Approved Projects for Physicians with a Relationship with Nicklaus Children's Hospital

The following projects are currently approved for ABP Part 4 MOC Credit through the Portfolio Sponsorship Program. Unless otherwise stated, these projects are only available to physicians with a relationship to Nicklaus Children's Hospital.


Project Title:
Improve Adherence to the Acute Gastroenteritis Guidelines

Project Expiration Date: June 27, 2023
Approving Board: ABP
Project Description:

There is unnecessary testing being ordered for AGE and unstandardized treatment. The goal of this project is to improve compliance in the ED and Hospitalist Service of AGE guidelines to reduce unnecessary GI laboratory testing and standardized treatment. The goal of this project is to improve compliance with the AGE guidelines by 20% and thus decrease unnecessary GI- specific laboratory testing/antibiotic treatment in children in the ED and Hospitalist Service with the diagnosis of AGE from 3mo to 18y/o by 20%. This project was presented as a poster presentation (after peer-review) at the annual scholarship week. (Poster attached)

Completion Criteria :
Physicians claiming credit must participate in the design, planning, implementation of interventions, review of data, and/or attendance of planning meetings for a minimum of 6 months

To participate, contact the Project Leader: Amanda Leigh Hoffman, MD


Project Title:
Antibiotic Stewardship in the CICU

Project Expiration Date: April 01, 2023
Approving Board: ABP
Project Description:

Overuse of Linezolid in our CICU for empiric Gram positive coverage in situations where Vancomycin is acceptable. Physicians are uncomfortable using linezolid and piperacillin/tazobactam together in patients with healthy kidneys. Culturally, our institution also likes to use linezolid. The aim of this project is to decrease the DOT/1000 days of linezolid within the CICU over the course of two 16 weeks intervention cycles. This is done by developing an algorithm that dictates when linezolid and is not appropriate, educating the CICU team regarding the use of the algorithm and holding antibiotics time-outs to assess ongoing needs for antibiotics. The goal is to decrease to national average the use of linezolid by measuring DOT/1000 days through pharmacy logs in CICU patients over the period of the project.

Completion Criteria :
Participants may claim MOC credit if they actively participated in the planning, implementation of interventions, data review and analysis, attending team meetings over a period of 6 months minimum.

To participate, contact the Project Leader: Jacob Convissar, MD


Project Title:
Improving provider knowledge of current mild traumatic brain injury (mTBI)/concussion guidelines in the Emergency Department (ED)

Project Expiration Date: June 01, 2023
Approving Board: ABP
Project Description:

There are no standardized protocols for the diagnosis and management of mild TBI in the emergency department despite CDC guidelines published in 2018. This is due to a lack of knowledge regarding the new CDC guidelines may be causing this gap. The aim of this project is to improve knowledge of ED providers about current guidelines on mTBI/concussion by 50%. We will obtain pre-and post-intervention surveys of ED staff, provide education to providers on mTBI through education to all emergency department clinicians during staff meeting as well as video and PowerPoint presentations to review mild TBI/concussion guidelines, diagnosis and management.

Completion Criteria :
Physicians can claim credit if they participated in the planning, design, implementation of interventions, data review and analysis and they participated in the QI team meetings.

To participate, contact the Project Leader: Ana Ruiz-Castaneda, MD


Project Title:
Use of Beta-Hydroxybutyrate in DKA Management

Project Expiration Date: May 01, 2023
Approving Board: ABP
Project Description:

Beta-hydroxybutyrate (BHOB) is the predominant ketone body present in patients with DKA. The presence of this ketone body is a useful marker of DKA and can be utilized to monitor resolution. Evaluation of Beta-hydroxybutyrate can help initiate intensive care earlier in patients who are hospitalized with diabetes. Also BHOB functions as a marker of DKA resolution with subsequent de-escalation of intensive care and earlier initiation of subq insulin, possibly leading to decreased hospital admission time for those presenting with DKA. Additionally, this can decrease excessive use of blood gasses and comprehensive metabolic panels in the Pediatric Intensive Care Unit. The aim of this project is to improve DKA management by using/trending beta-hydroxybuturate level in the PICU

Completion Criteria :
Physicians can claim credit if they have participated in the design, planning, or implementation of interventions; or review and analysis of data and attending the QI meeting as a team for a minimum of 6 months

To participate, contact the Project Leader: Gabriela Lins, DO

Project Title:
Improving the Methods for Identifying and Managing Childhood Obesity in PC Setting by an evidence-based approach

Project Expiration Date: March 03, 2023
Approving Board: ABP
Project Description:

Childhood obesity is one of the foremost threats to population health in the United States, which has only increased during the COVID-19 pandemic. The rising prevalence of childhood obesity is associated with the emergence of comorbidities such as obstructive sleep apnea, type 2 diabetes mellitus, dyslipidemia, hypertension, and non-alcoholic fatty liver disease, in addition to psychosocial problems such as low self-esteem, depression, and peer discrimination which carry significant societal and economic burdens. Underdiagnosis of overweight and obese pediatric patients remains a concern. We noticed a potential for improvement of identification and management on the Pediatric Care Center (PCC) at our institution. Identifying obesity and its complications early and initiating appropriate management is crucial in preventing morbidity and mortality. This project will aim at implementing systematization of obesity management in our PCC. We noticed different approaches by varied Resident and Attending physicians. We believe that obesity management could be improved by implementing guidelines and a systematized approach.

Completion Criteria :
In order to claim credits, physicians must participate in the planning, implementation, data analysis, and/ or planning meeting for the QI interventions as part of the team for a minimum of 6 months.

To participate, contact the Project Leader: Eva Maria Glenn Lecea, MD


Project Title:
Implementation of Breastfeeding Curriculum Into Pediatric Residency Training

Project Expiration Date: December 31, 2023
Approving Board: ABP
Project Description:

Exclusive breastfeeding for infants up to 6 months of age is the ideal form of infant nutrition and increasing rates of breastfeeding is a major public health priority. Yet, the AAP has recognized a “lack of knowledge, confidence, and positive attitudes towards breastfeeding counseling” in pediatricians, which is likely due to inadequate education provided during pediatric training. Often mothers encounter problems while breastfeeding and, due to inability or insufficient guidance, they renounce breastfeeding in an earlier stage than recommended. The AAP has developed a breastfeeding residency curriculum that has been successfully implemented at many institutions, however our residency program does not yet have a formal breastfeeding curriculum that will provide the tools to guide mother and families into a successful breastfeeding plan. we aim to address the lack of standardized education in pediatrics residency program.

Completion Criteria :
Physicians may claim credit if they have participated actively in the planning, implementation and evaluation of the project interventions as part of the QI team and attended the QI meetings or participated in the data assessment and analysis.

To participate, contact the Project Leader: Alejandra Frauenfelder, MD


Project Title:
Improving diabetes knowledge in adolescents transitioning form pediatric to adult endocrinology

Project Expiration Date: December 31, 2022
Approving Board: ABP
Project Description:

Adolescents with diabetes mellitus (DM) have knowledge gaps of their condition that persists at the time of transitioning to adult care. The aforementioned adolescents need an opportunity to review this knowledge by means of a dedicated clinic and interactive methods. The aim of this project is:
1. To close important DM knowledge gaps at the time of transition
2. If provided a brief DM knowledge questionnaire, they should be able to improve upon before-intervention scores.
3. Immediately upon completion of education activity and later 3 and 6 months after initial intervention

The intervention involves using an interactive, group educational activity with a certified diabetes educator (CDE) will be held at the transition clinic.

