A Code Curriculum at Your Fingertips: Improving Performance and - - PowerPoint PPT Presentation

SLIDE 1

Alyssa Buono, MD-R, Kelli Davis, DO-R, Erin Ricker, MD

A Code Curriculum at Your Fingertips: Improving Performance and Resident Confidence in Pediatric Codes A Code Curriculum at Your Fingertips: Improving Performance and Resident Confidence in Pediatric Codes

Prisma Health – University of South Carolina School of Medicine

• 1. Anderson, L. W., Berg, K. M., Saindon, B. Z., Massaro, J. M., et al. (2015). Time to Epinephrine

and Survival After Pediatric In-Hospital Cardiac Arrest. Journal of American Medical Association, 314(8), 802-810.

• 2. Hunt, E. A., Duval-Arnould, J.M., Bembea, M.M., et al. (2018). Association Between Time to

Defibrillation and Survival in Pediatric In-Hospital Cardiac Arrest With a First Documented Shockable

• Rhythm. Journal of American Medical Association Network Open, 1(5):e182643.
• 3. Hunt, E. A., Jeffers, J., McNamara, L., Newton, H., et al. (2018). Improved Cardiopulmonary

Resuscitation Performance With CODE ACES: A Resuscitation Quality Bundle. Journal of American Heart Association.

• 4. Hunt, E. A., Walker, A. R., Shaffner, D. H., Miller, M.R., Pronovost, P. J. (2008). Simulation of In-

Hospital Pediatric Medical Emergencies and Cardiopulmonary Arrests: Highlighting the Importance

• f the First 5 Minutes. Pediatrics, 121(1), e34-e43.
• 5. Nadel, F.M., Lavelle, J.M, Fein, J.A., et al. (2000). Assessing Pediatric Senior Residents’ Training

in Resuscitation: Fund of Knowledge, Technical Skills, and Perception of Confidence. Pediatric Emergency Care, 16(2):73-76.

• 6. Pediatric Mock Code Toolkit. (2012). Retrieved from

https://www.luriechildrens.org/globalassets/documents/emsc/education/mockcode2nded20122.pdf.

• 7. Sam, J., Pierse, M., Al-Qahtani, A., et al. (2012). Implementation and Evaluation of a Simulation

Curriculum for Pediatric Residency Programs Including Just-In-Time In Situ Mock Codes. Paediatrics & Child Health, 17(2): e16-e20.

• 8. Tibbals, J. and Kinney, S. (2006). A Prospective Study of Outcome of In-Patient Paediatric

Cardiopulmonary Arrest. Resuscitation, 71(3), 310-318.

Introduction

• The incidence of pediatric cardiopulmonary arrests is low but the majority of pediatric

codes tend to have poor outcomes, with an average survival-to-discharge rate of 14- 36% 1,3,8

• Data suggests that a shorter time to epinephrine, initiation of chest compressions

and prompt defibrillation are critical to improve outcomes in pediatric codes 1,2

• Studies have demonstrated deficiencies in pediatric residents’ confidence and

knowledge in managing codes, and have identified a need for routine multidisciplinary mock codes 4,5,6,7

• Barriers include fear, anxiety, low exposure, and poor long term retention and

translation of annual PALS training to real or mock resuscitation 5,6

• At Prisma Health Children’s Hospital, a resident code curriculum was first initiated in

July 2018 which was shown to increase pediatric residents’ self-confidence and code quiz scores but no significant improvement in mock code times

Results Discussion

• The continuation of the resident code curriculum with the additional intervention of a

reference Code Quick Card was found to improve average time to CPR initiation (decreased by 21.5%), Zoll lead placement (decreased by 11.1%) and defibrillation. (decreased by 38.5%) in mock codes during 2019-2020 compared to 2018-2019

• Time to CPR initiation came close to meeting our target goal but there was wide

variability in performance for each mock code and no improvements were made in time to airway support or time to epinephrine

• While written code quiz scores improved across all resident classes by an average of

70%, survey results showed a more modest overall improvement among all pediatric residents in self-rated comfort leading a code by about 16%

• Residents identified the most common barriers to comfort leading a code as lack of

confidence in leadership, fear of mistakes, chaos in the room, difficulty establishing

• rganization, and concern for adequate rhythm analysis
• These results show promise for continued improvements in pediatric code performance

as well as residents’ self-perceived confidence with codes but suggests that the code curriculum should place stronger emphasis on highlighting the importance of these goals in the first several minutes of a code in both resident and multidisciplinary education Limitations

• Residents not consistently utilizing the Code Quick Card
• Buy-in by residents and support staff to treat simulated mock codes as reality, especially

during times of high patient volume and stress

• Need for increased exposure and education to code protocols for full healthcare team
• Disruption of code curriculum during COVID-19 pandemic

