Grant Mussman, M.D. Cincinnati Children’s Hospital

1. 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

2. 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

3. 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

5. 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.

6. 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

7. Intervention #1: The Protocol: -Emphasizes frequent respiratory assessment and suctioning -Clear guidelines for starting and stopping monitors -Not a radical departure from current practice

8. Flow Sheet Elements • The Respiratory Assessment • Nursing Driven • Consistency in SaO2 measurement • Every 2 hours and PRN Patient Admitted to LA1W Parent Education by Physician Respiratory Assessment- Position Patient- Suction if needed - Record in EPIC - Check Oxygen Saturation

9. Clinical Pathway Elements • Monitor and O2 decision tree • Allows for rapid weaning • Movement to intermittent monitoring in 2 hours or less Patient on Oxygen? Continuous Oxygen Monitor, CV monitor Oxygen Saturation >91%? No Measure Oxygen Saturation Add Oxygen <90 Yes >94 Intermittent SpO2 monitoringConsider continuous CV monitor Wean O2 aggressively Increase O2 91-94 Wean O2 as tolerated

10. Clinical Pathway Elements • Discharge vs Reassessment • Return to top of flow chart Patient Improving? Wean O2 as tolerated 6 hours off O2? Meets all other discharge criteria? Re-assess in 2 hours or sooner if needed Discharge

11. 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

12. 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

13. 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

14. Feb 12: RN education, Protocol off chart to room Mar 5: admissions fall off Feb 4: Protocol started Feb19: “Huddles”

15. PDSA 1 PDSA 2

17. 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

18. 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.

19. 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”