Completion Criteria :
Completion criteria include active participation in the evaluation, administration, or implementation of the intervention and review and analysis of the data and participation in QI meetings over a 6 months period.

To participate, contact the Project Leader: Pedro Pagan Banchs, MD


Project Title:
Increasing Early Hospital Discharge

Project Expiration Date: May 31, 2023
Approving Board: ABP
Project Description:

Hospital crowding and subsequent resource strain have been associated with worse patient outcomes and increased length of stay. As pediatric hospitals face an overwhelming respiratory illness surge in the wake of the COVID pandemic, improving hospital patient flow is all the more critical. Nonetheless, a substantial proportion of patients, nearly 1 in 4 in one pediatric tertiary care study, who are medically ready experience delays in discharge. A growing number of quality improvement initiatives targeting increasing early discharges (EDCs) show promising data on improved emergency department (ED) patient flow without increased readmissions. At our institution, a 309-bed tertiary care pediatric hospital in south Florida, the pediatric hospital medicine team has low early discharge (before 12 pm) rates, with a baseline of 7.6% of all discharges in 2021. We suspect that a combination of workflow, resident comfort-level, and communication challenges contributed to this low percentage. In regards to workflow, attendings and teams round at variable times in the day which often leads to medically ready patients being seen later in the day. Meanwhile, lack of educational support may contribute to residents not identifying discharges early, and preparing them for discharge in a timely manner. Additionally, we identified communication gaps between residents, attendings and the nursing staff once a patient is ready for discharge that contribute to delays. This project aims at increasing early hospital discharges for medically ready Pediatric patients at Nicklaus Children’s Hospital

Completion Criteria :
Attend 3 team meetings, and provide feedback on PDSA cycles during meetings.

To participate, contact the Project Leader: Magi Dickinson, MD


Project Title:
Appropriate Thromboembolic Prophylaxis Therapy in IBD Patients Admitted to the Hospital: A Proposed Risk Stratification Algorithm

Project Expiration Date: Aug 01, 2022
Approving Board: ABP
Project Description:
Thromboembolism (TE) is a potentially life-threatening complication of IBD. The increased risk of TE in adults with IBD is well established, and anticoagulation prophylaxis is being instituted as a standard of care. TE risk in pediatric IBD compared with adults is lower, however studies report an increasing incidence in this population. We aimed to decrease risk in our hospital population given this facts. The aim of the project is to determine the percentage of admitted pediatric IBD patients who received appropriate TE prophylaxis therapy based on a risk stratification algorithm and increase the percentage of IBD patients receiving appropriate prophylactic therapy measured over a 16-week intervention period per cycle.

Completion Criteria :
To claim credit, physicians must be involved in the design, planning, implementation, data collection, analysis, review, or interventions for a minimum of 6 months.

To participate, contact the Project Leader: Maria Susana Lopez Gonzalez, MD


Project Title:
Impact of standardized documentation and migraine treatment on diagnosis, headache burden, and health care utilization in a pediatric population

Project Expiration Date: June 30, 2022
Approving Board: ABP
Project Description:
Migraine headache is a common diagnosis in the pediatric population with a wide variety of both symptomatic presentation and clinical management. Until recently there has been no standardized intervention, and routine neuroimaging is not indicated. Management differs between ER physicians, Hospitalists, and Neurologists based on physician and patient preferences. Furthermore, documentation plays a significant role in accurate diagnosis. Variation is seen in medication management, imaging studies and healthcare utilization. Our quality improvement project will look at the effect of standardizing inpatient migraine treatment and documentation in order to ascertain effects on diagnosis, headache burden and health care utilization.

Lack of standardization in medication management and documentation, contribute to longer treatment duration and suboptimal care. This project aims to improve compliance with a standardized protocol and decrease imaging, length of stay, and readmission rates in this population.

Completion Criteria :
Physicians participating in this project are eligible to claim credit if they have participated in the project design, implementation of intervention, data collection, results review and charting, discussions, or project evaluation over a period of 6 months at least.

To participate, contact the Project Leader: Jacklyn Smith, MD


Project Title:
Improving Depression Screening in Adolescents with Inflammatory Bowel Disease

Project Expiration Date: November 28, 2022
Approving Board: ABP
Project Description:
Patients with IBD have higher depression rates and are at risk for non-compliance, longer inpatient admissions, and complications. Resources (Psychiatry, Psychology, etc.) are available but not all patients with depression can take advantage due to low screening and detection rates. The problem exists because of low index of suspicion and low rates of screening in the outpatient and inpatient settings. The main aim of this project is to increase early detection of depression by 30% in patients > 12 years with IBD admitted to the inpatient unit and provide appropriate resources. Screening is done using the PHQ-9 on all admissions, weekly reminders sent via text to the care team and visual reminders placed in workroom.

Completion Criteria :
Physicians are eligible to claim credit if they participated in the planning, implementation of the interventions, data collection, data analysis, revision of plan, or QI team meetings over a minimum of 6 months.

To participate, contact the Project Leader: Claudia Riera Canales, MD


Project Title:
Improving EBM practice in Pediatric Residency

Project Expiration Date: December 1, 2022
Approving Board: ABP
Project Description:
Evidence-based medicine (EBM) practice is cornerstone for optimal clinical decision making among physicians since it can impact management to benefit the patients with most updated evidence. Residency is a great opportunity to train future doctors in the use of EBM and implement it into their clinical practice. Many barriers exist into EBM practice such as time, knowledge and skills. Identifying those barriers may improve EBM practice among training residents and subsequently improve medical practice. We utilized a standardized EBM questionnaire to obtain a baseline regarding comfort level, knowledge, identify barriers and estimate perceived practice. With the results, a series of workshops were designed to address the identified barriers to EBM application on clinical practice, general knowledge and overall comfort level of residents using EBM resources and terminology. We also implemented an “EBM prescription” reward program that incentivized the formulation of clinical questions and the use of EBM to answer them, which allotted points to residents for each time EBM is used, and were scored using standardized formats by senior residents during rounds.

Completion Criteria :
To qualify for claiming credit, physicians must participate in either the planning, implementation of the interventions, data collection, review of data, data analysis, or QI Team meetings for a minimum of 6 months

To participate, contact the Project Leader: Giancarlo Giovannini, MD


Project Title:
Increasing Awareness of The Montelukast Black Box Warning

Project Expiration Date: March 31, 2022
Approving Board: ABP
Project Description:
In March 2020 the FDA issued a black box warning to montelukast in order to raise awareness among health care providers regarding its potential neuropsychiatric side effects (SE). Montelukast has been associated with both worsened and new-onset suicide, depression, and irritability, among other neuropsychiatric symptoms. Due to the recent nature of the FDA black box warning, we sought to increase provider awareness of black box warning and thereby improve counseling patients regarding the black box warning. This project aims at improving documentation of questioning of pediatric patients of all ages on Montelukast neuropsychiatric effects from (0%) to 50% in one year and improving awareness of black box warning among residents and clinic attendings by 50%.

Completion Criteria :
Physicians are eligible to claim credit if they participated in the design, implementation of interventions, review of the data, or discussions and changes made on the project over a minimum of 6 months period.