Future Directions

• Early introduction of Code Quick Cards with other pocket reference materials during
• rientation to increase awareness and utilization
• Focus on optimizing time-sensitive interventions in first several minutes of a code by

pausing, debriefing and restarting mock codes to allow team to correctly perform steps

• Coordination with nursing education to arrange more frequent multidisciplinary code

workshops and soft drills

Methods

• A Code Quick Card was designed to guide a pediatric resident’s immediate response

in the first several minutes of leading a code

• The Code Quick Card was distributed to pediatric residents in December 2019 and

residents were encouraged to use this reference for simulated or real codes for the rest of the year

• The existing Mock Code Curriculum was continued, including monthly written code

quizzes, scheduled code assessments, unscheduled multidisciplinary mock codes, a code skills workshop, and “soft drills” for nursing education

• For each mock code, time to Zoll lead placement, time to establishing airway, time to

initiation of CPR from pulselessness, time to defibrillation, and time to epinephrine administration were recorded and averages times were compared to last year’s results

• Pre- and post-surveys were administered to pediatric residents before and after the

Code Quick Card intervention to assess self-perceived confidence in leading a code and basic code knowledge (0 – no confidence, 10 – full confidence)

• Residence code quiz scores were averaged by class year

References Project Aim

Evaluate the effectiveness of adding a reference Code Quick Card to the pediatric residency Mock Code Curriculum on:

• 1. Improving time to onset of key interventions in a code including: time to epinephrine

administration (goal 2 min), CPR initiation (goal 1 min), airway support (goal 1 min), Zoll lead placement (goal 1 min), and defibrillation (goal 2 min)

• 2. Increasing resident self perceived confidence in running a code

Acknowledgements

This study was a continuation of the resident code curriculum quality improvement project by Katie Macmillan, MD, Mark Murry, DO, and Erin Ricker, MD from the 2018- 2019 academic year. We appreciate Dr. Ricker’s vital role in curriculum development, implementation and data collection. Thank you to all of the pediatric residents, nursing and respiratory therapist staff for participating in the code curriculum.

Figure 1: Pocket Code Quick Card, Front and Back Figure 3: Pre- and Posttest Comparison of Resident Comfort Level in Running a Code by Resident Class Figure 5: Average Resident Code Quiz Scores For Each Post-Graduate Year 2018-2019 2019-2020 Administered Epinephrine 05:27 05:30 Supported Airway 03:39 04:21 Zoll leads placed 06:56 06:01 CPR started 01:33 01:13 Defibrillation 12:47 07:51 Table 1: Comparison of Average Mock Code Intervention Times Figure 2: Time to Intervention From Cardiac Arrest in Mock Codes (s)

SLIDE 2

Discussion

Meghan Brown, MD; Joshua Godwin, MD; Stephanie Gibson, MD Comparison of Outcomes of Infants at Risk for NAS Utilizing the Eat, Sleep, Console Model versus the Modified Finnegan Scoring System: A Quality Improvement Project

Department of Pediatrics, USC-Prisma Health Richland Midlands

• 1. Hudak ML, Tan RC. Neonatal Drug Withdrawal. American Academy of Pediatrics.

https://pediatrics.aappublications.org/content/129/2/e540. Published February 1, 2012. Accessed January 18, 2019.1.

• 2. Kocherlakota P. Neonatal Abstinence Syndrome. Pediatrics. 2014;134(2).
• 3. Gareau, S., Lòpez-De Fede., A., & Finney, C. (2015). South Carolina newborn illicit substance use and Neonatal Abstinence
• Syndrome. A report created by the SC Birth Outcomes Initiative Data Committee for the SC Birth Outcomes Initiative

Behavioral Health Committee. Columbia, SC: University of South Carolina, Institute for Families in Society.

• 4. Finnegan L, Connaughton J, Kron R, Emich J. Neonatal abstinence syndrome: Assessment and management. Addict Dis.

1975;2:141–158.

• 5. Grossman MR, Lipshaw MJ, Osborn RR, Berkwitt AK. A Novel Approach to Assessing Infants With Neonatal Abstinence
• Syndrome. Hospital Pediatrics. 2017;8(1):1-6.
• 6. Blount T, Painter A, Freeman E, Grossman M, Sutton A. Reduction in Length of Stay and Morphine Use for NAS With the

“Eat, Sleep, Console” Method. Hosp Pediatr. 2019;9(8):615-623.

• 7. Honein M, Boyle C, Redfield, R. Public Health Surveillance of Prenatal Opioid Exposure in Mothers and Infants. Pediatrics

Mar 2019, 143 (3) e20183801

• 8. Moore BJ, Freeman WJ, Jiang HJ. Costs of Pediatric Hospital Stays, 2016 #250. https://www.hcup-

us.ahrq.gov/reports/statbriefs/sb250-Pediatric-Stays-Costs-2016.jsp. Published August 2019. Accessed April 24, 2020.

