Berg Kathleen, Nedved Amanda, Richardson Troy, Montalbano Amanda, Michael Jeffrey, Johnson Matthew
Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri;
School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri; and.
Hosp Pediatr. 2020 May;10(5):385-391. doi: 10.1542/hpeds.2019-0284. Epub 2020 Apr 13.
Quality improvement (QI) initiatives have increased provider adherence to individual components of a bronchiolitis clinical practice guideline (CPG). Few have evaluated complete adherence to a guideline in multiple types of care settings. Our aim with this study was to increase complete adherence to our institutional bronchiolitis CPG in urgent care center, emergency department, and inpatient settings.
We conducted a QI study at a single pediatric institution with multiple care settings. Encounters for patients with bronchiolitis ages >60 days to <24 months occurring between October 1 and March 31 in 2015-2018 were included. Those in intensive or subspecialty care were excluded. Management of each encounter was considered adherent to the CPG if none of the following were ordered: respiratory pathogen panel, respiratory syncytial virus antigen, complete blood cell count, blood culture, chest radiography, bronchodilator, antibiotic, or systemic corticosteroid. Medical team education, family engagement, order set modifications, and data dissemination were employed to drive deimplementation. We used interrupted time series to assess changes in processes and outcomes both across and within seasons.
Analysis included 13 063 patient encounters. Hospital-wide complete adherence to the CPG increased ( < .001) from 40.9% (95% confidence interval 39.3%-42.5%) to 54.6% (95% confidence interval 53.2%-56.0%). Although CPG adherence improved in all 3 clinical settings, the use of individual CPG components varied by setting. Direct cost decreased in the urgent care center ( < .001) and emergency department ( = .001).
We created a strict definition of CPG adherence and used QI methodology to deimplement multiple overused tests and medications across the continuum of patient care.
质量改进（QI）举措提高了医疗服务提供者对细支气管炎临床实践指南（CPG）各个组成部分的遵循程度。很少有研究评估在多种护理环境中对指南的完全遵循情况。我们开展这项研究的目的是提高在紧急护理中心、急诊科和住院环境中对我们机构细支气管炎CPG的完全遵循率。
我们在一家拥有多种护理环境的单一儿科机构开展了一项QI研究。纳入2015年10月1日至2018年3月31日期间年龄大于60天至小于24个月的细支气管炎患者的诊疗记录。排除重症监护或专科护理的患者。如果未开出以下任何一项检查或药物：呼吸道病原体检测、呼吸道合胞病毒抗原检测、全血细胞计数、血培养、胸部X光检查、支气管扩张剂、抗生素或全身性皮质类固醇，则认为每次诊疗的管理符合CPG。采用医疗团队教育、患者家属参与、医嘱集修改和数据传播来推动减少不必要的诊疗行为。我们使用中断时间序列来评估不同季节以及同一季节内过程和结果的变化。
分析包括13063例患者的诊疗记录。全院对CPG的完全遵循率从40.9%（95%置信区间39.3%-42.5%）提高到54.6%（95%置信区间53.2%-56.0%）（P<0.001）。虽然在所有3种临床环境中CPG的遵循情况均有所改善，但各个CPG组成部分的使用因环境而异。紧急护理中心（P<0.001）和急诊科（P = 0.001）的直接成本有所下降。
我们制定了CPG遵循情况的严格定义，并使用QI方法在患者护理的连续过程中减少多种过度使用的检查和药物。
