Children’s Affinity Group Coaching Webinar: Improving Safety for all Pediatric Patients

Tuesday, May 14, 201312:00 noon to 1:00 pm Central

Objectives

• Review opportunities to reduce harm for all pediatric patients

• Discuss specific strategies used to improve quality and safety

• Review lessons learned• Identify potential solutions for your

organization

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Welcome & Introductions

• Shannon McDonnell Woodford, MPH - HRET Program Manager

• Denise Remus, PhD, RN – Improvement Advisor, Cynosure Health

• Vicki Montgomery, MD, FCCM – Chief Women and Children’s Division of Patient Quality, Safety, and Clinical Innovation; Chief, Pediatric Critical Care Medicine, Kosair Children’s Hospital, KY

• Kelley Miller, RN, BSN, RNC – Charge Nurse NICU, Freeman Health System, Joplin, MO

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4https://www.facebook.com/EngledowArtPhotography

Kosair Children’s Hospital Who we are. . . • 22nd largest children’s hospital with 263 beds• Magnet designated hospital• University affiliated – University of Louisville School

of Medicine• 115,000 patient encounters/year• 1800 employees, 620 nurses• 70,000 patient days, 10,000 admissions, 60,000 ED

visits• 12,000 surgeries• 70,000 radiology cases• 1200 NICU and 1800 PICU admissions

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Creating Culture

• Good Catch– Of the month– Team of the Year– Rewards / Prizes– Let folks know what you are

doing with the safety reports

Hospital Acquired ConditionsClinical Innovation Teams

-MD-RN co-chairs-Multi-disciplinary teams

-Standardize the improvement tools-Mentor/coach for each team

-Clinical Analysis support-Measure baseline

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Pediatric Patient Safety – Opportunities to Improve

• Medication Safety• Impact of new EMR• Pediatric dosing• Bedside medication verification

• Tracking use, regular reporting to care areas• Formulary• Smart pumps and limiting choices• Weight only in kg• Minimal verbal orders

• Medication error with serious harm/death• Hand Hygiene – 5 Moments (WHO)

• Secret observers• Mislabeled specimens

Barriers and Solutions

Time for meetings

Metrics and Data Collection

Messaging, Creating importance

Scope creep-Charters, keeping each other focused-Definitions – stick to them

-Find somebody creative-Story telling-Graphs that are meaningful to folks at the bedside-Pick projects that are relevant, important to folks at the bedside

-Take the time to do it well-Surrogate measures when unable to easily and reliably measure what you want

-Utilize technology (teleconference, SKYPE, Facetime)-Pick a recurring time-Do as much work as possible during meetings

Examples of Messaging

-One every other day-Every event results in a child re-experiencing the procedure

-Mortality associated with a BSI in a critically ill child

Secure Airways For EveryoneThe SAFE ETTS Project

Sustaining change-Gather voice-Real time investigations-Share and learn

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Lessons Learned

• BE inclusive – include bedside staff• Include physicians, find physician champions• Message, message again, and then again

• Message fit the audience• Story telling is very powerful

• Talk safety every day. It will become important to everyone – eventually

• Make sure that every project is associated with a patient outcome metric – not just a measure of compliance with a regulation

Next Steps

• HAC teams – develop solutions, start trials (rapid cycle testing)

• Patient safety page, blog, newsletter

• Increase involvement of families and patients

• Medication Safety Oversight Board and sub-teams

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Contact Information

Vicki Montgomery, MDVicki.montgomery@louisville.edu

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Freeman Health System Joplin, Missouri

Hospital Story – Who we are. . .

• Freeman Health System located in Joplin, Missouri• 517-bed, three-hospital system providing

comprehensive healthcare and behavioral health services

• Since the May 22, 2011, tornado, Freeman has responded to increased patient volumes by enhancing current services and opening new facilities to stay ahead of the needs of our community.

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Current Hospital Wide Success

• Elective Induction <39 Weeks• Pressure Ulcer• VTE• CLABSI• Primary C-section Reduction• VAP

Our NICU• Level 3: Providing total body cooling, nitric

oxide, PDA ligation, and area transport• Only NICU of its kind in the region• 24 beds• Average 300+ admissions each year

– 23+ weeks gestation upon admission– Transport services of 100 miles covering 4 states

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Pediatric Patient Safety – Opportunities to Improve

Our Aim: To decrease the number of CLABSIs by 50% in the Neonatal population by Dec 31, 2013

Background• Average Umbilical catheter 2-7 days• PICC 10-30 days• NNPs primarily insert lines and perform dressing

changes on an as needed basis

Process Reviewed• Insertion to Discontinued Time.

• Culture of the Unit – “What more can we do?” and “I don’t have time for anything else”

• Buy in from other departments – Showing that the whole does impact the one.

• Need for equipment – Restricted in cost and availability

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Barriers Encountered

Issues Found• Bedside RN attaching all lines to C. line fluids• No dedicated CL Cart• Differences between NNPs dressings• Breaks in C Line for piggy back changes• Concentration issues with fluids making PIV more

fragile and difficult to maintain patency• Inferior caps protecting tubing tips.• Lack of equipment• Supplies and supply amts in circulation that were no

longer needed

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Solutions Implemented

• Changed concentrations of fluids. Decreased need for C. Lines. CLdevice days decreased

• RX prepares all C. Line fluids under sterile hood

• Utilized locking cap to ensure sterility of tubing tips

• Eliminated individual Piggy Back tubing for each med- one tubing for all meds and stays connected, changed every 24hours

Solutions Implemented• Implemented enhanced piggy back tubing • Utilized savings ($3,000-4,000) from eliminating

supplies to purchase new equipment • “Scrub the Hub” campaign• Dressing education using “correct vs. incorrect”

dressings. Standardized dressing changes • Dedicated Central Line Cart with modified Bundle

Checklist• Changed awareness of insertion procedure to one of

surgical procedure• Educated ancillary departments

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Lessons Learned

• Not a fast process. Some of the easiest ideas are the hardest to implement

• Get support from unlikely places.• Tap into cost savings to obtain improved

equipment/supplies• Sell the changes as an improvement in

staff life. Don’t look to blame.• If you want changes to happen, you have

to be the example.• Don’t be afraid to ask and to ask again.

In the Beginning…

Where we are!

535 device line days since last CLABSI.535 device line days since last CLABSI.March 2012- May 2013, 1 CLABSI (23 wk infant with septic mother at birth) March 2012- May 2013, 1 CLABSI (23 wk infant with septic mother at birth)

Next Steps

• Looking at research to support closing the unit for fluid changes

• Altering fluid delivery times• RN audits on “Scrub the Hub”.• Changing all tubing to new tubing

with clave• Timers on cart to ensure proper

drying prep times.

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Contact Information

Kelley L Miller RN, BSN, RNCEmail- KLMiller@FreemanHealth.com

Questions

Affinity Group – Collaboration Opportunities

• Join our dedicated LISTSERV!– Email hen@aha.org and request to be added to the

Children’s Affinity Group listserv

• Next webinar July 16th at 12pm Central• More events to be announced soon – stay

tuned!

• What questions or comments do you have about your affinity group or today’s webinar?

• Please remember to fill-out the evaluation. https://www.surveymonkey.com/s/XDQPHQW

Thank you!

Julie Zaura, Program ManagerPhone: 312-422-2614 Email: jzaura@aha.org | HEN@aha.org Website: www.hret-hen.org

Q&A and Evaluation