Facilitating the everyday steward: Impact of mandatory antimicrobial indication/duration and a 48 hour time out
Ann L. Wirtz, Alaina N. Burns, Brian R. Lee, Tammy Frank, Laura Fitzmaurice, Richard Ogden, Brian O'Neal, and Jennifer Goldman
Introduction: Required indication, duration, and a 48-hour antimicrobial timeout are an integral part of antimicrobial stewardship standards; however, limited data are available to demonstrate an effect on antimicrobial utilization and antimicrobial stewardship practice. Therefore, we evaluated the impact of mandatory declared indication/duration along with a pharmacy-driven 48-hour timeout on antimicrobial utilization and antimicrobial stewardship interventions.
Methods: We performed a retrospective evaluation of ASP interventions and antimicrobial use following implementation of mandatory antimicrobial indication/duration at the point of computerized physician order entry (CPOE). A pharmacist-driven 48-hour antimicrobial timeout was introduced on the same date. This study was conducted at Children’s Mercy Kansas City, a 367-bed freestanding pediatric hospital servicing the Kansas City Metro Area and beyond. Data were collected from February 1, 2016 to January 31, 2018. A pre and post comparison was performed; interventions were implemented hospital-wide on February 14, 2017. ASP intervention rates were measured. Days of therapy (DOT) per 1000 patient days of antibiotics were also evaluated. Poisson models were utilized to compare DOT rates pre- and post-implementation, and seasonal decomposition analyses were performed to account for seasonal variability.
Results: A significant decrease in DOT rates was observed in non-ASP monitored antibiotics post-implementation, including cefazolin (39.7 to 36.9; p
Conclusions: Implementation of additional stewardship practices, including mandatory antimicrobial indication/ duration and a pharmacist-driven 48-hour timeout, resulted in a decrease in the use of antimicrobials, including those not monitored by our ASP. These efforts augmented, but did not replace existing stewardship efforts. These results support initiatives highlighted by national organizations to minimize unnecessary antimicrobial use through ASP.
Incredible Years (IY) Parents & Babies Well-Baby Program: Expanding the Reach through Cultural Adaptation
Ayanda Chakawa and Briana Woods-Jaeger
Libby Milkovich, Meredith Dreyer, Brooke Sweeney, Sarah Nyp, and Ben Black
Problematic mealtime behaviors (PMB) (externalizing behavior at mealtime) have been seen anthropologically when adult caregivers are absorbed in their mobile phones. Parents with mobile phone problematic use (MPPU) are more likely to be absorbed in a mobile device. Neither the correlation of MPPU to PMB, nor the frequency of PMB to perceived impairment of problem behavior have been quantitatively studied.
Evaluate correlation of caregiver MPPU and child PMB to improve understanding of the possible implications of caregiver MPPU
Participants included caregivers of children ages 2-8 years being seen in a pediatric hospital clinic. Participants completed a survey on an iPad via REDCAP. The survey included demographics (caregiver/child age, gender, race/ethnicity; child BMI; caregiver level of education), a validated measure for caregiver MPPU (Mobile Phone Problematic Use Scale; MMPUS) and a validated measure for perception of child PMB (Meals in our Household; MIOH). MIOH includes frequency of PMB and perceived impairment from PMB. Measures are continuous variables. Spearman correlation was used for the studied variables and possible confounding variables. Significant confounding variables were evaluated in a regression model.
100 caregivers (mean age 32.9 years, 65% white, 20% ≤ high school completion) participated. Correlation of MIOH problematic behavior total with MMPUS was significant (p=.004, r=0.289). MIOH perceived impairment from PMB had stronger correlation with MMPU (p=M (p=.005). No significant caregiver variables noted for PMB. Younger child age was significantly correlated with PMB (p=.007, r=-.274). No significant differences in child variables for MPPU. Significant variables were evaluated in regression model, and MPPU and PMB remained significant.
