scholarly journals Ultrasound guidance for pediatric vein cannulation: an emergency nurse quality improvement initiative and registry

2020 ◽  
Vol 43 (2) ◽  
pp. 8-9
Author(s):  
Domhnall O Dochartaigh ◽  
Christopher Picard ◽  
Warren Ma ◽  
Richard Drew ◽  
Tahira Daya ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Pediatric Patients ◽  
Linear Increase ◽  
Lessons Learned ◽  
Quality Improvement Initiative ◽  
Independent Practice ◽  
Ultrasound Guided ◽  
University Of Alberta ◽  
First Pass ◽  
Trained Staff

Background Between 10 and 25 percent of pediatric patients present to the emergency department (ED) with difficult to cannulate veins. Recent RCT evidence suggests that in pediatric patients assessed at being a predicted difficult IV start (by DIVA score of 3 or more), ultrasound guided catheter placement decreased the number of IV attempts, decreased time to successful IV placement, and improved first pass success, patient satisfaction, and catheter dwell time. Our QI project examines the specific learnings around ultrasound guided peripheral IV in pediatric patients and suggests opportunity for non-pediatric specialist hospitals to consider with the overall aim of minimizing IV attempts on all pediatric patients within our EDs. Building on a RCT led by Dr Curtis in pediatrics patients conducted at the Stollery from 2012-2014, a standardized ultrasound guided nurse performed procedure was implemented in 2016 at the University of Alberta and Stollery EDs, and expanded to the Royal Alexandra ED in 2017 and the Misericordia ED in 2019. Using the same education package and QI study methodology as previously reported in adult patients this study focused specifically on pediatric patients. Methods A quality improvement (QI) registry was utilized to track complications and success of pediatric patients at all sites. The aim was to assess for program success, and improve education, training, and procedural success as required. Staff who had achieved independent practice voluntarily completed a tracking form whenever an ultrasound procedure occurred. Completed forms were assessed on a continual basis for any opportunities for improvement. Qualitative feedback was also obtained from informal interviews, a focus group, and a survey of the trained nurses. Feedback was thematically analyzed and grouped into themes for reporting. Results There were no reported pediatric UGIV placed at the MCH and RAH during the study period. At the Stollery 126 cases were reported. Immediate insertion complications were noted in three cases as ‘pain or swelling at site’, and ‘unable to advance catheter’. In the first and second years of data collection the average number of traditional IV attempts prior to UGIV attempt decreased from 3.9 to 2.8; first ultrasound pass success increased from 65% to 86%; overall ultrasound success improved from 85% to 97.6% respectively. Increasing nurse skill was significant with a linear increase of first pass and overall success seen with increasing number of ultrasound starts: From 6-20 starts (54% first pass 64% overall success) through to >150 starts (97% first pass and 100% overall). QI staff feedback included ensure adequate pediatric specific supplies such as longer length small gauge catheters, and a procedural focus of patient, provider, and assistant set up. Location of IV placement was noted to change in a number of cases from hand and A/C to forearm. Advice and Lessons Learned The key for staff to transition to procedural competance was to ensure initial and ongoing oportunities to place many ultrasound guided IVs (i.e. when time allows in all patients with non-optimal IV placement locations or with non-easy predicted tradititional IV starts) Further work is required at non specilaist hospitals with trained staff to increase ultrasound guided use in pedatric patients At all particapting sites work continues on unit level QI to minimize the number of IV attempts on all pedatric patients as well as work towards a cohort of available staff that are comforable and competent with ultrasound that can provide 24/7 unit coverage. (with limited numbers of trained staff there is increase burden on these staff to assist others while also completing their own nursing assignment.

scholarly journals Emergency nurse use of ultrasound guidance for vein cannulation: a three site quality improvement initiative and registry