To participate, contact the Project Leader: Gabriel Mandel, MD


Project Title:
Standardizing Hearing and Vision Screening in the PCC

Project Expiration Date: March 31, 2022
Approving Board: ABP
Project Description:
The American Academy of Pediatrics (AAP) has put forth recommendations for scheduled hearing and vision screenings. Although screenings at our PCC were being completed, they were not following AAP guidelines regarding recommended ages of screening and subspecialty referral criteria. In addition, if screenings were completed there often was no consistent documentation of the screenings. Inconsistency in documentation made referring to appropriate subspecialties for continuous evaluation and care difficult and it prevented adequate continuity of care. The gap was likely multi-factorial in origin, likely secondary to gaps in education and large patient load/business of the clinic. Our aim was to provide a method to consistently and accurately document hearing and vision screens in order to increase screening rates to 100%. Our time limit was throughout the course of our project, approximately 18 months. Interventions included education of residents, and implementation of note template based on age-specific criteria

Completion Criteria :
To claim credit, physicians should have participated in the project design, planning, implementation of interventions, data collection, analysis of the data, or QI project meetings for a period of minimum of 6 months.

To participate, contact the Project Leader: Elisa Prebble, MD


Project Title:
Improving Pediatric Pain Management Practices Among Hospitalized Patients With Scheduled Non-Opioid Treatments

Project Expiration Date: March 17, 2022
Approving Board: ABP
Project Description:
Pain in the pediatric population is poorly understood and frequently mismanaged. This often leads to prolonged hospitalizations and adverse outcomes. Studies in a variety of populations, especially in the post-operative settings, have shown that scheduled pain medications instead of as needed dosing leads to decreased length of stay, better pain management and decreased opioid use. The aim of this project is to improve the utilization of fixed –schedule acetaminophen/NSAIDs dosing by 20% within the PDSA cycle in hospitalized pediatric patients admitted with skin and soft tissue infections including: cellulitis, abscesses, tonsillitis and gingivitis

Completion Criteria :
Participating physicians are eligible for credit if they participated in the planning, implementation of interventions, measurement of outcomes, review of the data, or feedback and education for a minimum of 6 months.

To participate, contact the Project Leader: Rose Mathews Berry, MD


Project Title:
Improving the Management of Acute Pancreatitis in Keeping With Most Updated NASPGHAN Recommendations

Project Expiration Date: June 01, 2022
Approving Board: ABP
Project Description:
After coming across the 2018 NASPGHAN recommendations released by the NASPGHAN Pancreas Committee for managing Acute Pancreatitis (AP) in pediatric patients, we wondered if our hospital was adequately following these guidelines. We had an idea that we probably were not as we noticed that several AP patients were on only 1x MIVF instead of the recommended 1.5 - 2 x MIVF. We also believed that our attendings tended to fare more on the conservative side of pain management and wondered if this may have an negative impact on adequately managing pain in these patients with AP. Overall, we believe the cause of this gap is due to lack of knowledge regarding the updated guidelines and conservative management practices.

This project aims to increase adherence to NASPGHAN guidelines >90% in 4 domains:
- Early initiation of enteral feeds
- No prophylactic antibiotic use in AP
- Adequate administration of IVFs
- Optimization of pain management

This project was presented at several meetings based on peer-review. Poster and Pathway included as attachments.

Completion Criteria :
In order to be eligible to claim credit, participating physicians must be part of the project through an active role including implementation of the intervention(s), or review of the data, or designing future interventions for the project over a minimum of 6 months period.

To participate, contact the Project Leader: Annette Roberts, MD 



Project Title:
Improving adherence to AAP 2011 Febrile seizure guidelines

Project Expiration Date: January 01, 2021
Approving Board: ABP
Project Description:
Work up for simple febrile seizures can be unnecessarily extensive and costly. There is a lack of adherence to AAP 2011 febrile seizure guidelines. The goal of this project is to improve adherence by physicians at NCH to the 2011 AAP guidelines for simple febrile seizures. This is done through (1) Correctly identifying patients who meet criteria for simple febrile seizures and thereby minimizing unnecessary lab work.

Baseline data identified 62.5% of patients who fit the study criteria did not undergo unnecessary labs/imaging, our goal is to increase this to 75% over 12 months period. Interventions included (1) Education about the guideline at the ER staff meetings and residents lecture and show the baseline data with statistics on overuse of labs. (Cycle 1) and (2) Review the data collected monthly and continue to provide the report card/feedback via email to the staff using visual representation. (Cycle 2)

Completion Criteria :
To qualify for credit, physicians must participate in either the care of patients, implementation of the intervention, review and analysis of the data and feedback about future interventions.

To participate, contact the Project Leader: Ana M. Ruiz-Castaneda, MD 


Project Title:
Improving Transport Efficiency of Mechanically Ventilated Pediatric and Neonatal Patients through Protocol Implementation

Project Expiration Date: October 29, 2021
Approving Board: ABP
Project Description:
Time at bedside for transport of mechanically ventilated pediatric patients being transported by the Nicklaus LifeFlight Team is impacted by complexity of patients, call back to medical command (accepting physician), excess blood gases  leading to delays. This project is ongoing and is in its third cycle. (1) The 1st cycle – Included baseline data and performing a process map with all stakeholders (Process measure) and lead to the creation of a transport protocol which was implemented. (2) 2nd cycle - A 30 day implementation trial and data collection on the new protocol. (3) 3rd cycle - The protocol was expanded to include all mechanically ventilated patients (not just HFOV patients, excluding cardiac patients, <32 weeks gestation, any concern for raised ICP) and collected post-implementation data for 6 months after implementation (in progress). The project aim is to reduce bedside time at outside institution by 10%  (from fall of 2019 to fall of 2021) for pediatric and neonatal patients (excluding infants < 32 weeks and cardiac patients) on high frequency oscillatory ventilation by the transport team by instituting new transport protocol.

Completion Criteria:
Active participation in the planning, implementation, data collection, and/or analysis for 6-12 months with participation in the meetings

To participate, contact the Project Leader: Manette Ness-Cochinwala, MD


Project Title:
Addressing COVID-19 Vaccine Hesitancy in Hematology-Oncology Patients

Project Expiration Date: March 31, 2022
Approving Board: ABP
Project Description:
As of December 2020, the FDA approved Pfizer COVID-19 vaccine to populations 16 years and older. Immunization is specifically recommended for populations at high risk of developing severe COVID-19 infection, amongst which are included patients with chronic conditions. In our institution, we follow 25 patients above the age of 16 with Sickle Cell Disease (SCD), of which only 7 have received the COVID-19 vaccine. Also noted by the specialists, the oncology patients have an apparent higher immunization acceptance, so we would determine the acceptance of the vaccine in these two populations and inquire about the social determinants that impact the vaccination rate, such as race or religion. 

Recently, vaccine administration was approved for children 12-15 years, increasing the population to be included in our project. This gap could be due to first and foremost lack of adequate information and knowledge about vaccine eligibility, recommendations, and benefits. There could also be a lack of offer from primary care physicians.

Completion Criteria:
Participate in the planning or implementation of intervention and/or data collection and/or analysis. Attend the scheduled QI team meetings. Active meaningful participation for a minimum of 6 months. 

To participate, contact the Project Leader: Andrea Montano Ballesteros, MD


Project Title:
ED Headache Protocol

Project Expiration Date: June 29, 2020
Approving Board: ABP
Project Description:
There is inconsistent decision making for treatment, and additionally delays and subsequent prolonged length of stay with patients diagnosed with migraines or headaches. Through our experience, that there is currently no standardization for the care of patients in the ED who present with the primary diagnosis of headache or migraine. With the implementation of a protocol and order set, we plan to decrease the return visits to the ED for patients with the diagnosis of migraine or headache by 10% by the end of 2019. This will be done by the implementation of a protocol in conjunction with the Neurology team, educating the physicians in the ED about the protocol, and subsequently creating a Power Plan within Cerner (EHR).
 
