Introduction: The United States is in the midst of an opioid epidemic and the pediatric population is vulnerable to prescription opioid misuse and overdose. There is a mismatch between the amount of opioids needed to treat pediatric acute pain and leftover opioids account for a substantial source available for unintentional overdose by young children and misuse among adolescents. It is imperative that providers seek to decrease the amount of excess opioids prescribed, while still providing adequate pain control. A quality improvement approach was taken at our pediatric institution to decrease excess opioid prescribing. …

Goal: Opioid misuse is a public health concern reaching epidemic levels and the pediatric population is not immune to the problem. Improving education of patients and families is crucial so they are aware of the need for appropriate monitoring, securing, transitioning, and disposal of opioid medications when prescribed for pain. A multidisciplinary Opioid Safety Task Force was developed as part of a quality improvement initiative at our pediatric institution. Nurses and prescribers were initially surveyed regarding their educational practices surrounding opioids and found that less than 25% of healthcare providers were routinely discussing opioid safety and disposal with patients and families. An aim of the Task Force was to Increase the percentage of patients discharged from surgical inpatient units prescribed opioids that received opioid safety education from 0% in 10/1/2016 to 50% by 7/31/2017 and then increase to 100% by 1/31/2018 and sustain for 6 months. Methodology: Educational handouts were created for patients and families on pain management and opioid safety practices in the home with the 4 tenets of Monitor, Secure, Transition and Dispose. Handouts on treating pain after surgery were also created to discuss use of acetaminophen and ibuprofen in conjunction with opioids. In order to meet the health literacy need of our patients and families, an educational video was created on opioid safety in the home which can be viewed through the hospital patient education system or online. Standardized documentation on if opioid education given was added to the electronic medical record (EMR) for data tracking purposes. All nurses on the surgical units were educated on the handouts and documentation. .Data was extracted monthly via a report generated from the EMR and plotted on a p chart. Results: The percentage of patients receiving opioid safety education on inpatient units has increased from the initial baseline of 0% to over 50% by March 2019. Multiple interventions have led to several process stage shifts. Discussion: Providing education on safe monitoring, securing, transitioning, and disposal of opioids is needed so that when opioids are prescribed, the potential for misuse is decreased. Our quality improvement initiative demonstrated the ability to increase education on opioid safety to our patients and families. The home opioid safety video is now assigned to all patients on the surgical units and has a >90% completion rate of reviewing. A new process will be implemented to add opioid safety education to the discharge instructions for all patients at our institution prescribed opioids, not just those discharged from surgical units, in the next month. It is our hope that pediatric organizations across the country can implement these processes at their own institutions to keep their patients, families, and communities safe.

Introduction: Acute appendicitis is the most common gastrointestinal condition requiring urgent operation in the pediatric population with laparoscopic appendectomy (LA) being the current surgical technique. We describe the implementation of a standardized protocol to reduce postoperative nausea and vomiting (PONV) and facilitate same-day discharge after LA. Methods: A multidisciplinary team developed this protocol to facilitate same-day discharge after observing high rates of overnight stay due to PONV among simple appendectomies performed in 2011–2012. The protocol was implemented in November 2014 and underwent a revision in June 2016. Following the implementation of the protocol, we monitored the patients undergoing an LA at Nationwide Children’s Hospital between November 2014 and August 2017. Results: We identified 691 patients (255 female) who underwent a simple LA at Nationwide Children’s Hospital between November 2014 and August 2017. The patient population had a median age of 11 years (interquartile range: 9, 14). Among these patients, 514 (74%) were discharged on the day of surgery, and 387 (56%) were protocol compliant. The rate of same-day discharge was higher for compliant cases (79%) than noncompliant cases (69%, P = 0.003). Multivariable statistical analysis associated compliance with an increased likelihood of same-day discharge (Odds ratio [OR] = 1.7, 95% CI: 1.2, 2.4, P = 0.002). Conclusions: Implementation of the LA protocol to reduce PONV demonstrated a significant increase in the rate of same-day discharge from the hospital among compliant patients. Also, the adoption of a protocol to select patients for early discharge after LA has shown results with a 45% reduction in the need for inhospital beds.

Objective The Cancer Care Index (CCI), a single metric that sums the number of undesirable patient events in a given time frame (either preventable harm events or missed opportunities to provide optimal care), resulted in a 42% improvement in performance. Our objective was to test the index concept in other service lines to determine whether similar performance improvement occurred. Study design Care indices were developed and introduced in 3 additional service lines: Nephrology (Chronic Kidney Disease Care Index; CKDCI), Pulmonology (Lung Transplantation Care Index; LTCI), and Otolaryngology (Tracheostomy Care Index; TCI). After reaching agreement on specific harms to be avoided and elements of optimal care that should be reliably delivered, these items were compiled into indices that were updated monthly. Reports included each element individually and the total for all elements. Baseline performance was calculated retrospectively for the previous year. Results Significant improvement in performance occurred in each program following implementation of the clinical indices. The CKDCI was decreased by 63.2% (P < .001), the LTCI was decreased by 89.5% (P < .001), and the TCI was decreased by 53.0% (P < .001). Surveyed staff indicated satisfaction with use of the metric. Conclusions Clinical indices are useful for evaluating and managing the overall reliability of a program's ability to deliver optimal care, and are associated with improved clinical performance and satisfaction by service line staff when incorporated into a program's operation.