Correlation was found between MPPU and PMB. Correlation was stronger when measure of perceived impairment was evaluated. This suggests that caregivers with increased MPPU perceive behavior as more problematic. Understanding the potential relationship between caregiver MPPU and child PMB, strengthens pediatricians’ ability to counsel about the implications of caregiver MPPU when discussing child PMB. Objective coding during mealtimes of caregiver mobile phone use and child mealtime behaviors will further evaluate this relationship.
Irina G. Trifonova, Troy E. Richardson, Jessica L. Bettenhausen, and Matthew B. Johnson
The increasing complexity of pediatric inpatients requires that all providers understand a comprehensive child’s medical and social needs. A survey administered to Children’s Mercy Hospital inpatient providers identified gaps in knowledge regarding the daily plan of care and discharge planning needs among Complex Chronic Care (CCC) patients. Multidisciplinary rounds (MDRs) create a shared decision model among all team members to ensure that all aspects of care for CCC patients are addressed.
To improve provider knowledge of the plan of care and discharge planning needs for CCC patients admitted to the Hospitalist service, from 40% to 75% of providers by implementation of MDRs.
All CCC patients (defined by ICD-10 code diagnosis; Fuedtner, et. al.) admitted to the Hospitalist service were candidates for MDRs. Patients with CCCs on resident teaching service were excluded. MDR team included a hospitalist, bedside nurse, nurse care manager, social worker, pharmacist and nutritionist. Providers were notified of qualified patients for MDRs three times a week prior to rounds. The MDR team members discuss the medical plan, address medication change, nutrition status, social and discharge needs. The process measure included the frequency of provider’s attendance at MDRs; the time spent rounding per patient was the balancing measure. Pre-round huddles were implemented 6/1/2017 to facilitate discussion of CCC patients among team members unable to attend bedside rounds (Figure 1). Statistical process control charts were used to assess the impact of pre-round huddles on percent provider attendance at MDRs. Following implementation of MDRs, providers completed subsequent surveys reflecting their knowledge on the plan of care for CCC patients.
MDRs were implemented 8/1/2016. Attendance remained unchanged until the introduction of pre-round huddles which significantly improved provider attendance (p
Implementation of the pre-round huddles had the most impact on providers’ attendance at MDRs, without increase the rounding time per patient. While providers reported some improvement in understanding of care for CCC patients, the impact of provider attendance at MDRs or pre-round huddles on readmission rate of CCC patients remains to be determined.
Brenda R. Pfannenstiel MALS, MA, AHIP; Courtney Butler MLS; Keri Swaggart MLIS, AHIP; and Megan Molinaro BA
Describes activities and resources provided by the Library Services department at Children's Mercy Kansas City.
Courtney R. Butler and Megan Molinaro
BACKGROUND: Children's Mercy is an independent, non-profit, 367-bed pediatric health system with multiple clinic locations and a strong focus on research. It offers a pediatric residency program and over 37 subspecialty fellowship programs.
New initiatives go through many steps from conception to implementation. The focus of this case study is to describe how gathering feedback from stakeholders during proposal development provided valuable insight, secured stakeholder collateral to support requests for administrative approval and funding, and marked the beginning of new productive institution-wide partnerships.
Conduct Focus Groups
Develop Fair Market Analysis/Executive Summary
Convene Task Forces for Implementation
GATHERING FEEDBACK: Gathering feedback is an important part of project development. Surveys can be a convenient and effective option, but they risk low response rates with stilted, fill-in-the-blank answers. Candid feedback was imperative for this initiative to ensure that all critical factors were being considered.
CONCLUSIONS: Using focus groups proved effectual in improving the project design. Feedback provided the opportunity to refine the proposal and highlighted issues that had not been sufficiently investigated such as interoperability with existing systems. It also revealed interest in additional use cases, such as the ability to host educational materials. Furthermore, the interactions resulted in stakeholders willing to advocate for the project and to participate in its development and implementation and better prepared Library Services to address administrative concerns. These newly built partnerships will allow future projects and service improvements to build off this project's success.
