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Introduction to the B-QIP Change Package

Introduction to the B-QIP Change Package. Presenters: Michelle Marks, DO, FAAP Cleveland Clinic Children’s Hospital Grant Mussman, MD, FAAP Cincinnati Children’s Hospital B-QIP Learning Session Webinar August 29, 2013. Agenda. Introductions. Michelle Marks, DO, FAAP

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Introduction to the B-QIP Change Package

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  1. Introduction to the B-QIP Change Package Presenters: Michelle Marks, DO, FAAPCleveland Clinic Children’s Hospital Grant Mussman, MD, FAAP Cincinnati Children’s Hospital B-QIP Learning Session Webinar August 29, 2013

  2. Agenda

  3. Introductions • Michelle Marks, DO, FAAP Cleveland Clinic Children’s Hospital • Grant Mussman, MD, FAAP Cincinnati Children’s Hospital Reminders: This webinar is being recorded. If you are a local physician leader seeking ABP MOC Part 4, please identify yourself via the Question chat box. The Quality Collaborative for Improving Hospitalist Compliance with the AAP Bronchiolitis Guideline (B-QIP) is funded by the AAP Quality Improvement Innovation Networks (QuIIN)

  4. Learning Objectives By the end of this webinar, you will be able to: Integrate, improve and test respiratory scores in the treatment of bronchiolitis Draft, adapt and test protocols or ordersets related to bronchiolitis treatment Know where to look for resources to help improve inter-departmental communication, tobacco screening and treatment, and other best practices

  5. Meaningful feedback from Pre-Survey I

  6. Meaningful feedback from Pre-Survey, cont’d

  7. Reality Check

  8. Right now you should be gathering your data from last bronchiolitis season • You should feel like you understand the measures we will be tracking for BQIP • You should have a sense of who makes up your team • Today you will be introduced to some potential tools • You will look at your local data and your current practices • You and your team will pick an intervention strategy with a goal to implement it before Jan 2014 Where are we now? Where am I going?

  9. B-QIP Change Package Outline The change package is not an exhaustive list of tools. It is merely a starting point of tools and strategies that can be adapted. The B-QIP coaching team is in support of you continuing to use strategies that work; please do share those strategies with your peer teams! The change package is a resource…we are sure you are already on the improvement journey!

  10. B-QIP Change Package Outline, cont’d • Organized by: • Clinical pathway • Respiratory Distress Score • Oxygen Weaning Protocol • Tobacco Smoke Exposure • Other Tools & References

  11. B-QIP Change Package Outline, cont’dChange Package Grid, Guideline and B-QIP Aims overlaid

  12. Integrating Respiratory Scores Grant Mussman, MD

  13. Integration of Respiratory Scores into treatment • Ideal Respiratory Score • Simple • Enough elements to fully capture respiratory status but only just enough • Usable by variety of clinical providers • Reliable • Responsive • WARM score • Adapted from the WARM-E asthma score developed at Cincinnati Children’s Hospital

  14. WARM score • Wheezing (0-2) • None • End expiratory • Entire/any expiratory • Air Exchange (0-2) • Normal (0) • Focal decrease (1) • More than one area of decrease (2) • Respiratory Rate (0-1) • Above age-normalized tachypnea threshold (1) • Muscle Use/Retractions (0-2) • None (0) • Subcostal/Intercostal (1) • Any neck or abdominal (2)

  15. WARM score • Score is additive, ranging from 0 to 7 • Lower score = less sick • For scores > 3, a trial of bronchodilator may be indicated • Reasonable to try suctioning of the nasopharynx first and then re-score • Improvement after bronchodilator • WARM decreased by 2 or more points • Can continue PRN bronchodilator • Avoid multiple trials without demonstrated improvement

  16. Scenario 1 • 6 month old infant with URI symptoms and fever • On exam in the ED: tachypneic with moderate retractions but little wheezing • Admitted with mild O2 requirement • At sign-out, ED physician reports that patient seemed to have responded to two albuterol treatment and is more comfortable now

  17. Scenario 1

  18. Scenario #1 • No change in respiratory score noted before or after albuterol treatment • Further bronchodilator trials unnecessary • Differences in patient “comfort” can be perceived for a variety of reasons • Control of fever • Suctioning • Oxygen • Mobilization of mucus plug