Background Depression affects 12% to 20% of adolescents and up to 30% of Appalachian residents. Given its frequency, routine adolescent depression screening and management is recommended by the American Academy of Paediatrics. However, routine depression screening is limited. Quality improvement (QI) practice facilitators (PF) can help clinicians standardise care, remove unwanted variation and improve outcomes. A QI PF model may improve depression screening and management. Objectives Increase use of a validated depression screening tool from 0% to 30%, and create a management plan for those diagnosed with depression from 43% to 85% by 6/30/2016 and sustain through 12/31/2016. Methods QI PFs from Partners For Kids, an affiliate of Nationwide Children's Hospital, supported a practice in Ohio's Appalachia region to initiate a depression screening and management project with 6 months follow-up. PFs used the IHI Model for Improvement and led recurring, on-site meetings. Interventions included training from a NCH developmental and behavioural paediatrician, new workflows and implementing a change package — establishing referral sources, process to manage emergencies and effective management plan checklist. PFs performed regular audits of the project. Results Screening for depression increased from 0% to 42% within 3 months with initial QI interventions and increased to 80% with subsequent interventions. Documentation of evidence-based management of depression increased from 43% to 85%. Depression diagnosis increased from 21 children in 2015 to 34 in 2016, a 62% increase. Conclusions Implementing behavioural health recommendations using PF led to increased screening, diagnosis and management of depression at an Appalachian primary care practice.

Background Quality improvement (QI) practice facilitators (PFs) may help primary care providers (PCPs) improve care by adapting approaches to practice characteristics. Partners For Kids, an accountable care organization affiliated with Nationwide Children9s Hospital (NCH), offers PFs to guide PCPs through QI projects to adopt clinical recommendations and improve patient outcomes. For example, one QI focus area is fluoride varnish (FV) application to prevent dental caries in young children, which was added to the American Academy of Pediatrics Periodicity Schedule for PCPs in 2015. Objectives Practice-specific aims were created, for example, to “Increase the % of children <3 yrs with FV applications at well-child visits from 0% to 50% by 6/30/2017 and sustain through 12/31/2017”. Methods From mid-2015 to mid-2016, 5 non-NCH-owned practices initiated FV QI projects with PFs and had at least 7 months follow-up. The PFs trained practices on the IHI Model for Improvement and led recurring, on-site meetings. Initial interventions included selecting products and training. Subsequent intervention themes included consent, visual reminders, and parent education. PFs shared successes among practices and hosted learning collaborative-style webinars. PFs regularly performed random audits of FV and aggregated practice data to evaluate program impact. Results Use of FV increased from 0.0% to a median of 44.2% within 3 months with initial interventions. With subsequent interventions during months 4–7, performance increased further to 54.8%, and the center line shifted to 51.2%. Conclusions Practices can benefit from assistance of PFs to effectively implement clinical recommendations.

Background According to the Association for Professionals in Infection Control, urinary tract infections are among the most common of healthcare-associated infections (HAIs), accounting for 25.6 percent of all hospital HAIs. 70%–80% of healthcare-associated UTIs are caused by indwelling urethral catheters. Catheter-associated urinary tract infections (CAUTIs) are associated with increased morbidity, mortality, hospital cost, length of stay, and antimicrobial use. Objectives The aim of this project was to decrease our hospital-wide CAUTI rate from 1.3 to <= 0.7 infections per 1000 catheter days. Methods A multidisciplinary team implemented a comprehensive strategy to decrease CAUTIs and increase patient safety. Evidence based initiatives focused on catheter insertion, utilization, maintenance, and staff/family education. Staff RNs completed simulated insertion training with return demonstration of competency. Daily Goals were completed to reduce unnecessary catheter use. A maintenance bundle was implemented to ensure standardized practice which focuses on the reduction of perineal bio-burden. Staff huddles were required after each CAUTI to determine root causes. Results In 2013–2014, the CAUTI annual rate was 1.3 infections per 1000 catheter days. To date in 2015, the rate is 0.6 infections per 1000 catheter days. The Pediatric Intensive Care Unit has decreased its rate from 2.9 in 2014 to zero in 2015. In addition to reduction in our CAUTI rate, we achieved 193 days between infections. Conclusions Published guidelines suggest that implementing evidence based practices can reduce CAUTIs. Our approach resulted in patient care standardization and reduction in patient harm. The reduction strategies used may help positively impact care in other hospitals. Figure 1 Figure 2

Introduction: In 2011, Nationwide Children's Hospital began using peripheral nerve catheters (PNC) to provide postoperative analgesia to patients undergoing select orthopedic and abdominal surgeries. While PNCs provide a significant improvement in the quality of care that our patients receive, introducing this new technology and process within our hospital presents an inherent risk.Methodology: In order to assure that our patients received the safest care, we assembled a multi-disciplinary team to complete a proactive risk assessment by utilizing Healthcare Failure Mode and Effect Analysis (HFMEA). HFMEA was designed by the VA National Center for Patient Safety to identify potential failure modes within systems, and to study the consequences the failure modes have on customers. The result of this process identified and evaluated 96 failure modes and therefore 19 specific interventions were developed and deployed.Conclusion: The HFMEA process gives us confidence that new pain management techniques and their related processes can be safely and effectively implemented in order to provide the safest and highest quality care to our patients.

There are limited data in the pediatric population regarding the incidence of, risk factors for, and means to prevent perioperative hypothermia. The Institute for Healthcare Improvement Model for quality improvement (QI) methodology was used to bundle the most effective techniques to prevent hypothermia. A multidisciplinary QI team was assembled with the goal to decrease the incidence of perioperative hypothermia by 50%. The baseline incidence of hypothermia was determined and causes identified using a flowchart and a cause-and-effect diagram. Pareto charts were formed and opportunities to decrease the incidence of perioperative hypothermia were trialed. The baseline incidence of hypothermia was 8.9%. Implementation of a standardized temperature management bundle in the operating rooms decreased the incidence to 4.2%. The QI methodology was useful to bundle the most effective techniques to prevent hypothermia, resulting in standardized perioperative care and a sustained reduction in the incidence of perioperative hypothermia.