Completion Criteria:
Participation in either the design, planning, implementation / intervention, data review, analysis and /or QI meetings for a minimum time of 6 months.

To participate, contact the Project Leader: Amanda Cruz-Deweese, DO


Project Title:
Improving Asthma Control Test Use in the Pediatric Care Center

Project Expiration Date: April 29, 2021
Approving Board: ABP
Project Description:
Poor asthma control is a risk factor for further exacerbations and impacts greatly patients’ quality of life. Current asthma recommendations include assessing patient’s level of control. The Asthma Control Test (ACT) is one of several validated asthma questionnaires to evaluate control in pediatric and adult patients. This questionnaire has been validated in patients over the age of four with the aim to identify poorly controlled individuals in need of treatment escalation. The established cutoff value of ACT scores of 19 or less, identifies patients under poor control. Additionally, these patients would benefit most from having a formal Asthma Action Plan (AAP).
The gap is lack of knowledge of staff regarding test importance and knowledge of accessing test and documentation. The aim of this project is to improve ACT documentation in patients with asthma diagnosis at Well Child Checks to 25% over 6 months period
 
Completion Criteria:
Physicians must participate in the planning, implementation of interventions, data collection, or data analysis and interpretation over a minimum time of 6 months. 

To participate, contact the Project Leader: Daniel Urschel, MD


Project Title:
Increasing Appropriate Albuterol Use in the PICU

Project Expiration Date: December 30, 2020
Approving Board: ABP
Project Description:
The inhaled nebulized albuterol use in our PICU is significantly higher than the national average. This might be due to the fact that inappropriate albuterol use/ overuse- for instance for bronchiolitis or for those with URI and no reactive airway or asthma history. The interventions will include posting Classes for Appropriate use in the Fishbowl, as well as share over WhatsAapp and in emails the same information.  Emails, WhatsApp messages, discussions, and education with residents, fellows, attendings, pharmacists, nurse practitioners, and respiratory therapists.
The project will be monitored with weekly updates to the fellows and attendings including the reminder of what is and isn’t appropriate albuterol use. data will be tracked and analyzed. 

Completion Criteria:
Completion criteria includes active participation in either the design or implementation of interventions, or review and analysis of the data, or providing feedback on the project.

To participate, contact the Project Leader: Deidre Anastas, MD 


Project Title:
Improving Transition of Care after Discharge from the NICU: Implementing a Post-discharge Telemedicine Visits

Project Expiration Date: May 30, 2021
Approving Board: ABP
Project Description:
Transition of care from the NICU to home generates significant issues that may lead not only to increase length of stay but also higher post-discharge healthcare utilization, due to hospital readmissions and emergency department visits. This transition is recognized as critical to address opportunities to promote patient safety and high-quality of care. The growth and evolution of telemedicine are opening new avenues for efficient, effective, and affordable pediatric health care services. Outcome studies have shown high parent satisfaction, reduction in absenteeism due to illness, decrease travel time and costs, high rates of visit completion, and reduction in ED and urgent care (UC) visits. The NICU at NCH is a quaternary care children’s hospital providing care to critical patients who are discharged home with medical complexities requiring multiple health care services. Implementing a post-discharge telemedicine visit is aligned within the “Ins and Outs” project’s goal, primary and transition drivers and added to the set of change ideas already implemented for this project. The unit has implemented two post -discharge telemedicine services. One provided by KIDZ Medical Services, the hospital outsourcing company that provides the medical services and academic training to the residents in the NICU. Another telemedicine service is provided by nurses with the project entitled “Baby Step: A telehealth Nursing Intervention to Improve the Transition to Home” supported by a Grant from Florida Blue Foundation. 
We identified an opportunity for pediatric residents to participate in the NICU telemedicine activities. Residents will engage with live telehealth learning experiences, explore the role of telemedicine in improving the transition of care for NICU graduates, and embrace the changing models of care resulting from advancing telehealth technologies.  

Completion Criteria:
Participants are expected to be an active participant in QI meetings, implementing the intervention, documenting and reviewing data. Meaningful participation/ completion require minimum of 6 months participation
 

To participate, contact the Project Leader: Adolfo Llanos, MD


Project Title:
Early administration of long-acting insulin during acute diabetic ketoacidosis in children

Project Expiration Date: May 30, 2020
Approving Board: ABP
Project Description:

There is a substantial time lag for reaching the desired home administration time for long acting insulin analog after hospitalization for diabetic ketoacidosis. The patients need to shift their long acting insulin administration time every day by 1-2 hours until they reach the home desired time. Our hospital follows the protocol of long acting insulin administration at the transition time. There are published studies providing the long acting insulin analogs at a fixed times without any complications which can prevent the time lag to reach the home administration time. 
Our goal was to reduce the time lag for reaching the home long acting insulin time by 50% in qualifying patients by May 2020 by implementing an electronic medical record (EMR) power plan and medical staff education. 
We implemented an EMR power plan in Cerner PowerChart by modifying the Pediatric ICU DKA power plan with tagged protocol, medication dosing and times. All patients admitted for DKA excluding patients < 5 years of age, anyone with concerns for cerebral edema, on home insulin pump, or hemodynamically unstable. We provided education and feedback to medical staffs monthly. We used PDSA to analyze outcomes and implement new interventions.

Completion Criteria:
Physicians participating in the project meet completion criteria if they participated in implementation of the intervention, data collection, analysis or review, and participated in the meetings.

To participate, contact the Project Leader: Kalpana Singh, MD


Project Title:
Clinical Effectiveness Program for the Treatment of Uncomplicated CA-PNA

Project Expiration Date: June 01, 2021
Approving Board: ABP
Project Description:
There is lack of knowledge regarding antibiotic guidelines for uncomplicated CA-PNA. Our chart review revealed that in pediatric patients, greater than >6m, who are hospitalized with uncomplicated community-acquired PNA, we treat with ampicillin only 43.1% of the time. Our goal is to seek improvement in antibiotic stewardship and judicious use of antibiotics in fully-immunized patients, with uncomplicated CA-PNA, meeting inpatient criteria. Our SMART aim is: To increase the use of ampicillin in this population to 50% by August 2020, and to 75% by December 2020. The plan is to achieve that through education, creation of a new CA-PNA HP, and development of PNA pathway  with the Clinical Effectiveness Program.

Completion Criteria:
Physicians are eligible for MOC points if they meet the following criteria: Participation in the QI meetings, project review, data review, interpretation, analysis, implementation of the interventions, and / or education of the stakeholder team.