• 9. Jones HE, Jansson LM, O’Grady KE, Kaltenbach K. The relationship between maternal methadone dose at delivery and

neonatal outcome: methodological and design considerations. Neurotoxicol Teratol. 2013;39: 110-115.

• 10. Bogen, D. L., Hanusa, B. H., Baker, R., Medoff-Cooper, B., & Cohlan, B. (2017). Randomized Clinical Trial of Standard-

Versus High-Calorie Formula for Methadone-Exposed Infants: A Feasibility Study. Hospital Pediatrics, 8(1), 7-14.

Introduction

• Neonatal Abstinence Syndrome (NAS) is a multisystem disorder affecting

infants following abrupt cessation of certain pharmacologic agents at birth

• Common medicines associated with NAS include opiates, SSRIs,

Benzodiazepines and/or other illicit substances .

• Typical symptoms of NAS includes irritability, decreased sleep, tremors,

diarrhea, and poor feeding.

• NAS is rarely fatal, but is associated with adverse outcomes such as

seizures, & severe weight loss.

• In South Carolina, rates of infants with NAS increased from 0.09% to 0.39%

between 2000 and 2013.

• The Eat Sleep Console (ESC) protocol is being investigated as an alternative

method to assess and treat infants with NAS.

• Under the ESC model, infants are scored on their ability to sleep > 1 hour,

be consoled within 10 minutes, and eat > 1 oz per feed or breastfeed well.

• The ESC Model utilizes non-pharmacological treatment prior to escalation
• f therapy to Morphine, either PRN or scheduled.

Results

• Length of Stay:
• Morphine Doses:

Finnegan: avg 27.3 doses per infant (629 doses to 23 infants) ESC: avg 3.5 doses per infant (118 doses to 34 infants)

Discussion

• The ESC Model demonstrates an almost 4 day decreased length of

hospital stay in our nursery.

• Decreased length of stay can lead to subsequent decreased healthcare

costs (estimated cost of $563 million in 2014 for all NAS in US).

• More Morphine doses were required using the Finnegan model compared

to the ESC protocol by an average of 24 doses per infant.

• Increased Morphine use is likely associated with commitment to

scheduled Morphine protocol and lack of PRN doses.

• Use of PRN Morphine may be sufficient pharmacologic treatment for

symptom management, and it can contribute to a shorter hospitalization.

• Less weight loss in Finnegan Model appeared secondary to prolonged

hospital stay allowing BW to be regained.

• Consider tracking weight velocity/nadir or weight at a specific day of life

in future studies.

• All three readmissions under the ESC Model were found to be for causes

unrelated to NAS.

Limitations

• ESC Model relies on parent participation: Comprehension, caretaking

abilities, and motivation can vary greatly amongst parents.

• Small Sample Size
• Unsure of generalizability to larger nurseries & NICU population.

Future Directions

• Follow to see if results are sustainable over time and across a larger

sample size.

• Long-term developmental and psychiatric comorbidities in infants treated

according to the ESC model.

• Expansion of the ESC protocol to infants with additional comorbidities.

Methods

• Two-Tiered approach of ESC Model implemented based off previous studies

at Yale New Haven’s Children’s Hospital.

• Primary measures: (1) Length of Stay (2) # of Morphine doses
• Balancing measures: (1) 30-day readmission rates (2) % Weight

loss at discharge

• First PDSA cycle: ESC model implemented
• Second PDSA cycle: Concentrated supplemental formula to 24kcal
• Infants identified by: NAS diagnosis code & retrospective chart review.
• Total sample size (N=57) included:
• Infants managed by Finnegan model (N=23)
• Infants managed by ESC model (N=34)
• ESC Assessment (q3hrs x 5 days):
• Sleeping > 1 hour
• Consolable within 10 minutes
• Eating > 1 oz per feed or breastfeeding well

References Project Aim

• To evaluate the effectiveness of the Eat, Sleep, Console protocol compared

to the Modified Finnegan model in decreasing unnecessary Morphine use & length of stay in infants at risk for NAS in the Prisma Health Richland Midlands Level 1 and Level 2 nurseries.

Passed ESC Assessment Continue q3hrs Failed ESC Assessment Maximize non- pharmacologic treatment Passed reassessment Continue q3hrs Failed reassessment PRN Morphine

• 30-day Readmission Rate:

Finnegan Model: Zero readmission out of 23 infants ESC Model: 3 readmissions out of 34 infants.

