Learning from Each Other: A Multisite Collaborative to Reduce Electrolyte Testing

Coe, Megan; Gruhler, Heidi; Schefft, Matthew; Williford, Dustin; Burger, Barrett; Crain, Emily E.; Mihalek, Alexandra J.; Santos, María M.; Cotter, Jillian M.; Trowbridge, Gregory; Kessenich, Jeri; Nolan, Mark; Tchou, Michael J.

doi:10.1097/pq9.0000000000000351

Cited by 4 publications

(11 citation statements)

References 31 publications

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“… 29 Assessing the health of their work environment will enable cardiovascular program leaders to evaluate targeted improvement strategies focused on any of the six AACN HWE standards, thus improving the health of their work environment in a meaningful and rapid manner. 29 Involving frontline staff and interprofessional stakeholders is critical to the success of these initiatives. Multiple disciplines must collaborate in the perioperative area to provide high-quality, safe care.…”

Section: Discussionmentioning

confidence: 99%

Measuring the Interprofessional Health of the Pediatric Cardiovascular Operating Room Work Environment

Thornton,

Connor,

Dwyer

et al. 2024

Pediatric Quality &Amp; Safety

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Introduction: Pediatric cardiac surgery is complex and has significant risk, requiring interprofessional teamwork for optimal outcomes. Unhealthy work environments have been linked to poor patient outcomes, staff dissatisfaction, and intention to leave. We describe the interprofessional health of pediatric cardiovascular operating room (CVOR) work environments in the United States and the establishment of a healthy work environment (HWE) benchmark score. Methods: Utilizing the American Association of Critical Care Nurses Healthy Work Environments Assessment Tool (HWEAT), interprofessional staff from 11 pediatric CVORs were surveyed. Responses were aggregated, summarized, and stratified by role to examine differences. The following phase used an e-Delphi approach to obtain expert consensus on a benchmark target. Results: Across 11 centers, 179 (60%) completed surveys were reviewed. The interprofessional mean HWEAT score was 3.55 (2.65–4.34). Mean scores for each standard were within the “good” range. Participants reported the highest scores for effective decision-making, with a mean of 3.69 (3.00–4.20). Meaningful recognition scored lowest, mean 3.26 (2.33–4.07). When stratified, surgeons reported higher overall HWE scores (M = 3.79, SD = 0.13) than nurses (M = 3.41, SD = 0.19; P = 0.02, two-tailed). The proposed benchmark was 3.50. Conclusions: This is the first time the American Association of Critical Care Nurses HWEAT has been used to describe the interprofessional health of work environments in pediatric CVORs in the United States. The targeted benchmark can support pediatric CVOR improvement strategies. Creating and sustaining an HWE is an interprofessional opportunity to support high-quality patient outcomes and clinical excellence.

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Section: Discussionmentioning

confidence: 99%

Measuring the Interprofessional Health of the Pediatric Cardiovascular Operating Room Work Environment

Thornton,

Connor,

Dwyer

et al. 2024

Pediatric Quality &Amp; Safety

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“…The SOFI participants reported lower uptake of laboratory reduction interventions than isotonic IVF interventions. Our findings reinforce the literature reporting the difficulties of deimplementation . Prior QI interventions, mostly at single institutions, have shown success in reducing laboratory testing; however, these studies incorporate frequent education, reminders, structured rounds of discussions, auditing, and feedback, which were not feasible in SOFI.…”

Section: Discussionmentioning

confidence: 99%

Effect of a Quality Improvement Bundle to Standardize the Use of Intravenous Fluids for Hospitalized Pediatric Patients

