Approved MOC Projects

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

Children who receive regular health supervision care are less likely to utilize the ED and to have avoidable inpatient admissions. The goal of this project and its associated interventions is to remove or lessen these barriers and increase the health supervision rates among the PFK population whether they are followed by PCPs within the NCH primary care network or in PFK contracted physician practices in the community.

Project Leader: Sean Gleeson, MD

Approximately 1700 patients with Cerebral Palsy receive care at Nationwide Children’s Hospital. The care is often fragmented, discontinuous, duplicative, and very costly. The team clinic is an interdisciplinary, annual “CP checkup”, in which the patient is seen by 12 different specialists. The existing Cerebral Palsy Team clinic can serve (at most) a population of 450 patients and the current enrollment is approximately 300 patients. Our data suggests that receiving care in the team clinic is associated with decreased hospital utilization and costs.

Project Leader: Garey Noritz, MD

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

A large percentage of parents are not aware that dental caries is an infectious disease and that many common practices and behaviors transmit Mutans streptococci to children. It is 4 times more common than asthma and more than 40 percent of children have tooth decay by the time they reach kindergarten. AAP recommends fluoride varnish application every 6 months until 3 years of age.Even so only 4% of pediatricians apply fluoride varnish to the primary teeth of children 0-3 years of age. Because primary care providers are more likely than dentists to see very young, high-risk children, it makes sense to educate and train primary care providers on the risk of early childhood caries and other aspects of oral health.

Project Leader: Olivia Thomas, MD

Influenza causes significant morbidity and mortality worldwide. Cancer patients on chemotherapy are at a higher risk for influenza and its complications. Traditionally, vaccines have been avoided in cancer patients on therapy because it was thought their immunosuppression would prevent efficacy of the vaccine. National guidelines recommend Flu vaccine be given to cancer patients on chemotherapy. Recent data suggests cancer patients can make an immunologic response to the flu vaccine, suggesting that high vaccination rates might potentially reduce costs of care, morbidity, and mortality in this population.

Project Leader: Timothy Cripe, MD

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

Patients with cystic fibrosis (CF) are frequently exposed to ototoxic antibiotics increasing risk for hearing loss, related poor quality of life, and increased healthcare costs. Current improvement projects have increased initial hearing screening of patients, however, few patients with abnormal screening results have completed a full audiology evaluation.

Project Leader: Chandar Ramanathan, MD

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

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

Children with nephrotic syndrome are at increased risk for developing serious infections (peritonitis) and the Pneumovax vaccine is recommended to help reduce that risk.

Project Leader: Hiren Patel, MD

Delays in entry of weight cause delays in administering medications to patients requiring pain medications from fractures or in need of steroids/albuterol for asthma exacerbations. Inconsistent process causes delays in patient care and has potential for medication errors.

Project Leader: James Naprawa, MD

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

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

Child physical abuse is an important cause of morbidity and mortality in young children. The skeletal survey (SS) is considered a mandatory part of the evaluation for suspected physical abuse in young children. Literature suggests that a follow-up SS performed 10 to 21 days after the initial SS can provide important additional information, but previous studies evaluating the follow-up SS have been small and included very selective patient populations.

Project Leader: Jonathan Thackeray, MD

Patients who have delays in antibiotic administration have increased morbidity and mortality. Improved time to antibiotics can improve intubation times and decrease ICU and overall hospitalization stays. Patients who have indwelling medical devices are at risk for infection. Baseline endotracheal cultures can help guide treatment and identify new infections when patient status changes.

Project Leader: Jeremy Larson, MD

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

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

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

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

Treat Me with Respect is a Strategic Priority seeking to transform the patient experience by re-engineering how clinicians interact with families. To ensure the family will experience this, the section of Infectious Diseases is committed to Family Centered Rounds for all of our inpatients. Rounds allow patient-centered care planning, prevention of harm, improved patient outcomes and higher levels of patient satisfaction.

Project Leader: Dennis Cunningham, MD

The Heart Center patient population consists of complex patients resulting in a complex discharge process. The discharge process often includes multiple new medications, parental education on the feeding regimen, CPR teaching, & complex cardiac diagnoses, multiple follow up appointments need to be made, and newborn discharges require hearing screens, care seat trials, and immunizations be given. The Journey Board is a way to prepare families to go home by creating a check list of the tasks required prior to discharge. Standardizing the discharge process with the Journey Boards will hopefully result in a shorter hospital length of stay and a decreased readmission rate.

Project Leader: Brian Joy, MD

Single ventricle palliation interstage mortality is 12-15%. A formal inpatient “rooming in” process before hospital discharge can improve family comfort with home care, medications, and feeding for this complex high risk population.

Project Leader: Kerry Rosen, MD

Medication errors remain one of the primary causes of morbidity and mortality in the operating room. Given the increased prevalence of look-alike drug vials, appropriate labeling of syringes is mandatory in the operating room setting.

Project Leader: Joseph Tobias, MD

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

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

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