• % Weight Loss at Discharge:

SLIDE 3

Paige Patterson, DO; Hollie Edwards, MD

The use of simulations to improve resident learning in hospital based scenarios: A quality improvement project

Prisma Health – University of South Carolina School of Medicine

• 1. Shetty, R., & Thyagarajan, S. (2016). Simulation in

pediatrics: Is it about time? Annals of Cardiac Anesthesia,19(3), 505-510.

• 2. Ojha, R., Liu, A., Rai, D., & Nanan, R. (2015). Review
• f Simulation in Pediatrics: The Evolution of a
• Revolution. Frontiers in Pediatrics,3(106), 1-6.

Introduction Despite studies that show that learning and knowledge retention is improved with simulation based learning, medical education continues to center around an apprentice based learning model. At Prisma Health Children’s Hospital, learning in the pediatric residency continues to be centered around a shadowing and apprenticeship model. A recent push has been made to implement mock code education for pediatric emergencies, however, there is still a gap in education when it comes to learning non- emergent hospital based medical scenarios through simulation. Results Discussion Resident learning was improved through the simulated cases and associated teaching. Residents also ranked the simulations highly in terms of their helpfulness for their learning and education. Residents additionally left comments on how beneficial and interesting the simulations were and requested more learning experiences like this. This study was successful because it improved resident performance on the simulation tests but also because it provided learning in a way that residents found to be interesting and helpful. Implications for Future Research There is a lot of room for growth of this project in the future as the simulation curriculum is continued at this program.

• It would be valuable to study the retention of

information after simulated learning as residents progress through the program.

• It would also be interesting to see if there is a

difference in retained learning based on the year of residency of each individual.

• Another outcome measure that could be tracked in the

future is the subjective comfort level of residents in approaching similar clinical scenarios due to their learning from the simulations. Methods

• Time was set aside for the residents to participate in

the simulations during each of their inpatient blocks.

• Residents took a pre-simulation test evaluating their

knowledge of the topic, completed the simulation with the high fidelity mannequin followed by a short teaching session, then answered the same questions in a post-simulation test.

• Pre and post-simulation test scores were averaged

and compared for improvement for each simulation topic.

• The post-test additionally surveyed how they would

rank the simulation in terms of helpfulness to their education on a scale from 1-10. References Project Aim This quality improvement project aimed to improve resident education through the institution of a simulation based learning curriculum that focuses on commonly encountered urgent inpatient clinical scenarios using high fidelity mannequins. The goal was for post simulation test scores to increase by 5% for each learning topic with a resident rating on the simulations of 8.0 or higher. For each of the four learning topics there were increases in average post simulation test scores. The simulations were all rated greater than 8.0 by residents in terms of helpfulness to their education.

SLIDE 4

April Hobbs MD, Dalton Renick DO, Melanie Blackburn MD

Stay Alert: A Quality Improvement in Response to SIRS/Sepsis in Pediatric Patients via Implementation of a Sepsis Alert Protocol

Prisma Health – University of South Carolina School of Medicine

Balamuth, Fran, et al. "Improving recognition of pediatric severe sepsis in the emergency department: contributions of a vital sign–based electronic alert and bedside clinician identification." Annals of emergency medicine 70.6 (2017): 759-768. "Fran Balamuth et al, “Improving Recognition of Pediatric Severe Sepsis in the Emergency Department: Contributions of a Vital Sign-Based Electronic Alert and Bedside Clinical Identification.” Annals of Emergency Medicine, published June 2, 2017 Emr, Bryanna M., et al. "Pediatric sepsis update: how are children different?." Surgical infections 19.2 (2018): 176-183. Randolph, Adrienne G., and Russell J. McCulloh. "Pediatric sepsis: important considerations for diagnosing and managing severe infections in infants, children, and adolescents." Virulence 5.1 (2014): 179-189. Mixon, Mark, et al. "Time to antibiotic administration: Sepsis alerts called in emergency department versus in the field via emergency medical services." The American Journal of Emergency Medicine (2020) Goldstein, Brahm, Brett Giroir, and Adrienne Randolph. "International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics." Pediatric critical care medicine 6.1 (2005): 2-8. Balamuth, Fran, et al. "Comparison of two sepsis recognition methods in a pediatric emergency department." Academic Emergency Medicine 22.11 (2015): 1298-1306.

Introduction

• Sepsis is the leading cause of death in pediatrics with delay in treatment

contributing to the high morbidity and mortality rates

• There are multiple studies implementing sepsis alerts within various emergency

departments across the nation; there are very few addressing the implementation

• f similar alerts within the inpatient setting, especially within pediatrics.
• A sepsis alert was initiated at Prisma Health Children's Hospital that combined lab

values, vital signs, and general appearance of a patient and notified nursing if a patient has triggered the alert (Goldstein criteria). This led to physician notification and ultimately a physician-nurse “huddle” to discuss necessity of intervention.

