high risk situations. The transition from home to hospital for the child with epilepsy is a period where failure to provide on time administration of anticonvulsants can lead to seizures, hospitalizations, brain injury and potentially death. What we model with regard to the importance of anticonvulsant administration can have significant implications beyond this single time period. Here at Nationwide we have seen seizures and hospitalizations and injury secondary to failure to give anticonvulsants during the transition from home to hospital. Prior to implementation of this project we knew from limited data that between 30% and 60% of Children were not receiving medication during the transition into the hospital.

Project Leader: Charlotte T. Jones

Improving the Systems to Detect and Address Hypertension in Children and Adults

Hypertension is a serious problem for both children and adults. In children, it may be a sign of underlying systemic problems that need to be investigated to prevent long-term sequellae. In adults, the risk of secondary events related to hypertension effects (MI, CVA, etc…) exists in the hypertensive patient. Failure to recognize hypertension in either of these populations runs the risk of morbidity and/or mortality. Our combined Internal Medicine-Pediatrics clinic sees patients in both specialties and patients of all age groups. In investigating our baseline level of care, we found situations leading to missed recognition of hypertension at the office visit. For adults, hypertension was most often not addressed when the patient came in for other health related concerns and an incidental finding of elevated blood pressure was noted. In children, recognition of hypertension is much more complicated. The parameters defining elevated blood pressure (>95%ile) in children are fluid based on gender, age and height. We found that nursing staff had limited understanding of these parameters and that height measurements were rarely obtained for children at ill visits. In addition, there were no resources readily available for staff or physicians to compare patient blood pressures to accepted norms. Baseline levels of addressing hypertension at the office visit were 79% for adults and only 26% for pediatric patients – showing significant room for improvement.

Treating hypertension begins by correctly identifying elevated blood pressure in both adults and children. This project seeks to identify those patients over 3 years of age in the NCH Primary Care Center with discussion of the elevated blood pressure in the physician progress note or hypertension/elevated blood pressure was added to the patient problem list.

Project Leader: Scott Holliday, MD

Increase Obesity Diagnosis in Nationwide Children's Hospital Primary Care Center

Nationally obesity has become an epidemic problem for all including children. Studies show that a child who is obese at age 6 has a 25% chance of being obese as an adult, and a child who is obese at age 12 has a 75% chance of being obese as an adult. Obesity leads to a multitude of diseases ranging from diabetes to high blood pressure, from heart disease to depression. The best way to “treat” obesity is to prevent it. This involves teaching and promoting healthy lifestyles from birth. If prevention fails, intervention starts with identification of the obese child as early as possible so that treatment may be initiated.

Project Leader: William Cotton, MD

Increasing use of Asthma Action Plan in the Pediatric Pulmonary Clinic

Asthma is a major public health problem in the United States. The disease affects approximately 15 million people, nearly 5 million of whom are under the age of 18. Franklin County experiences poor outdoor air quality, poverty, stress and decreased access to health care. All of these factors combined can contribute to an increased incidence of asthma. Although asthmatic care has been dramatically improved within the hospital the care is not sustained once the asthma patient is discharged.

NCH is committed to creating optimal health for all children in our community and strive to close the gap between self-management and hospital care. The Asthma Action Plan (AAP) is a best practice that was successfully implemented in the Pulmonary Clinic visits. The NCH Core Asthma Team now looks to implement these interventions into the NCH Primary Care Clinics with the global aim to reduce Asthma related Emergency Department visits.

Project Leader: Beth Allen, MD

Interferon-gamma release assay testing for tuberculosis (TB) and effect on completion of therapy for latent tuberculosis infection (LTBI) in children

It is important to identify new methods of improving compliance to therapy of latent tuberculosis infection (LTBI), which typically consists of 270 doses of isoniazid completed within a maximum of 12 months. The lifetime risk of developing TB disease for otherwise healthy children ≤15 years of age with LTBI is 5–15%.1. The most recently published guidelines for treatment of LTBI in children and adolescents pointed out that completion rates for treatment of LTBI are suboptimal and suggested that “strategies to monitor and improve adherence to treatment are needed.”2

We previously reported a retrospective analysis of prospectively collected data for the completion of therapy in patients ≤ 15 years of age with LTBI, defined as a tuberculin skin test (TST) of ≥ 10 mm of induration and a negative chest radiograph, referred for medical evaluation to Nationwide Children’s Hospital Tuberculosis Clinic (TBC) between August 1, 2005 and July 31, 2006.3 The overall completion rate of the 545 patients evaluated was 54.4%, similar to the completion rate of 58% for the only other pediatric study that evaluated a treatment course of nine months of isoniazid.4 There were significant differences among ethnicities with regard to parental refusal to initiate medication, which was noted in 54% of Eastern European children and 80% of Asian children who failed to complete therapy.