2020 ◽  
Vol 43 (2) ◽  
pp. 6-7
Author(s):  
Domhnall O Dochartaigh ◽  
Warren Ma ◽  
Christopher Picard ◽  
Richard Drew ◽  
Matthew Douma
Keyword(s):  
Quality Improvement ◽  
Vascular Access ◽  
Independent Practice ◽  
Peripheral Vascular ◽  
Ultrasound Guided ◽  
Quality Registry ◽  
Program Success ◽  
Qualitative Feedback ◽  
First Pass ◽  
Procedural Success

  Background   AHS suggests a limit of four attempts at traditional peripheral vascular access, however there are limited current options at many sites for these patients. Between 10 and 25 percent of patients present to the emergency department (ED) with difficult to cannulate veins. In these patients ultrasound guided catheter placement decreases the number of IV attempts, decreases time to successful IV placement, improves patient satisfaction, and in adult patients decreases central line use. Emergency nurses have been shown to successfully employ ultrasound-guided peripheral vascular access. Physician and Nursing clinical practice guidelines place a high recommendation for this practice. Despite the evidence and recommendations, in Canadian EDs, with notable exceptions there remains minimal standard procedural uptake or ED research.   Implementation For difficult peripheral intravenous access a standardized ultrasound guided nurse performed procedure was implemented in 2016 at the University of Alberta (UAH) ED, in 2017 to the Royal Alexandra Hospital (RAH) ED, and in 2018 the Misericordia Community Hospital (MCH) ED. An education module was created that included didactic learning and an exam, approximately one hour of in-person training which included vessel and structure identification and cannulation practice on a gel model until competence was achieved, and finally three successful mentored starts prior to independent practice. Mentorship ensured good technique was followed, provided additional tips to improve practice, and most importantly ensured an IV attempt was on a patient with veins amenable to a novice ultrasound provider attempt (e.g. if a patient was assessed to be a challenging ultrasound start with limited vein options the mentor would place the IV in much the same way as traditional IV placement mentoring). The ultrasound technique taught was a single operator, short access or traverse approach with dynamic tip tracking where the catheter needle tip is continually visualized as the target vessel is cannulated. Catheter placement is confirmed with the catheter tip visualized intraluminal and with an ultrasound visualized saline flush. This study reports on the first 30 nurses trained at the UAH, 12 at the RAH and 6 at the MCH.   Evaluation Methods A quality improvement (QI) registry documented complications and was used to improve education, training, and procedural success. The two QI study objectives were 1) to determine ultrasound program success for all sites by comparing QI results to historic results from other programs 2) to determine if an abbreviated training regimen (shorter than previously documented for adult patients in Canada) can be used to train nurses in EDs with minimal support or pre-existing experience with UGIVC. Staff who had achieved independent practice voluntarily completed a tracking form whenever an ultrasound procedure occurred. Completed forms were assessed on a continual basis for any opportunities for improvement. Qualitative feedback was also obtained from informal interviews, a focus group, and a survey of the newly trained nurses. Feedback was thematically analyzed and grouped into themes for reporting. Data and trends from the registry were used to reinforce education to promote greater procedural success. Also identified were questions to add to the tracking form to improve the usefulness of the registry. Ongoing review will identify if these efforts improve practice. Opportunities for system improvements were managed through consultation with all stake holders including nursing management, CNEs, physicians, and bedside nurses. Program evaluation will shape all aspects of the program development.   Results At the UAH, RAH, and MCH respectively; the mean number of failed IV attempts [SD] before UGIV was: 4.2 [2.5]; 3.4 [2.1]; 4.77 [2.9]; while first pass success by novice provider (1-10 UGIV starts) was 76%; 66%; and 62%. Success increased rapidly with the number of starts and plateaued after 100. Complications occurred in 4/374 (1%) starts. Qualitative feedback suggests that provider and patient positioning, and equipment preparation improve individual success; engaged staff and a QI registry improve program success; even in cases with more reported pain, patients prefer UGIV to traditional placement.  Advice and Lessons Learned  Creating an ultrasound guided peripheral IV program and quality registry that supports emergency nurse use of this procedure is possible. First pass and overall catheter success rates and low reported compilications are reassuring. The quality registry has provided useful data to support practice and suggest modifications to the education and site specific system level supports provided. An example of system feedback is that newly trained staff need to have a clinical assignment that allows the opportnuity to utilize the procedure. Also enough mentors are required to support new staff. A third interesting system issue identifed is the possible effects of the training on traditional difficult IV placement skill and how to best support this. Emergency physicians and nurse champions can play a key supportive role to ensure the success of the program.