To participate, contact the Project Leader: Sophia Hassor, MD


Project Title:
Improving Venous Thromboembolism (VTE) Prophylaxis in the Pediatric Intensive Care Unit

Project Expiration Date: December 31, 2019
Approving Board: ABP
Project Description: 
There is a lack of appropriate prophylaxis (mechanical or pharmacologic) for venous thromboembolism in our PICU. Inadequate education and national guidelines.  Mechanical prophylaxis (SCDs) is a low risk, low effort intervention, but there is a not a culture of ordering and implementing them in our unit. 
Our goal was to improve VTE prophylaxis (mechanical or pharmacologic) to >75% in qualifying patients (≥12 years of age) by December 2019 by implementing an electronic medical record (EMR) pop-up and automatic order for sequential compression devices in patients who qualify. We implemented an EMR pop-up in Cerner PowerChart with a VTE screening tool to assess risk in patients in the PICU.  We then attached an auto-order for SCDs after multiple PDSA cycles to improve appropriate prophylaxis.  We used PDSA to analyze outcomes and implement new interventions. The project was completed and was peer-reviewed by my SOC Committee and the DIO (Dr. Gereige) who directs and evaluates the quality of the QI Projects

Completion Criteria:
Participating physicians meet the completion criteria if they participated in the planning, implementation of intervention, review and analysis of the data, and/or assisting with the imporvment process and connection to stakeholders (Via education or practice)

To participate, contact the Project Leader: John Kotula, MD


Project Title:
Standardization of Post-operative Management after Fontan Procedure

Project Expiration Date: June 01, 2020
Approving Board: ABP
Project Description:

Overall mortality and the incidence of early failure after the Fontan operation has significantly decreased over the last few decades, however perioperative morbidities still exist and a considerable number of patients require prolonged hospitalization after the procedure. The aim of this study was to describe our Fontan playbook (a standardized care pathway) and compare the postoperative outcomes with our institutions historical data. Specifically, this study aims at: (1) Describing our Fontan playbook (a standardized care pathway) and compare the postoperative outcomes with our institutions historical data (2) Improvement or goal is to decrease duration of chest tube placement and length of stay (3) The time limit for assessment is on a 6 month basis. Interventions include: 1) Create an algorithm pathway that can be followed by bedside nursing and the primary team to ensure patient is following an expected path of recovery. 2) Introduction of intervention: meeting with RT, nursing, physicians and ensure buy-in to pathway and answer questions prior to each fontan admission. 3) Training in proper use of pathway with flexibility. Ensure copy of pathway is available at bedside.

Completion Criteria:
Physicians must participate in the project for a minimum of 6 months. Participation may include attending QI meetings, reviewing the data collected, and/ or participating in implementation and design of the interventions.

To participate, contact the Project Leader: Kamalvir Gill, MD


Project Title:
Cardiac Arrest Prevention (CAP) Quality Initiative 

Project Expiration Date: May 01, 2021
Approving Board: ABP
Project Description:

Cardiac arrest in the cardiac intensive care unit is high and is associated with poor outcomes. Being able to detect early signs of an impending cardiac arrest can allow bedside providers to intervene prior. By implementing the elements of the CAP bundles, bedside providers are able to identify signs of impending decompensation as well as be better prepared if the patient arrests. This project aims at implementation of the 5 elements of the cardiac arrest bundle: twice daily huddles, vital signs posted at bedside, presentation discussion, weight specific epinephrine at bedside, formal review of all arrests Interventions include:

  1. “CAP SAFETY HUDDLE” – MULTIDISCIPLINARY DISCUSSION OF CA PREVENTION 2 TIMES/DAY, (AM SHIFT, PM SHIFT, CALL HAND-OFF) –GOALS AND PLANS POSTED AT BEDSIDE
  2. PATIENT-SPECIFIC VITAL SIGN GOALS ESTABLISHED AND ALARM PARAMETERS ADJUSTED & COMMUNICATED/POSTED AT BEDSIDE 
  3. PRE-SEDATION DISCUSSION FOR NOXIOUS STIMULI 
  4. EMERGENCY MEDICATIONS (EPINEPHRINE) AVAILABLE AT BEDSIDE 5.FORMAL REVIEW OF ALL CARDIAC ARREST EVENTS

Completion Criteria:
Physicians who participate in this project will need to meet the following criteria for completion: Participation in meetings of the team, implementation of intervention, review of the data, and/or designing new interventions.

To participate, contact the Project Leader: Kinjal Parikh, MD


Project Title:
Improving Efficacy and Safety of Pediatric Intensive Care Unit Patient Transfers

Project Expiration Date: May 25, 2016
Approving Board: ABP
Project Description:

Patient transfers from the Pediatric ICU were largely inefficient. Time to floor transfer ranged from hours to multiple days. Due to delays, initial handoff from ICU to floor team was inaccurate at the actual time to transfer and transfer orders were obsolete, thus increasing risk of medical errors. While awaiting floor bed, some patients were discharged home from the PICU, but floor team was never notified and patients continued to be counted in the floor team census affecting resident physician-to-patient ratios. This project aims to decrease the time lapse between the notification of PICU transfer to the floor team and actual arrival of the patient to the floor to <120 minutes within one year.

Completion Criteria:
Physicians participating in the project are eligible for MOC Credit if they meaningfully participate in the QI meetings, data review, design and implementation of interventions. Participation for a minimum of 6 months in the project is also a criterion.

To participate, contact the Project Leader: Bhavi Patel, MD


Project Title:
Brief Resolved Unexplained Events (BRUEs)

Project Expiration Date: October 12, 2020
Approving Board: ABP
Project Description:

BRUEs are a relatively new diagnosis, created from the AAP clinical guideline published in 2016. There is currently no data on whether this diagnosis is being correctly applied or on whether patients are being correctly classified as higher or lower risk. There is also no data on whether the recommendations for lower risk patients are being followed (minimal testing, no admission needed) and whether these recommendations are improving clinical outcomes. the Global Aim of this project is: To improve the care and management of infants presenting with BRUE by improving the recognition and classification of BRUE.

This is done using the following interventions proposed:

  • Creation of a note template for inpatient H&Ps with BRUE characteristics and risk classification included.
  • Conduct education with ED providers, hospitalist attendings and NPs and residents to review BRUE diagnosis, risk classification and recommendations for management.
  • Creation of a method for ED providers to give specific discharge instructions for patients with BRUE including information about CPR training.

Completion Criteria:
Physicians participating in the project are eligible for MOC Credit if they meaningfully participate in the QI meetings, data review, design and implementation of interventions. Participation for a minimum of 6 months in the project is also a criterion.

To participate, contact the Project Leader: Kathleen Murphy, DO


Project Title:
Assessment of HIV Screening in Adolescent Patients: A QI Project

Project Expiration Date: June 23, 2019
Approving Board: ABP
Project Description:

Universal HIV screening is recommended in all health-care settings after the patient is notified, unless the patient declines (opt-out screening). HIV screening was not being routinely offered in our institution’s Adolescent Medicine clinic. Residents feel uncomfortable approaching patients regarding sexual behaviors. Ignorance of HIV testing guidelines. Lack of EMR reminders. The Plan Do Study Act method of quality improvement was used. Baseline assessment consisted of a survey to evaluate residents’ knowledge regarding HIV screening guidelines, and a review of patient medical records for 2 weeks pre- intervention looking for documentation of HIV risk factors, previous HIV testing, and discussion/offering of HIV testing. Three PDSA cycles were completed. The aim of this project was to increase the rate of HIV screening offering and discussion to 90% of all patients seen in the adolescent clinic in our hospital in the 2 weeks following the interventions, with the overall goal of increasing rate in the following year.

Completion Criteria:
Physicians participating in the project are eligible for MOC Credit if they meaningfully participate in the QI meetings, data review, design and implementation of interventions. Participation for a minimum of 6 months in the project is also a criterion.

To participate, contact the Project Leader: Michell M. Lozano Chinga, MD


Project Title:
Implementation of a Toolkit for Transition Readiness Assessment in Patients with JIA: A QI project

Project Expiration Date: June 23, 2019
Approving Board: ABP
Project Description:

The American College of Rheumatology (ACR) has recommends assessment of transition readiness (TR) with previously validated tools, for all patients starting at 14 years of age, and interventions to achieve transition readiness by age 21. The Rheumatology clinic at our institution did not have a policy in place for transition readiness assessment. A smooth transition process has been associated with greater rates of patient satisfaction, empowerment and loss of follow up. The project aims to change lack of awareness of the need of a transition policy, lack of EMR reminders. Two cycles were performed. The aim was to increase the rate of TR assessment to 90% during visits to the Rheumatology clinic for patients with JIA, by launching the implementation of a TR toolkit (including GotTransition questionnaire) and advance notification to clinic staff.