et al. 2022

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IMPORTANCEGiven that hypotonic maintenance intravenous fluids (IVF) may cause hospital-acquired harm, in November 2018, the American Academy of Pediatrics released a clinical practice guideline recommending the use of isotonic IVF for patients aged 28 days to 18 years without contraindications. No recommendations were made regarding laboratory monitoring; however, unnecessary laboratory tests may contribute to health care waste and harm patients.OBJECTIVE To examine the effect of a quality improvement intervention bundle on (1) increasing the mean proportion of hours per hospital day with exclusive isotonic IVF use to at least 80% and (2) decreasing the mean proportion of hospital days with laboratory tests obtained. DESIGN, SETTING, AND PARTICIPANTSThis stepped-wedge, cluster randomized clinical trial (Standardization of Fluids in Inpatient Settings [SOFI]) was sponsored by a national quality improvement collaborative and was conducted across 106 US pediatric hospitals. The SOFI intervention period was from September 2019 to March 2020.INTERVENTIONS Hospital sites were exposed to educational materials, a clinical algorithm and order set for IVF use, electronic medical record interventions to reduce laboratory testing, and "harms of overtesting" cards.MAIN OUTCOMES AND MEASURES Primary outcomes were mean proportion of hours per hospital day receiving exclusive isotonic IVF and mean proportion of hospital days with laboratory test values obtained. Secondary measures included total IVF duration per hospital day, daily patient weight measurement while receiving IVF, serum sodium testing, and adverse events. Baseline data were collected for 2 months; intervention period data, 7 months. Outcomes were analyzed using linear mixed-effects regression models.RESULTS A total of 106 hospitals were randomly assigned to 1 of 3 intervention start dates (wedges), and 100 hospitals (94%) completed the study. In total, 5215 hospitalizations were reviewed before the intervention, and 6724 hospitalizations were reviewed after the intervention. Prior to interventions, the mean (SD) proportion of hours per day with exclusive isotonic IVF use was 88.5% (31.7%). Interventions led to an absolute increase of 5.4% (95% CI, 3.9%-6.9%) above baseline in exclusive isotonic IVF use but did not change the proportion of hospital days during which a laboratory test value was obtained (estimated difference, 0.1%; 95% CI, -1.5% to 1.7%; P = .90), IVF use duration (estimated difference, -1.2%; 95% CI, -2.9% to 0.4%), serum sodium testing, or adverse events. There was an absolute increase of 4.4% (95% CI, 2.6%-6.2%) in the mean proportion of hospital days with a patient weight measurement while receiving IVF. CONCLUSIONS AND RELEVANCEIn this stepped-wedge, cluster randomized clinical trial, an intervention bundle significantly improved the use of isotonic maintenance IVF without a concomitant increase in adverse events or electrolyte testing. Further work is required to deimplement laboratory testing.

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“…This threshold was chosen by consensus based on prior improvement studies demonstrating this to be an achievable change in routine testing. [16][17][18][19] We then used this measure of clinically meaningful change to group hospitals into one of three mutually exclusive groups: increasing testing rates, decreasing testing rates, and the remaining hospitals with no clinically significant change in testing rates.…”

Section: Identifying Hospitals With Increasing or Decreasing Rates Of...mentioning

confidence: 99%

“…These outcomes are common measures in retrospective and quality improvement studies to measure the effect of changes in utilization directly and as balancing measures against potential adverse outcomes from changes in testing rates. 8,11,12,16,[18][19][20][21] Outcomes were adjusted for patient severity using the Hospitalization Resource Intensity Scores for Kids (H-RISK) score, a pediatric-specific relative cost weight used to measure resource intensity of patient admissions based on the APR-DRG (3M Health-care). 22 To evaluate if changes in case mix over time impacted results, we also determined hospital-specific case mix indices calculated as the mean H-RISK score of hospitalizations for each hospital and study year.…”

Section: Outcome Measuresmentioning

confidence: 99%

Changing patterns of routine laboratory testing over time at children's hospitals

Tchou,

Hall,

Markham

et al. 2024

Journal of Hospital Medicine

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BackgroundResearch into low‐value routine testing at children's hospitals has not consistently evaluated changing patterns of testing over time.ObjectivesTo identify changes in routine laboratory testing rates at children's hospitals over ten years and the association with patient outcomes.Design, Settings, and ParticipantsWe performed a multi‐center, retrospective cohort study of children aged 0–18 hospitalized with common, lower‐severity diagnoses at 28 children's hospitals in the Pediatric Health Information Systems database.Main Outcomes and MeasuresWe calculated average annual testing rates for complete blood counts, electrolytes, and inflammatory markers between 2010 and 2019 for each hospital. A > 2% average testing rate change per year was defined as clinically meaningful and used to separate hospitals into groups: increasing, decreasing, and unchanged testing rates. Groups were compared for differences in length of stay, cost, and 30‐day readmission or ED revisit, adjusted for demographics and case mix index.ResultsOur study included 576,572 encounters for common, low‐severity diagnoses. Individual hospital testing rates in each year of the study varied from 0.3 to 1.4 tests per patient day. The average yearly change in hospital‐specific testing rates ranged from ‐6% to +7%. Four hospitals remained in the lowest quartile of testing and two in the highest quartile throughout all ten years of the study. We grouped hospitals with increasing (8), decreasing (n = 5), and unchanged (n = 15) testing rates. No difference was found across subgroups in costs, length of stay, 30‐day ED revisit, or readmission rates. Comparing resource utilization trends over time provides important insights into achievable rates of testing reduction.

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Learning from Each Other: A Multisite Collaborative to Reduce Electrolyte Testing

Abstract: Supplemental Digital Content is available in the text.

Cited by 4 publications

References 31 publications

Measuring the Interprofessional Health of the Pediatric Cardiovascular Operating Room Work Environment

Measuring the Interprofessional Health of the Pediatric Cardiovascular Operating Room Work Environment

Effect of a Quality Improvement Bundle to Standardize the Use of Intravenous Fluids for Hospitalized Pediatric Patients

Changing patterns of routine laboratory testing over time at children's hospitals

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