A Multidisciplinary Quality Improvement Initiative to Facilitate Penicillin Allergy Delabeling Among Hospitalized Pediatric Patients

2021 ◽  
Vol 11 (5) ◽  
pp. 427-434
Author(s):  
Maureen Egan Bauer ◽  
Christine MacBrayne ◽  
Amy Stein ◽  
Justin Searns ◽  
Allison Hicks ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Pediatric Patients ◽  
Penicillin Allergy ◽  
Quality Improvement Initiative

scholarly journals GETTING TO YES . . . I WILL RESPOND: CHALLENGES AND SUCCESSES SURVEYING AGING SERVICES PROVIDERS TO PRODUCE QUALITY DATA

2019 ◽  
Vol 3 (Supplement_1) ◽  
pp. S582-S582
Author(s):  
Lauren Harris-Kojetin
Keyword(s):  
Quality Improvement ◽  
Assisted Living ◽  
Academic Research ◽  
Response Rates ◽  
Lessons Learned ◽  
Research Network ◽  
Research Quality ◽  
Quality Data ◽  
Quality Improvement Initiative ◽  
Aging Services

Abstract Voluntary surveys of aging services providers are important data sources for research, quality improvement, and program evaluation efforts to inform evidence-based decision making. Ideally, provider surveys—a type of establishment survey—offer valuable information on providers and services users. However, decreasing survey response rates in recent years raise data quality concerns. This symposium highlights challenges leading to lower response rates (e.g., time constraints, skepticism, confidentiality concerns, getting to the correct respondent); specific data collection techniques tested, what did and did not work, and lessons learned. Although the surveys focus on long-term services and supports (LTSS) providers (e.g., assisted living) and services users (e.g., residents), the session is generalizable to other establishment surveys. Presenters bring extensive survey experience and diverse organizational perspectives—academic research center, national provider association, federal statistical agency, and research contractor. Over the years, the presenters have used their research network to share challenges and lessons learned with each other, which addresses the GSA conference theme, “Strength in Age: Harnessing the Power of Networks.” The first presentation describes test results of a state survey protocol to obtain sampled resident information from assisted living providers. The second presentation examines approaches to increase provider participation in a quality improvement initiative. The third presentation discusses efforts to address response challenges in an on-going national survey of providers in two LTSS sectors. The session allows time for and facilitates interaction with audience members to share their insights and lessons learned.

scholarly journals A standardized protocol to reduce preoperative hypothermia in pediatric spinal fusion surgery: a quality improvement initiative

2021 ◽  
pp. 1-4
Author(s):  
Katrina Ducis ◽  
R. Dianne Seibold ◽  
Tylyn Bremer ◽  
Andrew Jea
Keyword(s):  
Quality Improvement ◽  
Spine Surgery ◽  
Surgical Procedure ◽  
Pediatric Patients ◽  
Subcutaneous Fat ◽  
Surgical Patients ◽  
Quality Improvement Initiative ◽  
Spinal Fusion Surgery ◽  
Increased Risk ◽  
Spinal Deformity Surgery

