Introduction:Human papillomavirus (HPV) infections and HPV-related cancers are preventable with vaccination. Initiating the HPV vaccine series at ages 9-10 years is associated with improved vaccination uptake and series completion. This quality improvement (QI) initiative aimed to increase first-dose HPV vaccination rates among 9- to 10-year-olds through the implementation of evidence-based interventions. Methods:Data were collected from electronic health records (EHRs) of established patients aged 9-10 years with at least 1 documented well-child visit annually from 2021 to 2024. Baseline data were obtained from January 2021 through May 2022. Interventions included provider education, adoption of a system-wide "Start at 9" policy, patient-facing educational materials, and EHR modifications to integrate HPV vaccine orders for patients aged 9 years and older. Monthly vaccination trends were evaluated using a P-chart. Results:A total of 9315 patients aged 9-10 years were included. The percentage of eligible patients receiving their first HPV vaccine increased from a baseline of 2% to 14% following the adoption of the "Start at 9" policy in conjunction with targeted educational interventions and EHR integration. A P-chart demonstrating special cause variation aligned with 2 QI interventions, indicating a sustained process shift. Tetanus, diphtheria, and acellular pertussis (Tdap) vaccination rates, used as balancing measures, remained stable throughout the study period. Conclusions:A coordinated, systems-level QI approach was associated with significant gains in early HPV vaccine initiation, supporting initiation of vaccination at age 9 years as an effective strategy to promote timely vaccination and strengthen preventive health outcomes.
Introduction:Extremely preterm infants face a high risk of bronchopulmonary dysplasia from prolonged mechanical ventilation. Early extubation to noninvasive respiratory support may reduce lung injury. Evidence suggests that nasal intermittent positive pressure ventilation (nasal IPPV) lowers reintubation compared with continuous positive airway pressure. Understanding neonatal intensive care unit providers' practice preference, an aspect of unit culture, can facilitate adoption of practice change. This quality improvement initiative aimed to reduce rates of reintubation within 7 and 10 days of first extubation among intubated infants born before 28 weeks' gestational age within 1 year of implementing the practice change and to assess changes in unit culture following guideline implementation. Methods:A guideline recommending extubation to nasal IPPV for infants born before 28 weeks' gestational age and/or 1250 g or less at birth was developed following measurement of staff practice preferences using the Neonatology Survey of Interdisciplinary Groups in Healthcare (NSIGHT) and internal data review, implemented in a level III neonatal intensive care unit in 2023. Data from January 2020-September 2025 were analyzed using statistical process control charts. The validated NSIGHT was repeated in August 2025 and compared with preimplementation results. Results:Over 5.5 years, 200 eligible infants were extubated. Reintubation rates within 7 days changed (from 39% in 2020 to 13% in 2025; P = 0.058). Rare-events analysis demonstrated special cause variation in 2025, with an increasing number of extubations between reintubation events. A significant shift was detected in the extubation rate to nasal IPPV from 32% to 83%. The 2025 NSIGHT results showed a net unit preference for nasal IPPV after extubation (P < 0.001). Conclusions:A practice guideline, informed by NSIGHT results and internal data, was implemented to promote extubation of extremely preterm infants to nasal IPPV. Changes were achieved in clinical practice, reintubation rates, and unit culture.
Introduction:Central line-associated bloodstream infections (CLABSIs), despite the application of best practices, are still prevalent and cause significant morbidity and mortality in pediatric patients. We describe a quality improvement project with an aim to reduce inpatient CLABSIs focused on standardization and proactive risk assessment. Methods:The aim was to reduce inpatient CLABSI rates by 30% within 3 years beginning in January 2021. An apparent cause analysis in 2018 suggested that the lack of escalation of concerns was a potential focus area. We used Plan-Do-Study-Act cycles starting with a pilot in 2019 to roll out a CLABSI Watcher Program. After a CLABSI prevention summit in 2020, a reorganization of drivers reidentified the need for a standardized escalation process for central line (CL) concerns. A CL nurse program was then scaled across the hospital, focusing on timely proactive huddling. Hospital-wide standardization of practices occurred from 2021 to 2023. We used statistical process control charts to assess changes in CLABSI rates. Results:Special cause variation, with a downward shift in the CLABSI rate process mean compared with baseline (0.97 per 1,000 CL days), was observed starting June 2021 (0.13 per 1,000 CL days). A second shift occurred from August 2023 through December 2024 (0.00 per 1,000 CL days). The CLABSI rate decreased by 65% (0.34 per 1,000 CL days) through December 2023. Conclusions:Significant reductions in hospital CLABSI rates can be achieved by using additional measures beyond focusing on CL maintenance and insertion bundles, and particularly through developing proactive risk assessment and escalation processes.
Introduction:Severe traumatic brain injury (TBI) is a major cause of pediatric morbidity and mortality; yet, adherence to national guidelines remains variable. Methods:We conducted a single-center quality improvement initiative in our 48-bed pediatric intensive care unit at a level 1 trauma center. Interventions included adding a TBI order set to the electronic health record and a structured "report card" audit-and-feedback system to monitor compliance with specified metrics in the first 72 hours of admission. The primary outcome measure was the number of severe TBI encounters with 50% or greater adherence to institutional guidelines. Process measures included the use of the order set and timeliness of report card dissemination. Key clinical metrics were also tracked. Analyses involved run charts, descriptive statistics, and nonparametric tests. Results:Of 72 children with severe TBI admitted, 60 were eligible for full guideline adherence assessment. Order set adoption increased from 13% to 92% following the implementation of the report cards and remained above 89% annually thereafter. Guideline adherence increased from 21% to 38.9% postreport cards and stabilized between 42.9% and 59.8% thereafter. Adherence was highest for temperature management, seizure prophylaxis, and cerebral perfusion pressure, whereas sodium and carbon dioxide targets remained challenging. Mortality did not differ by adherence. Higher adherence correlated with longer pediatric intensive care unit, hospital, and rehabilitation stays. Conclusions:Decision support tools and audit and feedback improved adherence to severe pediatric TBI guidelines. Future multicenter studies should assess how adherence affects functional recovery.