Results Discussion Methods

• The computer program assessed labs and vital signs for children on the 4th floor of

the Children’s Hospital. Parameters were put into place for vital signs, laboratory findings and nursing scales.

• Body temperature, white blood cell count, heart rate and respiratory rate were
• evaluated. If temperature or WBC were high or low based on pre-set ranges, the

system was triggered for a Systemic Inflammatory Response Syndrome (SIRS)

• alert. If there were 2 criteria out of range, the computer checked for organ

dysfunction, including cardiovascular, hematologic, hepatic, neurologic, renal and respiratory.

• If there was non-cardiac organ dysfunction noted, a Sepsis Alert was posted and if

2 or more organ systems involved or cardiac organ dysfunction, a Severe Sepsis alert was fired. Baseline Data Collected from September 1, 2019 – November 11, 2019. The algorithm was running within the EMR - however, the sepsis alert system had not been initiated to be visible by physician or nurses. PDSA Cycle 1

• Starting November 12, 2019, a protocol was put into place where the nurse

received a notification when there was a SIRS or Sepsis alert. The nurse then went through an algorithm which decided if there needed to be a Sepsis Huddle with the upper level resident taking care of the patient.

• During each huddle, the nurse and physician discussed the criteria which triggered

each alert, reviewed HPI, and performed a focused physical exam to decide if intervention was necessary.

• Retrospectively, the data was evaluated through chart review for total number of

alerts, type of alert, percentage of responses, time to intervention, and number of

• huddles. This post-data was gathered from November 12, 2019 through the end of

January 2020.

References Project Aim

Implement a sepsis alert protocol within the EMR at Prisma Health Children’s Hospital 4th floor. The first aim was to have a meeting between nurse and physician for 100%

• f patients that set off the alert. The second aim was to decrease the time to

escalation of treatment (if indicated) by 50% in patients who trigger the Sepsis Alert

• n CH4 within the two months following implementation.

Figure 1: SIRS/Sepsis Alert Patient Breakdown Figure 2: Percentage of SIRS/Sepsis Alerts That Drew a Response Figure 3: Average Time to Response The average response slightly increased from 24.9 to 26.7 minutes. Data collected prior to the implementation of the SIRS/Sepsis alerts showed that there was a 38% response rate to patients who met SIRS/Sepsis criteria. After the alert system was implemented, the response rate increased to 51.7%. It is important to note that some

• f the alerts did not necessarily require an intervention based on the information

regarding their current treatments at that time. There was no significant change in response time, however we did see a significant increase in response rate. It is also highly likely several poor outcomes may have been prevented but were undetectable through chart review. Post-data was only collected for only three months after the protocol was

• implemented. There is an obvious learning curve for the start of a new electronic tool

and therefore, further data collection should be obtained to assess its usefulness in the pediatric inpatient setting.

Limitations / Moving Forward

• Confounding factors that may have caused alerts, i.e. post-op pain, sickle cell

crisis

• Repeated SIRS/Sepsis alerts were noted to occur when additional lab values/vital

signs were documented although, interventions may have been previously implemented based off the initial alert. For example, fever and tachycardia

• ccurring 2 hours prior to labs being posted caused a SIRS alert, however, once

the abnormal lab values were documented later that day, another alert was initiated, despite previous intervention.

• In the future, it could be considered to implement a “Discussion and Plan” section

always present in the same location in the EMR where nursing documents not only that a discussion took place but what, if any, interventions took place.

SLIDE 5

Rachel Burch, MD PGY-2, Christina New, MD PGY-2, James Gambrell, MD

Back Is Best: Testing Parents’ Knowledge on Safe Sleep Practices

Prisma Health – University of South Carolina School of Medicine

• 1. “Infant Mortality.” Centers for Disease Control and Prevention, Centers for Disease

Control and Prevention, 27 Mar. 2019,

• 2. “Definitions.” American Sudden Infant Death Syndrome Institute, sids.org/what-is-

sidssuid/definitions/.

• 3. Infant Mortality and Selected Birth Characteristics: 2018 South Carolina Residence Data.

S.C Department of Health and Environmental Control. Nov. 2019, scdhec.gov/sites/default/files/Library/CR-012142.pdf.

• 4. Moon, Rachel Y

. “How to Keep Your Sleeping Baby Safe: AAP Policy Explained.” HealthyChildren.org, American Academy of Pediatrics, 10 Feb. 2020, www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe- Sleep.aspx.

• 5. Task Force On Sudden Infant Death Syndrome. “SIDS and Other Sleep-Related Infant

Deaths: Updated 2016 Recommendations for a Safe Infant Sleeping Environment.” Pediatrics, American Academy of Pediatrics, 1 Nov. 2016, pediatrics.aappublications.org/content/138/5/e20162938.