OBJECTIVEHypothermia in adult surgical patients has been correlated with an increase in the occurrence of surgical site wound infections, increased bleeding, slower recovery from anesthetics, prolonged hospitalization, and increased healthcare costs. Pediatric surgical patients are at potentially increased risk for hypothermia because of their smaller body size, limited stores of subcutaneous fat, and less effective regulatory capacity. This risk is exacerbated during pediatric spinal surgery by lower preoperative temperature, increased surface exposure to cold during induction and positioning, and prolonged surgical procedure times. The purpose of this quality improvement initiative was to reduce the duration of hypothermia for pediatric patients undergoing spine surgery.METHODSDemographic and clinical data were collected on 162 patients who underwent spinal deformity surgery between October 1, 2017, and July 31, 2019. Data points included patient age, gender, diagnosis, surgical procedure, and temperature readings throughout different phases of perioperative care. Temperatures were obtained upon arrival to the day of surgery, upon presentation to the operating room, during prone positioning, at incision, and at the end of the procedure. Twelve patients were analyzed prior to implementation of a protocol, while 150 patients composed the post-protocol group.RESULTSUsing descriptive statistics, the authors found that the average body temperature at the time of incision was 34.0°C prior to the adoption of a preoperative warming protocol, and 35.3°C following a preoperative warming protocol (p = 0.001). There were no complications, such as burns, hyperthermia, or arrhythmias, related to preoperative warming of patients.CONCLUSIONSThe placement of a warming blanket on the bed prior to patient arrival and actively targeting normothermia reduced the incidence and duration of hypothermia in pediatric patients undergoing spine surgery with no adverse events.

scholarly journals Optimizing Pediatric Esmolol Dosing Using Computerized Practitioner Order Entry

2014 ◽  
Vol 19 (4) ◽  
pp. 302-309
Author(s):  
Tihua Chao ◽  
James C. Perry ◽  
Gale L. Romanowski ◽  
Adriana H. Tremoulet ◽  
Edmund V. Capparelli
Keyword(s):  
Intensive Care ◽  
Quality Improvement ◽  
Pediatric Patients ◽  
Vital Signs ◽  
Therapeutic Targets ◽  
Systemic Hypertension ◽  
Quality Improvement Initiative ◽  
Concurrent Administration ◽  
Protocol Adherence ◽  
Target Effect

OBJECTIVES: The aims of this study were to 1) describe the cardiovascular dose-response of esmolol and dose-limiting adverse effects in pediatric patients; 2) assess an institutional guideline for protocol adherence, efficacy, and achievement of therapeutic targets for pediatric patients with tachyarrhythmias or systemic hypertension; and 3) revise the protocol accordingly. METHODS: In this prospective study, pediatric/neonatal subjects were identified using a medication utilization report in the electronic medical record and treated with esmolol for blood pressure or rhythm control at Rady Children's Hospital San Diego between November 1, 2012, and February 28, 2013. Inclusion criteria required subjects to be under intensive care and have bedside telemetry monitoring. Data collection consisted of patient demographic information, administration history of esmolol, concurrent administration of other cardiovascular medications, patient cardiovascular goals, and vital signs. RESULTS: A total of 8 subjects representing 10 administrations of esmolol were included in the study. Whereas esmolol was found to be safe and effective overall for control of hypertension and tachyarrhythmia, protocol adherence was poor, leading to subtherapeutic dosing schemes, dose changes prior to achievement of presumed steady-state pharmacokinetics, and erratic dosing to target effect. CONCLUSIONS: After the review, the data were revealed at a program-wide conference and consensus was reached on a new, data-driven protocol. As a result of this quality improvement initiative, the new protocol provides more precise dosing and clearly delineated therapeutic targets and is designed to reflect specific esmolol pharmacokinetics. The effort emphasizes the need to construct foundations for follow-up quality improvement efforts in intensive care pharmacology.

Developing a hospital quality improvement initiative in Lesotho

2014 ◽  
Vol 27 (1) ◽  
pp. 15-24 ◽  
Author(s):  
Joshua Berman ◽  
Elizabeth Limakatso Nkabane ◽  
Sebaka Malope ◽  
Seta Machai ◽  
Brian Jack ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Health Care Systems ◽  
National Level ◽  
Hospital Staff ◽  
Steering Committee ◽  
Lessons Learned ◽  
Quality Improvement Initiative ◽  
Content Type ◽  
Skill Sets ◽  
Care Systems