Completion Criteria:
Participation in QI meetings, data review, design and implementation of interventions, and feedback.

To participate, contact the Project Leader: Diana Sofia Villacis Nunez, MD


Project Title:
Increasing Discussions on Early Peanut Introduction - A Quality Improvement Project

Project Expiration Date: October 31, 2018
Approving Board: ABP
Project Description:

Resident’s working in our continuity clinic were not aware of the LEAP addendum guidelines therefore they were not practicing these guidelines or discussing peanut introduction at well visits in our clinic. Through the use of education and visual cues, we wanted to increase resident knowledge on the LEAP guidelines. We wanted to improve discussions on peanut introduction at well visits which will include documentation. Lastly we wanted to have appropriate referral for patients that met criteria for the LEAP protocol. Our timeline included 12-18 months- 6 months of pre intervention data and 3 months for each cycle (2 cycles in total). Our goal is to improve documentation at 4 and 6 months well visit on peanut introduction.

Completion Criteria:
Physicians must be involved in the planning/ implementation/ data review/ or discussions of the various aspects of the project. The physicians involvement will be subject to attestation by the project leader.

To participate, contact the Project Leader: Priyanka Seshadri, MD


Project Title:
Improving Pediatric Resident Education at Nicklaus Children’s Hospital NICU

Project Expiration Date: May 31, 2019
Approving Board: ABP
Project Description:

The Accreditation Council for Graduate Medical Education (ACGME) states that for the resident, the essential learning activity is interaction with patients under the guidance and supervision of faculty members who give value, context and meaning to those interactions . With increasing pressures to treat patient as efficiently as possible, teaching of medical students and residents has become a challenge for neonatologists working in the neonatal intensive care unit (NICU). The introduction of the electronic health records has added further burden to the teaching process by shifting focus from the patient to the computer screen. Factors unique to the NICU environment that make the process of teaching more demanding compared to other pediatric rotations are: 1)Opportunities to learn NICU specific material not found in other rotations. 2)Reduction in the number of work areas and NICU rotations required by ACGME. 3)High patient acuity and complexity create a highly stressful NICU environment with fewer opportunities for formal resident education. Factors that are relevant to the NICU at NCH include: 1) Lack of labor & delivery and nursery services which limit the teaching to level IV NICU setting. 2) Lack of a fellowship program. 3) Teaching responsibilities assumed by a group of private practicing neonatologists. 4) Limited knowledge for participant neonatologists about the their teaching responsibility as required by ACGME 5) Two different Electronic Heath Record System for documentation in the NICU creating an additional burden to residents and neonatologists.

Completion Criteria:
Physicians will meet completion criteria by having a 6 months participation period in the project, participation in the review of the data, implementation of the various interventions.

To participate, contact the Project Leader: Adolfo R. Llanos, MD


Project Title:
Improving Vaccination Rates in Premature Infant in a Freestanding Children’s Hospital

Project Expiration Date: May 31, 2019
Approving Board: ABP
Project Description:

The AAP/CDC guidelines recommend that at 60 days of age, infants should receive diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine, Haemophilus influenza type b (Hib) vaccine, inactivated polio vaccine (IPV), and hepatitis B virus (HBV) vaccine. The first dose of HBV vaccine is dependent on infant birth weight (BW) and maternal hepatitis B surface antigen (HBsAg) status. Only monovalent hepatitis B vaccine should be used for PT or FT younger than 6 weeks. Administration of a total of 4 doses of hepatitis B vaccine is permitted when a combination vaccine containing hepatitis B vaccine is administered after the birth dose. Because all preterm infants are considered at increased risk of complications of influenza, 2 doses of inactivated influenza vaccine, administered 1 month apart, should be offered for all preterm infants beginning at 6 months of chronologic age as soon as influenza vaccine is available. (Saari, & the Committee of Infectious Disease, 2003; Schillie et al, MMWR 2018; AAP Committee on infectious Disease Red Book, 2018). Suboptimal immunization rates in NICU graduates has been widely reported in the literature. Delayed or non-immunization during hospitalization has been also related to an increased risk for delayed immunizations after discharge. Children who are under immunized at 2 months of age are more likely to remain under immunized at 6 months, 24 months, and 36 mont1 of age. (Macintosh et al. 2017). Improving vaccination rates in NICU setting is a complex process requiring a multidisciplinary approach. A quality improvement (QI) project could be helpful in identifying and overcoming barriers related to real-time recognition of vaccine eligibility, addressing clinician’s perceptions of side effect associated to vaccine, and use of information technology and innovative solutions to improve care. This QI project aims to improve immunization rates in the NICU at Nicklaus Children’s Hospital (NCH NICU). Process and outcome measures will be assessed after various interventions targeting barriers. This pilot targets patients cared by pediatric residents and excluded admission from the emergency department.

Completion Criteria:
To be eligible for credit, physicians must have substantial participation in key activities of the projects from reviewing data, to interventions, or to measurement of outcomes.

To participate, contact the Project Leader: Alejandro Frade Garcia, MD


Project Title:
Improving Time to Antibiotic Administration in Patients with Fever and Neutropenia in the Emergency Department

Project Expiration Date: November 30, 2016
Approving Board: ABP
Project Description:

Patients with fever and neutropenia are at a high risk of developing sever life-threatening infections. Studies have shown that administration of IV antibiotics within one hour of arrival to the ED can potentially abrogate this serious event. Our initial impression was that this was not achieved at our institution due to multiple barriers. In fact our baseline data showed only 3% compliance (97% non-compliance). The aim of this project is to decrease the time to antibiotic (IV) administration in patients with fever and neutropenia presenting to the ED to < 60 minutes and lower the rate of non-compliance by 50% from baseline by tracking the rate Q 3 months for 2 years. This was achieved through multiple stakeholders and interventions including: ER flow, EMR Power Plan, Pharmacy, IV Team, Physicians, Nursing, and ER staff. Project completed with increase in compliance rates. Process was hard-wired into the ED Flow.

Completion Criteria:
Completing 2 cycles, participation in data review, interventions, and / or process implementation.

To participate, contact the Project Leader: Kamar Godder, MD


Project Title:
Work Flow Analysis and Efficiency in a Pediatric Cardiac Intensive Care Unit

Project Expiration Date: January 15, 2016
Approving Board: ABP
Project Description:

The following interventions were implemented Cycle 1: After recording the time spent rounding on each patient for a few weeks, (Baseline data), all stakeholders were gathered for a brainstorming session to decide what items needed to be covered for every patient admitted to the CICU (during and before rounds) and round flow was standardized step-by-step. Intervention 1: Agreeing on the standard process/steps - Then, team members and intensivists realized that there are inputs that were upstream to the Contributors to Quality, which could not be captured by these flow sheets, but that still needed to be addressed to help reduce to a minimum the variation in rounds. Factors were listed Intervention 2: Education & following/adoption of the standard steps: Individual Patient Encounter Work Flow Sheet (Tool Designed) & Daily Rounds Flow Sheet (Tool for Rounds and Pre-Rounds Designed)

Completion Criteria:
To qualify for Credit completion, team members should have contributed to the QI project through attending the educational sessions, team meetings, reviewing the data, implementation of the tools, and revising the tool as needed.