• 6. Dufer, Heather, and Kathleen Godfrey. “Integration of Safe Sleep and Sudden Infant

Death Syndrome (SIDS) Education among Parents of Preterm Infants in the Neonatal Intensive Care Unit (NICU).” Journal of Neonatal Nursing, Elsevier, 28 Sept. 2016, www.sciencedirect.com/science/article/abs/pii/S1355184116301107?via%3Dihub.

Introduction

As of 2017, SIDS related deaths are the 4th leading cause of sudden infant death in infants (1). SIDS is defined as the “sudden death of an infant under one years of age which remains unexplained after a thorough case investigation, including performance of a complete autopsy, examination of the death scene, and review of the clinical history” (2). Back in 2016, the AAP expanded their recommendations for safe sleep practices due to an increase in sleep related deaths in

• infants. It is important to model safe sleep practices for families while

patients are in the hospital in effort to promote safe sleep practices at home.

Results Discussion

Overall, we believe that this project had a positive impact on the safe sleep environment for our patients. We were able to surpass the goal

• f at least half of the caregivers surveyed scoring a 75% on the PSSQ

with 68% of caregivers scoring at least 75%. Through review of surveys it appears that parents struggle the most with identifying safe sleep surfaces compared to other guidelines of safe sleep practices. Weaknesses:

• Small Sample Size
• Only able to assess the knowledge of AAP recommended safe sleep

practices of the caregivers and not their comprehension due to the lack of a pre-test prior to education

• Did not formally assess if nursing education was completed at
• admission. It would have been beneficial to add a question to the

PSSQ asking if the educational handout was reviewed by nursing or providers throughout the hospital stay. Further Directions:

• Address safe sleep surfaces and other frequently missed questions

in more detail during nursing or provider education

• Ensure that the educational handout continues to be printed and

incorporated into all future children’s hospital admission packets on all floors, including the Cancer and Blood Disorder unit and the PICU, to provide appropriate education to all families or caregivers

• Increase sample size
• Provide Pretest prior to giving education

Methods

An educational handout, “The ABCs of Safe Sleep” was developed and included modified AAP recommendations for safe sleep practices. This document was approved by PRISMA Health and provided in the admission folder for all patients 1 year and under. Nurses were informed that the handout was added to the admission packet for the intention of review with families on admission. Parents then filled out the Parental Safe Sleep Questionnaire (PSSQ) prior to discharge to assess their knowledge of safe sleep practices.

References Project Aim

The goal of this project was to develop a standardized educational handout based off of current AAP guidelines to maximize safe sleep practices for infants up to 1 year of age and assess parent knowledge of safe sleep practices prior to discharge. Our goal is that at least half of parents or caregivers surveyed will score at least a 75% or greater on Parental Safe Sleep Questionnaire.

Figure 1: “The ABCs of safe sleep”

A total of 19 surveys were given during our data collection

• period. 68% of those surveyed scored at least a 75% or

greater on Parental Safe Sleep Questionnaire.

Acknowledgements

William Cooke and PRISMA Health Marketing for development of standardized handout

• Dr. James Gambrell for faculty advisement throughout project

Figure 2: Question 1 Figure 3: Question 2 Figure 4: Question 3 Figure 5: Question 4 Figure 6: Question 5 Figure 7: Overall Scores

SLIDE 6

Elizabeth Beaty, MD, PGY2, Heather Lynn, MD, PGY2, Melanie Blackburn, MD

Readmissions in Pediatrics: Results of a Resident-Aimed Quality Improvement Project to Reduce Readmission Rates at a Medium-Sized Academic Pediatric Hospital

Prisma Health – University of South Carolina School of Medicine

1 Markham JL, Hall M, Gay JC, et al. “Length of Stay and Cost of

Pediatric Readmissions.” Pediatrics. 2018; 141 (4): e20172934

2 Flippos R, NeSmith E, Stark N, et al. “Reduction of 30-Day

Preventable Pediatric Readmission Rates with Postdischarge Phone Calls Utilizing a Patient- and Family-Centered Care Approach.” Journal of Pediatric Health Care. 2015; 29 (6): 492-500

3 Berry JG, Hall DE, Kuo DZ, et al. “Hospital Utilization and

Characteristics of Patients Experiencing Recurrent Readmissions Within Children’s Hospitals.” JAMA. 2011; 305 (7): 682-690

4 Berry JG, Toomey SL, Zaslavsky AM, et al. “Pediatric

Readmission Prevalence and Variability Across Hospitals.”

• JAMA. 2013; 309 (4): 372-380

5 Coller RJ, Klitzner TS, Saenz AA, et al. “Discharge Handoff

Communication and Pediatric Readmissions.” Journal of Hospital Medicine. 2017; 12 (1): 29-35

6 Kansagara D, Englander H, Salanitro A, et al. “Risk Prediction

Models for Hospital Readmission: A Systematic Review.”