Purpose – Hospital-based quality improvement (QI) programs are becoming increasingly common in developing countries as a sustainable method of strengthening health systems. The aim of this paper is to present the results and lessons learned from a QI program in a large, rural, district hospital in Lesotho, Southern Africa. Design/methodology/approach – Over a 15-month period, a locally-relevant, hospital-wide QI program was developed and implemented. The QI program consisted of: planning meetings with district and hospitals staff; creation of multi-disciplinary QI teams; establishment of a QI steering committee; design and implementation of a locally appropriate QI curriculum; and monthly consultation from technical advisers. Initial QI programming was developed in three distinct areas: maternity care, out-patient care, and referral systems. Findings – Partogram documentation in the maternity department increased by 78 percent, waiting time for critically ill patients in the out-patient department was reduced by 84 percent, and emergency referral times were reduced by 58 percent. Originality/value – The design and early implementation of QI programs should focus on easily achievable, locally-relevant improvement projects. It was found that early successes helped to fuel further QI gains and the authors believe that the work building sustainable QI skill sets within hospital staff could be useful in the future when attempting to tackle larger national-level quality of care indicators. The findings add to the existing evidence suggesting that an increased use of locally-relevant quality improvement programming could help strengthen health care systems in low resource settings.

scholarly journals 16. An Ambulatory Quality Improvement Initiative to Optimize Influenza Vaccination Amongst Adults Living with HIV During the COVID-19 Pandemic

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S132-S133
Author(s):  
Deborah A Kahal ◽  
Christopher James ◽  
Brian Wharton ◽  
Sherine Eaddy ◽  
Elizabeth Gaines ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Influenza Vaccination ◽  
Vaccination Coverage ◽  
Lessons Learned ◽  
Virtual Space ◽  
Quality Improvement Initiative ◽  
People Living With Hiv ◽  
Vaccination Rates ◽  
Increased Risk ◽  
Living With Hiv

Abstract Background Seasonal influenza vaccination decreases individual and population-level morbidity and mortality, mitigates risk of acquiring influenza-like illness, and prevents healthcare system overburdening. Vaccination is important for people living with HIV (PLWH) who have increased risk for severe disease, hospitalization, and poor outcomes. Moreover, influenza vaccination has been associated with decreased COVID-19 mortality in older patients. Historical annual adult influenza vaccinations rates at the study site were 65%, exceeding local and national benchmarks. Amidst COVID-19, we recognized a need to increase influenza vaccination rates. Methods A multifaceted, bundled quality improvement (QI) initiative aimed to achieve ≥ 80% influenza vaccination coverage for the 2020-21 season in PLWH ≥18 years of age at our Wilmington site (N=750). Stakeholders were identified, and a voluntary multidisciplinary team formed to lead the initiative (Fig. 1). Fishbone diagram outlined clear, rapidly implementable, and reproducible levers for change (Fig. 2). Physical and virtual space changes included: diverse clinical displays (visuals, patient materials), phone messaging, and virtual platform use. Staff education and updates were consistently provided by the team. Institutional Review Board exemption was received, and electronic medical record and CareWare data were extracted from 1 Oct 2020 through 31 March 2021. All external vaccinations were confirmed. Overall and eligible in-clinic vaccination rates were updated and displayed weekly. Results 86% vaccination coverage was achieved (Fig. 3) with a median weekly in-clinic vaccination rate of 67% (Fig. 4). Conclusion A QI project to improve 2020-21 influenza vaccination rates exceeded our goal in adult PLWH at an urban mid-Atlantic HIV clinic during the COVID-19 pandemic. A multidisciplinary approach that engaged stakeholders was vital to success. Rapid roll-out of changes was challenging, requiring flexibility and clear communication. Data collection was consistent, albeit imperfect, and needs enhancement. Elucidating the effects of each change and the COVID-19 pandemic on vaccination rates is not yet known. Lessons learned may be applicable to other ambulatory settings and will inform future vaccination efforts. Disclosures Deborah A. Kahal, MD,MPH, FACP, Gilead (Speaker’s Bureau)Viiv (Speaker’s Bureau)

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