To participate, contact the Project Leader: Darline Santana-Acosta, MD


Project Title:
Initiative to Decrease Length of Stay in the Emergency Department for Patients with Orthopedic Injuries

Project Expiration Date: November 30, 2018
Approving Board: ABP
Project Description:

Implementation of a nursing initiative where a trained group of nurses will place appropriate X-Ray orders for patients with orthopedic injuries before the physician sees the patient. Nurses will have a didactic instruction on orthopedic injuries and will see and examine at least one patient per type of injury. Once checked off by a physician, they will be able to order X-rays.

Completion Criteria:
Participating physicians will complete the project and obtain credit if they: 1) Actively participate in implementation of the intervention(s) - education/ training 2) Collect and/or analyze and review data

To participate, contact the Project Leader: David A. Lowe, MD


Project Title:
Maximizing ED Communication for Ensuring Safe Transition for Admitted Patients to the Floor

Project Expiration Date: October 1, 2018
Approving Board: ABP
Project Description:

Admitted emergency department patients are sometimes sent to the floor by nursing without the knowledge of the treating emergency department physician. Nursing priorities include transferring patients to the floor as soon as a bed is assigned to the patient and this sometimes supersedes appropriate communication between emergency department physicians and nurses. This project aims at improving communication. Through the implementation of a check mark in the electronic medical record to be completed by the physician. This checkmark verifies that the physician is okay with the patient being sent to the floor. Monthly reminders will be given to nurses at their meetings. Physicians working in the ED will be provided with daily reminders to complete the checkmark. The SMART aim includes: Within 6 months 90% of admitted patients will be approved by the treating physician before being sent to the floor by the nurse.

Completion Criteria:
Physicians are eligible for credit if they: 1) Participate in the implementation of the intervention related to the project 2) Actively participated in data collection and/or review and analysis.

To participate, contact the Project Leader: David A. Lowe, MD


Project Title:
End of Life Palliative Care in Oncology Patients with Non-Curative Cancer

Project Expiration Date: June 30, 2018
Approving Board: ABP
Project Description:

The aim of this project would be to involve end of life palliative care upon identification of patients with terminal or advanced cancer, encourage discussions about end of life care and decrease the incidence of ICU deaths in this population in the hopes to reduce aggressive interventions that may not provide reasonable benefit to patient. This is achieved through the planned steps: Development of a screening tool: Using various screening tools that are published or obtained from other hospitals we have reviewed and developed our own screening tool. The screening tool is enclosed. Development of a palliative care consultation form: With inputs from various physicians and palliative care team members we have developed a palliative care consultation form. Involvement of palliative care team nurse: Changes included early consultation with palliative ARNP and referrals on 6T floor admissions by resident scoring system and notifying MD whether palliative consult needed. Periodic education of residents rotating through 6T and 3T (PICU): PL3 and the Chief Pediatric Resident involved in this improvement project have prepared educational materials and have provided education every block with new residents arriving for the rotation in 6T and 3T. Additional educational sessions were conducted when the compliance was lower. Educational material is included. Education of oncology attendings: We have improved awareness of the aim of the project among oncology faculty through presentations in their Division Meetings. In addition, we have presented monthly updates on the progress of the project in their meetings. Presentation of data and education to PICU attending: We have presented periodic updates on the progress of the project in the Critical Care Division faculty meetings.

Completion Criteria:
Completion criteria include physician involvement in the project for 6-12 months as a team participant in either screening, implementation, or review and providing input on the project results.

To participate, contact the Project Leader: Balagangadhar R. Totapally, MB, BS


Project Title:
Depression Screening in Adolescents with Type 1 Diabetes Mellitus

Project Expiration Date: June 1, 2018
Approving Board: ABP
Project Description:

Patients with diabetes mellitus are at increased risk for depressive symptoms and disorders, particularly female patients. About 1 in 4 patients with diabetes suffer from depression. Therefore, there is a consensus on the need for periodic screening for depression in this population. At the same time, it appears that integrating mental and physical health care may improve outcomes. It was noted that formal mental health screening was not part of the visit for diabetic patients. This project aimed at increasing (to >90%) the rates of mental health screening using a validated Quality of Life tool PHQ-9 of adolescents with Type 1 DM and consequently increase mental health referrals to >90% of those who screen positive. Interventions included Education of providers, automated text in EMR for documentation , email reminder to staff. The project was peer-reviewed and accepted for presentation as a poster at the AAP Florida Chapter Annual meeting.

Completion Criteria:
Attend QI Team meetings, participate in data collection, review or intervention.

To participate, contact the Project Leader: Alfonso Hoyos Martinez, MD


Project Title:
Increasing Meningococcal Booster Vaccination in a Primary Care Practice: A Quality Improvement Initiative

Project Expiration Date: May 28, 2018
Approving Board: ABP
Project Description:

Age appropriate MCV#2 (booster) vaccination rates (68%) in the pediatric care clinic are noted to be well below our MCV#1 vaccination rates (94%) resulting in missed doses of MCV#2 vaccinations. This is due to incomplete EMR vaccination schedule and decreased awareness of vaccination recommendations. The aim of this project is to increase the rate of MCV#2 booster vaccination for 16-17 year old patients in our pediatric care clinic with a goal to match our MCV#1 vaccination rates over the course of 1 year. The poster was presented at the Annual Scholarship Day (peer-reviewed) and at the Florida AAP Chapter annual meeting (Peer-reviewed)

Completion Criteria:
Participation in implementation of the interventions, data review or analysis. Attends QI team meetings.

To participate, contact the Project Leader: Raphael Sturm, MD


Project Title:
Pediatric Residents' Knowledge and Proficiency of Epinephrine Auto-injector Administration and Handling: A QI Project

Project Expiration Date: May 31, 2017
Approving Board: ABP
Project Description:

Patients diagnosed with anaphylaxis are often discharged from the hospital with prescriptions for epinephrine autoinjectors (EAI). The purpose of this study was to evaluate the baseline knowledge of pediatric residents regarding proper handling and administration of EAI, and to assess their knowledge after providing them with a formal one-on-one training at the time of discharge. Since education among providers and patients is needed, we believe that efforts to improve the correct use of EAI among providers responsible for training is an essential component to ensuring that patients and families receive the most accurate guidance on how to use this life saving device. The goal of this project is: To increase the percentage of residents who are confident in how to properly use and care for an Epinephrine auto-injector from baseline to 70% or higher over a 3 week period All residents participating on the study will receive one-on-one education by Allergy and Immunology Fellow of the proper administration and handling of Epinephrine autoinjector. Materials and tools Used: Attached can be found the training tool (questionnaire) used for measuring resident’s knowledge on the proper use and handling of epinephrine autoinjector.

Completion Criteria:
Completing of 2 cycles, Participation in meetings, review of the data or implementation of the plan.

To participate, contact the Project Leader: Hanadys Ale, MD


Project Title:
Decreasing Empiric Use of Vancomycin in Late Onset Sepsis

Project Expiration Date: March 30, 2017
Approving Board: ABP
Project Description:

Starting in the 3rd week of October 2016, we educated residents on unit guidelines for LOS at the onset of the NICU rotation and implemented a LOS checklist to assess provider behaviors in the evaluation and treatment of episodes of suspected LOS (see attached checklist and guidelines). The lead resident in the project met with each group of residents at the beginning of their NICU rotation to explain the importance of adherence to LOS guidelines, including the limited indications for the use of vancomycin as well as the adverse effects associated with the overuse of this antibiotic. We then explained the methodology of data collection including the indications to fill out a LOS checklist and where to find it and return it. We engaged the residents by providing reminders in their workstations to fill out the checklist for cases of suspected LOS (stickers on the computers). The residents would then be prompted to bring the checklist to rounds, thus prompting a discussion with the attending about appropriate evaluation for LOS and the choice and duration of antibiotic treatment. The checklist included an area that had to be filled out 48 hours after initiating antibiotics, thus prompting the resident to discuss with the attending if it was appropriate to continue antibiotic treatment depending on whether or not there was a microbial indication.