• JAMA. 2011; 306 (15): 1688-1698

7 Auger KA, Shah SS, Tubbs-Cooley HL, et al. “Effects of a

1-Time Nurse-Led Telephone Call After Pediatric Discharge: The H20 II Randomized Clinical Trial.” JAMA Pediatrics. 2018; 172 (9): e181482t

Introduction

➢ Studies have shown that $17.4 billion dollars are spent

• n preventable readmissions 2.

➢ There are several characteristics that put patients at risk for readmission. ○ Chronic medical conditions ○ Age 13-18 ○ Non-Hispanic Black race ○ Public Insurance ➢ Additionally, it has been found that a small group of patients, approximately 2%, account for 18% of admissions to pediatric hospitals 3, 4. ➢ Few interventions have been successful to prevent readmissions in the pediatric population 5-7. ➢ Goal of Project - in coordination with Prisma Health Children’s Hospital Midlands Readmissions QI Team: ○ Primary outcome: to reduce the rate of inpatient readmissions within a 30-day period by 10% by March 2020 through the implementation of standard discharge instructions for specific diagnoses. ○ Secondary outcome: to collect data aimed to identify the role of patient and resident demographics on the impact of readmissions in a 30-day time period.

Results

• July 2018 - March 2019: 5,604 discharges and 49 readmissions
• July 2019 - March 2020: 5,774 readmissions and 236 discharges

Discussion

➢ No statistically significant difference in the rate of readmissions with the use of Discharge Smart Phrases ➢ No statistically significant changes in the number of patients readmitted with comorbid conditions, percentage

• f discharges who received discharge instructions, use of

the Discharge Smart Phrases, rate of scheduled follow up, percentage of private versus resident clinic patients, or percentage of patients readmitted with Medicaid insurance ➢ Strengths: ○ One of the first studies looking at the impact of resident- aimed interventions on readmissions ○ Utilized data from the EMR looking at all 7 and 30 day readmissions which resulted in a large sample size ○ Created a set of standardized discharge instructions ➢ Weaknesses: ○ Limited generalizability ○ The process for data collection on pediatric readmissions changed ○ Off service residents did not receive the same education ➢ Potential future projects: ○ Implementation of recurrent resident education on the importance of proper discharge instructions ○ Education for off service residents ○ Tracking the rate of adherence to standardized discharge instructions after receiving formalized education. ➢ Even though, there was no reduction in the rate of readmissions, a more standardized approach to discharge instructions was created through the use of Discharge Smart Phrases.

Methods

➢ Project took place from July 2018 to March 2020. ➢ Data from July 2018 to March 2019 was utilized for baseline data. ➢ Inclusion Criteria ○ Admission/ readmission to general pediatric inpatient service ○ Admission/ readmission to pediatric critical care service ○ Patient discharged from the neonatal intensive care unit or newborn nursery by a general pediatric resident and readmitted to the general pediatric inpatient service. ➢ Exclusion Criteria ○ Primary admission to the pediatric hematology/oncology ○ Primary admission to the pediatric surgery services ○ NICU or newborn discharge done by a team other than the general pediatric residents. ○ Admission under a private pediatrician who had admitting privileges to the hospital. ➢ Intervention = creation of Discharge Smart Phrases sent July 2nd, 2019, when the new intern class started and on January 6th, 2020. ➢ Postdata was collected from July 2019 to March 2020. ➢ Data analysis was performed using a Fisher exact test to compare the pre and post-intervention groups. Results are shown in Table 1.

References Project Aim

The purpose of this project was to reduce the rate of inpatient 30-day readmission by 10% by March 2020 through the implementation of standard discharge instructions for specific diagnoses.

SLIDE 7

Long Winded: : A Quality Improvement Project to Increase the Usage and Understanding of Asthma Action Plans in the Pediatric Inpatient Setting

Thank you to Gabrielle Amarante, DNP, CPNP-BC, who graciously allowed us to use the action plan that she constructed. Also, thank you to Dr. Heather Staples for guiding me through this process.

Introduction

• Asthma affected more than 5.5 million children and adolescents in the US in

2018

• Leading cause of admission in SC1.
• Low health literacy is associated with worse asthma outcomes2,3
• Our action plans were rated above a 7th grade reading level
• Language barriers contribute to health literacy
• 41% of minority patients in our area speak Spanish9
• Studies have proven that Asthma Action Plans (AAPS) improve health care
• utcomes.4,5
• Our pediatric residents encountered several barriers to providing each

discharged patient with an AAP

Results Discussion

This project led to an improvement in the frequency of asthma action plans provided to discharged asthma patients despite missing our projected goal of 100%. With the decreased reading level of the new asthma action plan, we provided information at a more attainable reading level. Additionally, residents reported not

• nly more consistent distribution of AAPs, they also were educating the patients

and their families more regularly prior to discharge. Strengths:

• The new format of the action plan used in this study improved resident

compliance and decreased the time spent filling out the plans.