Over the past three years, the interferon-gamma release assay QuantiFERON®-TB Gold In-Tube (QFT-GIT), which has similar sensitivity and improved specificity in comparison to the TST for detection of tuberculosis infection, has been used in the TBC to confirm infection in children with a “borderline” positive TST of 10-15 mm. The proposal for this study was to use control chart methods to evaluate a positive QFT-GIT as a surrogate for improved rates of initiation of therapy secondary to enhanced specificity and improved parental motivation.

1. Horsburgh CR Jr. Priorities for the treatment of latent tuberculosis infection in the United States. N Engl J Med. 2004 May 13;350(20):2060-7.
2. Pediatric Tuberculosis Collaborative Group. Targeted tuberculin testing and treatment of latent tuberculosis infection in children and adolescents. Pediatrics. 2004;114:1175–1201.

Project Leader: W. Garrett Hunt, MD, FAAP

Reduce Adverse Drug Events

ADE represents the largest single portion of our harm index and a majority of those ADE events occur in our Critical Care Areas (NICU, PICU, HEMATOLOGY). This ADE Collaborative (ADEQC) addresses ways to reduce the number of preventable ADEs per month that reach the patient and cause harm, decrease health care costs by avoiding ADEs and improving ADE prevention bundle compliance per participating unit using the IHI Model for Improvement.

Project Leader: Richard McClead, MD

Reduce Surgical Site Infections

Surgical site infections (SSIs) in three areas have been the subject of review for many years because of their severity and frequency: Cardiac surgery; neuro ventriculoperitoneal (VP) shunt surgery; and spinal surgery for correction of scoliosis. This project aims to decrease the number of Solutions for Patient Safety (SPS) defined SSIs.

Project Leader: Brian Kenney, MD

Reduce the Unplanned Extubation rate

When a patient in the intensive care unit needs mechanical ventilation, an endotracheal tube is required to provide respiratory support. Unplanned extubation is the displacement or removal of the endotracheal tube at a time other than that specifically chosen for a planned extubation and is a serious adverse event [B–D, based on the National Coordinating Council Medication Error Reporting Program Index]. If an endotracheal tube is dislodged or accidentally removed, it affects patient safety by prolonging time of intubation thereby increasing the patient's exposure to hazards of airway intervention and mechanical ventilation and can increase morbidity and mortality.

• Project Leader: Anthony Lee, MD

Reducing Staff Exposures to Pertussis in the Emergency Department

Pertussis can be a deadly disease in infants and is highly communicable. Central Ohio, along with other parts of the country, is currently experiencing an outbreak of Pertussis. Many patients seek care in our Emergency Department who has signs and symptoms that could be pertussis. Without proper isolation of these patients our staff is exposed and may transmit the disease to other patients and/or their own families. This project addresses ways to appropriately increase isolation of these patients at the earliest possible point in our system to decrease staff exposure, decrease the cost of prophylactic antibiotics and most importantly decrease further spread of the disease.

Project Leader: Leslie Mihalov, MD

Surgical Hypothermia Incidence Reduction Project

Patients are arriving to the PACU with hypothermia following surgeries that are greater than 60 minutes in length. When a person is under anesthesia, he or she loses the ability to regulate body temperature. This means that his or her body temperature mirrors that of the room. If the body cools down so much as to lead to mild hypothermia, this restricts the movement of white blood cells, which are important for fighting off bacteria. If white blood cells can’t travel where they need to, this increases the chance of a surgical site infection. Other consequences of hypothermia also include thermal discomfort and issues with coagulation/drug metabolism. We’re concern about thermal discomfort in the recovery room because if you ask adults, if they were to rank their discomfort in the recovery room, they will frequently rate thermal discomfort, or the discomfort from being cold even over their incisional pain. As in adults we don’t want our children suffering either.

Project Leader: Thomas Taghon, DO