Completion Criteria:
Completing of 2 cycles, Participation in meetings, review of the data or implementation of the plan.

To participate, contact the Project Leader: Jessica Barreto, MD


Project Title:
Decreasing Antibiotics Use by Standardizing Diagnosis and Management of Ventilator Associated Infection in the NICU

Project Expiration Date: May 31, 2019
Approving Board: ABP
Project Description:

We will target activities related to the primary drivers “hospital ASP and ID consultant participation” and improving “adherence to unit guidelines”.

  • Intervention 1: Develop algorithms for diagnosis and management of VAI The existing literature does not offer specific criteria for the diagnosis and management of VAI in the newborn period. Diagnosis of VAP is based on the definition provided by the Center of Disease Control for infant <1 year, which requires a combination of radiologic, clinical and laboratory criteria. Additionally, we developed an algorithm for the management of infant with suspected VAI adapted from the “Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Healthcare-Associated Pneumonia” created by the American Thoracic Society Documents.
  • Intervention 2: Education and discussion of algorithm with staff. Conduct an educational campaign with the nursing staff, residents and attending physicians on the appropriate diagnosis and treatment of ventilator associated infection following the developed diagnosis criteria and management algorithm. The educational objective will highlight the difficulties.
  • Intervention 3: Implementation of Guidelines We will use the checklist that was developed in October of 2016 for the iNICQ project. The checklist was modified to evaluate if the presence of a prior ETA positive culture was included in the decision of selecting the empiric antibiotic treatment for infant with VAI.

Completion Criteria:
We anticipate conducting a minimum of 6 PDSA cycles during the 6-months period starting July 1st 2017. Completion Criteria include: - Participation in one of more of the interventions - Attendance of QI meetings to review data and provide feedback - Educating staff and fellows re. the interventions and its tools/checklists/ criteria.

To participate, contact the Project Leader: Adolfo R. Llanos, MD


Project Title:
Improving Accuracy of Location of Peripherally Inserted Central Venous Catheters Using a Tip Locating System (TLS) During Placement

Project Expiration Date: May 31, 2019
Approving Board: ABP
Project Description:

Studies in adults and adolescents of Peripherally Inserted Central Catheters (PICC) found a right atrial malposition rate of 18% and other malpositions at 13.4%. in pediatrics, correction of these malpositions is a time consuming process and involves discomfort to the family and patient. Additional time is needed by the bedside and PICC nurses, ordering physicians, radiology techs and radiologists. Furthermore, additional healthcare supplies are used which leads to increased waste and costs. The PICC line tip termination point is determined by external measures on the patient body (estimates) rather than real time tip location devices during PICC insertion. The aim of the project is to evaluate and compare the rate of malpositioned PICCs on the first attempt after introduction of an Ultrasound-guided Tip Locating System (TLS) compared to the baseline data gathered before its use.

To participate, contact the Project Leader: Dr. Michael Leoncio


Project Title:
Decreasing the Oversuse of CXR in Children (3y-18y) with Uncomplicated Asthma

Project Expiration Date: June 30, 2018
Approving Board: ABP
Project Description:

Preliminary data from 2016 show that there is overutilization of CXR in the Nicklaus Children’s Hospital Emergency Department (ED) and Urgent Care Centers (UCCs). The numbers of ordered CXR in cases of uncomplicated asthma are significantly higher than the national benchmark. This leads to increased exposure of children to unnecessary radiation and increased cost of care. Despite the presence of Asthma national Guidelines, there is lack of adherence to the guidelines. This could be due to multiple factors including: (1) Lack of education of providers (2) Perceived expectations of parents by the providers and (3) other historic practice patterns (4) Fear of missing diagnosis (5) Fear of litigation. This project aims at decreasing the number of CXR ordered for children with uncomplicated asthma.

To participate, contact the Project Leader: Dr. Mario Reyes


Project Title:
Decreasing the Oversuse of CXR in Young Children (1m - 1 y) with Uncomplicated Bronchiolitis

Project Expiration Date: June 30, 2018
Approving Board: ABP
Project Description:

Preliminary data from 2016 show that there is overutilization of CXR in the Nicklaus Children’s Hospital Emergency Department (ED) and Urgent Care Centers (UCCs). The numbers of ordered CXR in cases of uncomplicated bronchiolitis are significantly higher than the national benchmark. This leads to increased exposure of children to unnecessary radiation and increased cost of care. Despite the presence of new AAP Bronchiolitis Guidelines since 2015, there is lack of adherence to the guidelines. This could be due to multiple factors including: (1) Lack of education of providers (2) Perceived expectations of parents by the providers and (3) other historic practice patterns (4) Fear of missing diagnosis (5) Fear of litigation . The aim of this project is to decrease the number of CXR ordered in patients with uncomplicated bronchiolitis between 1m-1year of age. This project is only opened to hospital physicians staff.

To participate, contact the Project Leader: Dr. Mario Reyes


Project Title:
Improving Documentation of Newborn Screen in a Free Standing NICU

Project Expiration Date: December 31, 2015
Approving Board: ABP
Project Description:

Newborn Screening (NBS) is a highly successful public health program that requires timely confirmatory testing, diagnosis, and clinical management so that optimal long-term outcomes can be achieved. NICU population represents a challenge for the eddcative implementation of NBS. Contrary to infants admitted to the regular newborn nursery, who are born healthy, full-term and > 2500g; infants admitted to the NICU are sick and/or premature and/or low birth weight with a prolonged hospital stay. The interventions routinely used in these settings such as blood transfusions, NPO, and TPN solutions have the potential to affect the NBS results and may lead to delay in diagnosis and clinical management. Our analysis of NBS documentation in the NICU in January 2015 revealed a 35% rate of documentation of NBS obtained during hospitalization. The aim of thsi project is to improve the NBS documentation in the NICU to 90% over the next 12 months.

To participate, contact the Project Leader: Dr. Magaly Diaz-Barbosa


Project Title:
Improvement in the Safe and Efficient Management of Acute Scrotal/Testicular Pain

Project Expiration Date: December 31, 2017
Approving Board: ABP
Project Description:

Delays in the definitive diagnosis of testicular torsion can lead to poor outcomes and loss of function. All members of the Emergency Department team may not recognize the acute and emergent nature of this condition. Baseline data indicate that there is room for improvement in the time from presentation to the ED until final U/S read and report. The goal of this project is to improve the time required between presentation to Nicklaus Children's Hospital ED and the time of definitive diagnosis for patients presenting with acute scrotal pain to rule out testicular torsion. An institutional standard pathway is created and the project will aim at increasing adherence to the standard pathway.
To participate, contact the Project Leader: Dr. Jefry Biehler


Project Title:
Severe Sepsis Bundle Implementation at Nicklaus Children’s Hospital

Project Expiration Date: May 31, 2019
Approving Board: ABP
Project Description:

Sepsis is a dangerous systemic infection that often leads to poor patient outcomes, including mortality. Severe sepsis is a significant problem among acutely ill children. A bundle for recognition, initiation and continuation of treatment of severe sepsis based on national guidelines has been created at Nicklaus Children's Hospital but not yet implemented. The goal of the project is to Implement severe sepsis bundle at Nicklaus Children's Hospital thereby improve sepsis-related outcomes.

To participate, contact the Project Leader: Dr. Bala Totapally