• This plan was easy to implement, had minimal risk to patients, and had plenty of

buy-in from the residents. Weaknesses:

• It was difficult to determine the true number of plans provided as calculations

were not based off EMR documentation.

• There was a small sample size for the data collection and post-intervention

patient follow up was over a limited project time frame. These results reemphasized that low literacy, updated and customized plans can help asthmatic patients and their families better understand their disease and manage medications, leading to improved control. Written, individualized action plans should be used in conjunction with asthma teaching for every patient encounter.4, 7

Methods References Project Aim

0% 10% 20% 30% 40% 50% 60% 70% 80% Pre-Intervention PDSA-1 PDSA-2 RESIDENT SURVEY ON FREQUENCY AND UNDERSTANDING OF AAPS Giving out AAP >75% of the time Teaching to families >75% of the time Families understanding >75% of the information 0% 10% 20% 30% 40% 50% 60% 70% 80% Pre- Intervention PDSA-1 PDSA-2 MOST COMMON BARRIER TO RESIDENT COMPLIANCE Forgetting to give the plan Time contraints

The goal of this quality improvement project was to improve the frequency of delivery and patient understanding of asthma action plans being given to patients admitted to the Children’s Hospital. We aimed to provide an updated, customized, low literacy action plan to 100% of the patients admitted with an asthma-related illness between January 2020 to March 2020.

• Baseline Data: All residents completed a pre-survey assessing the percentage of

patients to whom AAPs were provided at discharge, who were educated about their asthma and AAP by the resident and any perceived barriers to providing the plans to patients.

• A low literacy, fillable, and colored plan developed by Gabrielle Amarante, DNP, CPNP-

BC was used

• Flesch-Kincaid Grade Level for the document was 5.9.6
• Residents were taught how to use the action plan, correct dosing, and usage of

medications during a resident lunch lecture.

• They were printed in color and in both English and Spanish.
• They were placed in a brightly colored and labeled folder in a visible place in the

inpatient resident work room.

• PDSA-1: Ran from Jan-Feb 2020, where inpatient residents were reminded of the

AAPs weekly.

• A post survey was then provided.
• PDSA-2: Ran from Feb-March 2020, with a new group of inpatient residents who were
• nly reminded once of the AAPs.
• A post survey was provided.
• Data was analyzed in Excel.

Acknowledgements

• 1. CDC.gov. (2018) CDC- Asthma- Most Recent Asthma Data. National Current Asthma Prevalence from the National Health

Interview Survey NHIS 2016-2018. https://www.cdc.gov/asthma/most_recent_national_asthma_data.htm

• 2. DeWalt DA, Dilling MH, Rosenthal MS, Pignone MP. Low parental literacy is associated with worse asthma care measures in
• children. Ambul Pediatr. 2007;7(1):25–31
• 3. Adams RJ, Appleton SL, Hill CL, Ruffin RE, Wilson DH. Inadequate health literacy is associated with increased asthma

morbidity in a population sample. J Allergy Clin Immunol. 2009;124(3):601–603

• 4. Agrawal, SK, et al. Efficacy of an individualized written home-management plan in the control of moderate persistent

asthma: a randomized, controlled trial. Acta Paediatr. 2005 Dec; 94(12):1742-6.

• 5. Gibson PG, Powell H. Written action plans for asthma: an evidence-based review of the key components.

Thorax 2004;59:94-99. https://thorax.bmj.com/content/59/2/94

• 6. Flesch- Kincaid Grade Level Score. https://readabilityformulas.com/flesch-grade-level-readability-formula.php
• 7. Yin, H.S., Gupta, R.S., Mendelsohn, A.L., Dreyer, B., van Schaick, L., Brown, C.R., . . . & Tomopoulos, S. (2017). Use of a low

literacy written action plan to improve parent understanding of pediatric asthma management: A randomized controlled

• study. Journal of Asthma, 54(9), 919-929. http://dx.doi.org/10,1080/02770903.2016.1277542
• 8. Asthma and Allergy Foundation of America (AAFA) (2018). Asthma facts and figures. Retrieved from http://www.aafa.org/page/asthma-

facts.aspx

• 9. DHEC Bureau of Community Health and Chronic Disease Prevention (2015). Asthma in South Carolina: Common, costly, and climbing.

Retrieved from https://dc.statelibrary.sc.gov/bitstream/handle/10827/19498/DHEC_Asthma_in_SC_2015- 05.pdf?sequence=1&isAllowed=y.