Quality and Safety

In the pediatric hospital setting, parents are the best advocate for their child’s health and safety. If a child suddenly declines, then a parent can make a phone call and activate the Rapid Response Team (RRT). The Rapid Response Team is a safety net of dedicated clinical providers, including an intensive care physician, nurses, respiratory therapist and a nursing leader, who will assess the child and provide any emergency care needed.

In the fall of 2018, Director of Medical Nursing Jacqueline Newton, RN, MSN, CPEN, NE-BC, noticed that families at Children’s National weren’t taking advantage of this critical resource. Less than a handful of family-activated events had occurred since 2016. The problem was that the program was not well publicized and implemented. Newton made it her goal to increase family awareness of the Rapid Response Team by empowering families with the support, skills and knowledge to activate an RRT.

By implementing some key measures – such as ensuring all patient rooms have signs explaining how to call an RRT, collaborating with the operators on an RRT call script and encouraging nurses to promote the program – Newton has managed to achieve her goal. Since implementing these changes in November 2018, the hospital has seen an increase in the number of families who report knowing how to escalate concerns. Moreover, because families are more aware of the Rapid Response Team, they are better equipped to advocate for their children and work with the hospital staff to ensure their children get the best and safest care possible.

Unintended extubations, or the accidental dislodging of a breathing tube in a baby, are the fourth-most common negative event in neonatal intensive care units (NICUs) around the country. Unintended extubations can lead to airway trauma, bleeding and cardiovascular collapse.

A team led by Children's National NICU medical director Lamia Soghier, M.D., found some simple solutions that cut unintended extubation rates by more than half.

"These babies have complex care needs, however lowering the rates of these life-threatening events came down to instituting a series of simple changes to standardize what we do, including how we tape the endotracheal tube to the child's mouth, how we position infants during X-rays and who we include on daily rounds when the medical team discusses intubated patients' care plans," explains Dr. Soghier.

The team also implemented bedside reviews within 72 hours of an unintended extubation to determine contributing factors, such as wet or loose tape, and reduced how often newborns received chest X-rays.

The result was a decrease in unintended extubations by 60% over 10 years, which saved the hospital an estimated $1.5 million per year. Dr. Soghier’s team not only improved safety, but also lowered overall healthcare spending for the hospital.

The teams at Children’s National work hard to ensure that safety is the highest priority in everything they do. Paying attention to even the smallest safety event can help improve the process before, during and after a procedure, so capturing surgical safety events is critical for our staff.

Recently, a team at Children’s National developed a comprehensive way of streamlining the system to capture and address surgical safety events. The program is called Tiered Children’s Surgery Verification. Silvia Espinal, MSN, RN, a surgery quality improvement manager, is a key player on the verification team and says that the undertaking of the program was no easy task, but the efforts are worth it to provide the best care.

Silvia’s work involves collaborating with different departments to review surgical cases flagged with a safety event, according to the metrics set by the American College of Surgeons. She collects, organizes and monitors data to determine opportunities for improvement. The new verification program enhances the hospital’s ability to identify surgical safety events, which then go through multi-level reviews from several disciplines.

Silvia and her team saw a 14% increase in their ability to capture events from June through October in 2018. This success resulted in the American College of Surgeons awarding them the Best Pediatrics Abstract, and also inviting them to share their work with other pediatric hospitals in the future.

Discharge day is an exciting time for our young patients. They finally get to return home to their friends and family after spending time in the hospital. To make the discharge process easier on the hospital staff, patients and families, Children’s National has what’s called a “Conditional Discharge.” This allows the doctors to place discharge orders several hours – or even days – before the actual discharge, enabling the care team and family to complete tasks such as paperwork, home care arrangements and transportation, so discharge can happen as soon as the specified clinical criteria are met.

However, Director of Clinical Resource Management Kathleen Rigney, MSN, RN, CCM, in collaboration with her team, realized that most Conditional Discharge Orders (CDOs) at Children’s National were being written within one to two hours of the estimated discharge time. By not making proper use of the CDOs, clinicians weren’t optimizing patient flow through the hospital.

Rigney set a goal to increase the percent of CDOs written at least six hours before estimated discharge time for orthopedic patients on the Surgical Care Unit, and to sustain that increase for at least 6 months. Working with the hospital staff, she and her team made sure that care teams and hospitalists were well trained in the CDO process, and that clinicians were working to identify conditional discharges during their morning rounds.

Rigney met her goal, and her strategies have been so effective that they are now being used for all patients on the Surgical Care Unit, Heart and Kidney Unit and Hospitalist teams at Children’s National.

Vancomycin is an antibiotic that is used to treat antibiotic-resistant bacteria, such as methicillin-resistant Staphylococcus aureus (MRSA). But vancomycin can also cause kidney injury when it’s used for more than 48 hours, so it’s important to only use it when necessary, because better and safer alternative antibiotics are available for most situations.

As director of the antimicrobial stewardship program at Children’s National, Rana Hamdy, M.D., MSCE, M.P.H., tracks antibiotic use at the hospital. When Dr. Hamdy looked at how much vancomycin was being used in the neonatal intensive care unit (NICU), she discovered that the department was prescribing the antibiotic almost three times as much as other hospitals, even though the rates of MRSA infections were very low.

Prompted by this finding, Dr. Hamdy assembled a multidisciplinary team consisting of neonatologists, NICU nurses and nurse practitioners, infectious disease experts and pharmacists. Their goal was to reduce vancomycin use in the NICU by 50% in one year and to sustain that level for at least another year. The team developed and implemented several interventions, including standardizing the hospital’s approach to treating several types of infections, integrating pharmacists into the antibiotic review process, and educating clinicians on antibiotic use.

Within one year, vancomycin use in the NICU was down by 60%. Before the project, one infant per week was developing vancomycin-associated kidney injury, but in the six months after the last phase of the project, there were no episodes of vancomycin-associated kidney injury in the NICU. As an added benefit, the use of other antibiotics in the NICU also declined by about 20%.