Melissa D. Elliott
Title: Use of personalized patient heart diagrams at the bedside to improve quality of care
Background/Introduction: With congenital heart disease no two hearts are exactly the same. Even with the same lesion, the anatomy of the heart can be completely different. In response to a bedside nursing idea following a cardiac arrest, advanced practice nurses (APN) initiated a program to provide personalized cardiac anatomy diagrams at the bedside of every patient on the cardiology service.
Methods: When a cardiac patient is admitted to cardiology floor, the nurse will check the patients chart for an anatomy picture, then will place the patient’s initials on a worklist for the APN if no picture is available. The APN is responsible for creating a personalized cardiac anatomy picture, delivering it to the bedside, and providing education to the nurse and the patient’s caregiver. The diagram is saved in the patients chart.
Results: This project started on October 24, 2016. Initially data was tracked to ensure that nurses were requesting the pictures in a timely matter. This data was reviewed with nursing staff daily at the shift huddles. Additionally, anatomy picture at bedside was added to the nursing admission checklist. The team reached 100% compliance consistently by May 2017. A post implementation survey was completed by 60% of the nursing staff.
Conclusion: The value added from providing personalized patient heart diagrams at the bedside is improved care of cardiac patients through understanding of cardiac lesions and hemodynamics, increased education to the multidisciplinary care team and caregivers, and overall improved quality of care overall for this unique patient population.
The next goal is to expand this project to other units including the intensive care unit, fetal health, and preadmission testing.
Sarah M. Lagergren, Bryan Beaven, Suma Goudar, and Megan Jensen
Background/Introduction: Post-operative hospitalization for the Fontan procedure tends to have an extended hospital length of stay (LOS). From 2013-2014, the average LOS at Children’s Mercy for the Fontan procedure is 14 days, whereas the U.S. national reported average is 11 days. Post-operative management of this patient population is often caregiver dependent. It has been theorized that developing a more standardized post-operative management regimen tailored specifically toward the unique physiology of Fontan patients may be able to improve outcomes and decrease LOS.
Methods: A review of literature was performed and revealed three pediatric institutions have published their post-operative Fontan care guidelines. Common elements from these care guidelines were identified and then trialed in 2016 on our post-operative Fontan population. Three patients were included in four individual PDSA cycles. Adherence to each intervention was tracked and information gathered regarding potential issues.
Results: Use of supplemental oxygen prior to chest drainage tube removal had 100% adherence and no harm or negative side effects (such as nosebleeds, or impeding ability to ambulate) reported. Restriction of fluids had a 33% adherence rate with IV fluids started or IV fluid boluses administered over the 80% restriction in 2/3 patients. Following a standardized diuretic regimen had 100% adherence with no negative patient outcomes. Obtaining central access within 48 hours post-operatively via a PICC line had 100% adherence.
Conclusion: By performing individual PDSA cycles prior to full implementation of a post-operative clinical pathway, potential areas of concern were able to be identified and addressed or disproved. The Fontan clinical pathway was fully implemented for 2017 with plans to complete another full PDSA cycle.
Keri Swaggart, Courtney Butler MLS, and Linda Taloney
Ahead of Their Time: The Story of Alice Berry Graham and Katharine Berry Richardson, the Founders of Children's Mercy Hospital in Kansas City
Jane F. Knapp MD and Robert Schremmer
Describes the founding of Children's Mercy Hospital through the story of its founders, Katharine Berry Richardson and Alice Berry Graham.
Robert Schremmer and Jane F. Knapp MD
The Orphan Train Movement was responsible for relocating thousands of children from large eastern cities to rural areas and can be seen as the forerunner to today's foster care system.
Keri Swaggart and Nancy Allen
MCMLA 2012 Annual Meeting Presentation
Robert D. Schremmer MD and Jane F. Knapp MD
Describes the career of Arthur Emmanuel Hertzler, MD, 1870-1946, who practiced in Halstead, Kansas.