No abstract

Background and Objective Clinical pathways standardize care for common health conditions. We sought to assess whether institution-wide implementation of multiple standardized pathways was associated with changes in utilization and physical functioning after discharge among pediatric inpatients. Methods Interrupted time series analysis of admissions to a tertiary care children’s hospital from 12/1/09–3/30/14. Based on diagnosis codes, included admissions were eligible for one of 15 clinical pathways implemented during the study period; admissions from both before and after implementation were included. Post-discharge physical functioning improvement was assessed with the PedsQL™ 4.0 generic core or infant scales. Average hospitalization costs, length of stay (LOS), readmissions, and physical functioning improvement scores were calculated by month relative to pathway implementation. Segmented linear regression was used to evaluate differences in intercept and trend over time before and after pathway implementation. Results There were 3808 and 2902 admissions in the pre-pathway and post-pathway groups, respectively. Compared to pre-pathway care, post-pathway care was associated with a significant halt in rising costs (pre-pathway vs. post-pathway slope difference −$155/month [95% CI −$246, −$64]; P=.001) and significantly decreased LOS (pre-pathway vs. post-pathway slope difference −0.03 days per month [95% CI −0.05, −0.02]; P= .02), without negatively impacting patient physical functioning improvement or readmissions. Conclusions Implementation of multiple evidence-based, standardized clinical pathways was associated with decreased resource utilization without negatively impacting patient physical functioning improvement. This approach could be widely implemented to improve the value of care provided.

Standardizing care for ED and inpatient management of CAP led to immediate and sustained improvements in antimicrobial stewardship and guideline-recommended testing without significantly affecting costs.

OBJECTIVE: We sought to create and implement recommendations from an evidence-based pathway for hospital management of pediatric diabetic ketoacidosis (DKA) and to sustain improvement. We hypothesized that development and utilization of standard work for inpatient care of DKA would lead to reduction in hypokalemia and improvement in outcome measures.METHODS: Development involved systematic review of published literature by a multidisciplinary team. Implementation included multidisciplinary feedback, hospital-wide education, daily team huddles, and development of computer decision support and electronic order sets. RESULTS:Pathway-based order sets forced clinical pathway adherence; yet, variations in care persisted, requiring ongoing iterative review and pathway tool adjustment. Quality improvement measures have identified barriers and informed subsequent adjustments to interventions. We compared 281 patients treated postimplementation with 172 treated preimplementation. Our most notable findings included the following: (1) monitoring of serum potassium concentrations identified unanticipated hypokalemia episodes, not recognized before standard work implementation, and earlier addition of potassium to fluids resulted in a notable reduction in hypokalemia; (2) improvements in insulin infusion management were associated with reduced duration of ICU stay; and (3) with overall improved DKA management and education, cerebral edema occurrence and bicarbonate use were reduced. We continue to convene quarterly meetings, review cases, and process ongoing issues with system-based elements of implementing the recommendations. CONCLUSIONS:Our multidisciplinary development and implementation of an evidence-based pathway for DKA have led to overall improvements in care. We continue to monitor quality improvement metric measures to sustain clinical gains while continuing to identify iterative improvement opportunities. Pediatrics 2014;134:e848-e856 Dr Koves drafted, wrote, and submitted the manuscript; developed the design for manuscript and metrics data definitions; interpreted the data; formatted the manuscript; facilitated contributions; developed the figures, tables, references, and reference formatting; and facilitated publication of the final version; she provided oversight for all aspects of the development of the diabetic ketoacidosis (DKA) clinical standard work package; Dr Leu made substantial contributions to the conception and revision of clinical guidelines, architected and updated clinical decision supports used to support the project, reviewed analysis of data, composed a portion of the original manuscript, and edited all of the final manuscript; Ms Spencer performed data analysis and statistical significance testing and contributed writing to the methods of evaluation, results, and analysis sections; Ms Popalisky contributed writing to the methods and discussion sections and assisted with review and revising drafts of the manuscript; Ms Drummond contributed to writing the methods and discussion sections...

Background and Objective: There is no accepted nutrition approach for wound healing in children. Our aims were to determine optimal nutrition support for pediatric wound healing. Methods: We applied local methods to create evidence- and consensus-based recommendations, supported by implementation tools, including algorithms, clinical decision supports, and measures. We applied these recommendations to the care of 49 patients from December 5, 2011, to December 5, 2012. Results: Six articles were found that addressed our clinical questions, and we formulated 5 clinical recommendations. Evidence supported evaluating patients for vitamin C, zinc, and protein deficiency. Of the patients where laboratory values were checked, 9 patients were zinc deficient (33%) and 12 patients were vitamin C deficient (48%). Discussion and Practical Application: The implementation of our recommendations has led to increased identification of micronutrient deficiencies and closer monitoring of nutrition status and intake. Online clinical decision supports can accelerate the adoption of clinical recommendations and reduce provider practice variation.