  19. Scenario #2 • 6 month old infant with URI symptoms and fever • On exam in the ED: tachypnea, retractions, head bobbing, and nasal flaring • Suctioned once and then given an albuterol treatment, now has much easier WOB • Admitted with mild O2 requirement

  20. Scenario #2

  21. Scenario #2 • Respiratory score actually increases after bronchodilator trial (increased tachypnea) • Further bronchodilator trials unnecessary • Patient did benefit significantly from suctioning

  22. Scenario #3 • 6 month old infant with URI symptoms and increased work of breathing • On exam in the ED: mildly tachypneic, no retractions, scattered wheezing • Admitted with mild O2 requirement

  23. Scenario #3

  24. Scenario #3 • Mild symptoms and WARM < 3 • Bronchodilator trial not indicated

  25. Scenario #3: Continued • Now 12 hours after admission, and nurse calls to report that patient afebrile but slightly more tachypneic, with retractions and wheezing • WARM score from RT as follows:

  26. Scenario #3: Continued • No response to suctioning on the floor • WARM score > 3 • Bronchodilator trial indicated at this point

  27. Scenario #3: Continues • Patient admitted with PRN albuterol available • Twenty minutes after the treatment ends, the nurse again calls with a concern for the same patient • Oxygen requirement has increased from 0.5 liters to 2 liters by nasal cannula • Wheezing and retractions have returned • Suctioning ineffective once again

  28. Scenario #3 • A second bronchodilator has been administered

  29. Scenario #3: Conclusion • Bronchodilators not helping at this point • Lack of response clearly documented • Suctioning also not providing benefit • Time to do something else! • Call the PICU • Initiate high flow nasal cannula on the floor (if available on the floor)

  30. Conclusion • WARM score is a simple, reliable, and responsive method of objectively assessing response to bronchodilators and suctioning • Respiratory therapists can reliably administer and document the score • Threshold score of 3 identifies those who may benefit from a bronchodilator trial • A decrease of 2 or more in WARM score indicates response to therapy • Bronchodilators available PRN to responders

  31. Questions?

  32. Integration of Ordersets and Protocols into treatment Michelle Marks, DO

  33. QI concept: ordersets/guidelines/protocols • Shared baseline • Intended to provide ideal care for the “routine” patient • Educate users regarding evidence for care thus promoting change • Decrease variation in care

  34. Examples

  35. Guideline • Unit secretary notifies Respiratory Therapist (RT) assigned to that pediatric area when a patient is admitted with orders for Bronchiolitis Protocol. • Orders for Q4 Hypertonic will be placed in Cerner. • Patient will be assessed and score. • Score < 3 no intervention • Score >2 patient will be nasally suctioned and wait at least 5 minutes and then scored again. • Score >3 give treatment of Hypertonic Saline only, unless patient meets exclusion criteria. • Score again 15-30minutes after treatment positive response ( decrease in score by 2 or more) • If score increase by 2 or more on just hypertonic give albuterol and add albuterol to hypertonic saline treatments. • Do treatment Q4 x 3 and if score decrease by 2 or more, space to Q6x 2. • If patient does not respond after third Q4 treatment (score that does not decrease by 2 or more or increase no more treatments given). • If patient score < 4 for 24 hours treatments are discontinued.

  36. Patient admitted for Bronchiolitis Bronchiolitis Care Path Nasal tracheal suctioning with normal saline drops performed for all patients Oxygenation Assessed - Administer O2 by nasal cannula for SpO2 < 91 % or increased work of breathing Clinical Assessment repeated following suctioning and O2 administration If scored > 3, Aerosol treatment (Racemic epi) should be administered x 1 Responsive as evidenced by improvement in clinical score If unresponsive to Racemic epi treament Assess every 2 hours with continued aerosol treatments of Racemic epi if clinical scores greater than 3 Consider Albuterol or Levabuterol for patients with responsive wheezing (patients with history of RAD) Responsive to Albuterol/Levalbuterol Unresponsive to Albuterol /Levalbuterol Discontinue all inhaled medications if patient is non-responsive as evidenced by the bronchiolitis clinical assessment score Assess every 2 hours with continued treatments of Albuterol/Levalbuterol for clinical scores greater than 3

  37. Barriers Difficulty getting consensus • Desire for perfection • Lack of understanding of QI/process improvement cycle • Lack of evidence to support recommendations

  38. B-QIP ASKs • Review current order sets and guidelines for needed updates and streamlining • Do your current resources address all the elements of the project ??(particularly tobacco)

  39. Questions?

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