standardization of oxygen monitoring and suctioning for inpatient care of bronchiolitis in an...

Standardization of Oxygen Monitoring and Suctioning for Inpatient Care of Bronchiolitis in an Academically-Affiliated Community Setting

Grant Mussman, M.D.

Cincinnati Children’s Hospital

Liberty Township Inpatient Facility

• 12 bed inpatient satellite facility – Attending-only coverage– Experienced nursing staff

• Most patients with bronchiolitis admitted from the ED or from Children’s Hospital-run urgent cares

• Small quality improvement team – 3 Respiratory Therapists– 4 Nurses– 2 MDs

• Less red tape

Why Standardize our Management?• Bronchiolitis is a big problem

– 2.9% of infants in the U.S. hospitalized with bronchiolitis each year, at an estimated cost of $543 million dollars annually.

– Hospitalization rates and length of hospital stays have increased dramatically in recent years.

• Considerable practice variability exists in the use and interpretation of pulse oximetry data, which has been shown to be associated with increased resource utilization and length of stay (Willson 2001, Plint 2004)

• Variability in care is confusing, leads to communication problems, and can be costly and detrimental to care (extra procedures, increased length of stay)– Informal survey results: perception of variation

Our Goals

• Global Aim: To standardize care, utilizing the best available evidence.

• Specific Aim: By March of 2010, 90% of otherwise healthy infants < 1 year and > 2 months of age admitted to LA1W with a diagnosis of bronchiolitis should receive care conforming to an evidence-based care pathway.

Key Drivers

• Knowledge of Respiratory Status• Defined Criteria for Oximetry and Oxygen use• Awareness and buy-in of staff, especially

nursing• Awareness and buy-in of parents

MD initials for informal education:

Yes

No

No

< 90-91%> 94%

91-94 %

No

Yes

No

No

Did any deviation from the pathway occur? (cicle one)Yes No

If yes, describe briefly here or in EPIC

Did discharge occur within 6 hours after O2 weaned? Yes

NoIf not, why not? (circle one)

Nutrition/PO intake Suctioning

Social Reasons Other (describe briefly)

Yes

Yes

Yes

Patient Admitted to LA1W

Respiratory Assessment- Position Patient

- Suction if needed - Record in EPIC

- Check Oxygen Saturation

Patient on Oxygen?

Measure Oxygen

Saturation

Intermittent SpO2 monitoringConsider continuous CV monitor

Continuous Oxygen Monitor, CV monitor

Oxygen Saturation

>91%?

Add Oxygen

Patient Improving?

6 hours off O2?

Meets all other discharge criteria?

Discharge

Wean O2 aggressively

Increase O2

Re-assess in 2 hours or sooner if needed

Wean O2 as tolerated

Parent Education by

Physician

Intervention #1:The Protocol:

-Emphasizes frequent respiratory assessment and suctioning

-Clear guidelines for starting and stopping monitors

-Not a radical departure from current practice

Flow Sheet Elements

• The Respiratory Assessment– Nursing Driven– Consistency in

SaO2 measurement– Every 2 hours and

PRN

Patient Admitted to LA1W

Respiratory Assessment- Position Patient

- Suction if needed - Record in EPIC

- Check Oxygen Saturation

Parent Education

by Physician

Clinical Pathway Elements

• Monitor and O2 decision tree

• Allows for rapid weaning

• Movement to intermittent monitoring in 2 hours or less

Patient on Oxygen?

Measure

Oxygen Saturati

on Intermittent SpO2 monitoringConsider continuous CV monitor

Continuous Oxygen Monitor, CV monitor

Oxygen Saturati

on >91%?

Add Oxygen

Wean O2 aggressively

Increase O2

Wean O2 as tolerated

>94<90

Yes

No

91-94

Clinical Pathway Elements

• Discharge vs Reassessment

• Return to top of flow chart

Patient Improving?

6 hours off O2?

Meets all other

discharge criteria?

Discharge

Re-assess in 2 hours or sooner if needed

Wean O2 as tolerated

Outcome Metrics: Primary Outcomes

• Variation from pathway, as reported by nurses or physicians– Failure to complete paper documentation

assumed to mean variation from pathway

• Number of respiratory assessments performed as documented in EMR– Normalized to 2-hour time blocks– So, the more assessments per 2 hour block, the

better

Other Metrics

• Length of Stay– Short baseline (28.5 hours in 2009)

• Albuterol Usage– Infrequent use at baseline

• Patient Satisfaction Score– Baseline is very high at our satellite facility– New feedback form specific for bronchiolitis

Results

• Fifty-nine qualifying admissions between January 10th and March 3rd

– Admitted to satellite facility with diagnosis of bronchiolitis, RSV, or viral pneumonia

• Average length of stay: 29 hours• Ages: 11 days – 18 months• Average age: 5.6 months

Variation and Use of Clinical Guideline

0

10

20

30

40

50

60

70

80

90

4-Feb 12-Feb 19-Feb 5-Mar

Percent

% RN compliance

% MDCompliance

% MonitoringVariation

% DischargeVariation

Feb 4: Protocol started

Feb 12: RN education, Protocol off chart to room

Feb19: “Huddles”

Mar 5: admissions fall off

Decrease in Standard Deviation of Respiratory Assessment Frequency

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

1/2/2010 1/12/2010 1/22/2010 2/1/2010 2/11/2010 2/21/2010 3/3/2010 3/13/2010

Asse

ssm

ents

per

2 h

ou

r b

lock

PDSA 1

PDSA 2

Length of Stay

0

20

40

60

80

100

120

140

1/2/2010 1/12/2010 1/22/2010 2/1/2010 2/11/2010 2/21/2010 3/3/2010 3/13/2010

ho

urs

Lessons Learned

• Desirability of standardization of evidence-based practice in bronchioiltis

• Quality improvement is a useful tool for achieving that standardization

• Staff “buy-in” very important• Having an EMR can facilitate more powerful

data analyses, making improvement more effective

Conclusion

• Quality improvement can be a very useful clinical tool

• Knowing what to do isn’t always enough; you have to be able to actually do it, and know how you know you did it.

Future Directions

• Increasing compliance from 70% to 90%– Addressing shift discrepancy

• More specific metrics– Process measures (e.g. discharge efficiency)– Effects on outcomes?

• Other QI processes– Liberty as a “clinical laboratory”