1 Weighing Children in Metric Units - PowerPoint Presentation

1. 1Weighing Children in Metric UnitsBundle Deep Dive SessionJuly 17, 2018Presenters: MD, FAAP, FACEP, FAEMSDr. Kate Remick, MD, FAAP, FACEP, FAEMS Krystle Bartley, MADiana Fendya, MSN (R), RN

2. The HRSA, MCHB EIIC is supported in part by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U07MC29829. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.2ACKNOWLEDGEMENTS

3. Sign Up for CreditPRQC members joining today’s deep dive can earn Continuing Nursing Education or Continuing Medical Education credit. Please complete the following survey to receive additional information: https://tch-redcap.texaschildrens.org/REDCap/surveys/?s=LWHMXA44R8Name of Learning Session Attending: WEIGHT IN KG DEEP DIVE3CNE | CME CREDITS

4. WEIGHT IN KILOGRAM DEEP DIVETALKING POINTSSPEAKERSIHI Collaborative ModelCommon Concepts for QI CollaborativesSupport Available for Affiliate SitesPRQC: CultureWeight in Kilogram Bundle: FrameworkWeight in Kilogram Bundle: Background; Aim Statement; Change Strategies; Quality Measures; VariablesNext StepsHousekeepingDiana FendyaDr. Kate RemickKrystle Bartley4Welcome to the Pediatric Readiness Quality Collaborative (PRQC)

5. IHI COLLABORATIVE MODEL5The Breakthrough Series: IHI’s Collaborative Model for Achieving Breakthrough Improvement. IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2003. (Available on www.IHI.org)

6. COMMON CONCEPTSAim StatementsModel for Improvement | Plan-Do-Study-Act (PDSA) cyclesQuality Measures/MetricsTools: Key Driver Diagrams; Workflows; Process Maps; SWOT Analyses; Fishbone Diagrams/Cause and Effect Diagrams6

7. SUPPORT FOR AFFILIATESLevel 1: Trainers that committed to providing mentorship to series of affiliate hospitals on their team (Expertise in PEM; QI; EMSC)Level 2: Formal QI education available through Institute for Healthcare Improvement Open School AND Reinforce concepts throughout the collaborativeLevel 3: Sharing of best practices at intervention-specific webinars and learning sessionsLevel 4: Distribution of new content/resources available 7

8. 8PRQC CULTURESharing Progress & Challenges with TrainersEnsure high quality emergency care for all children!All Teach – All Learn!Improvement =SuccessGrass-Root EffortTransparency

9. TEAM MEETINGSPlanned exclusively for training site(s) and their designated affiliate sites. Trainers will be scheduling team meetings in the coming months (virtual; in-person; teleconference)Topics of DiscussionBundle Selection; Implementation Plan; Hospital Engagement; QI Integration (Smart Aims/Tools Available/Change Strategies); Progress9

10. 10Weighing Children in Metric UnitsIntervention Bundle Deep Dive

11. BUNDLE FRAMEWORK11

12. 12cONSIDERATIONS This intervention bundle was designed exclusively for sites participating in the Pediatric Readiness Quality Collaborative, and as such, this content should not be used for other purposes or by other sites without written consent from the EMSC Innovation and Improvement Center.This intervention bundle may conflict with “existing” local quality improvement efforts. You are encouraged to seek support from ED and hospital leadership regarding the adoption of the proposed change strategies as standard practice for your emergency department.

13. 13Introductionsubject matter experts Sue Cadwell, RN, MSNAssistant Vice President, Women’s & Children’s Services, Hospital Corporation of America (HCA)/Clinical Services GroupMarianne Gausche-Hill, MD, FACEP, FAAP, FAEMSMedical Director, Los Angeles County EMS Agency, Los Angeles, CaliforniaProfessor of Clinical Emergency Medicine and Pediatrics, David Geffen School of Medicine at UCLAClinical Faculty, Harbor-UCLA Medical Center, Department of Emergency MedicineJeffin Bush, RNDirector for Emergency Services, Hospital Corporation of America (HCA)/Clinical Services Group

14. To Err is Human – Building a Safer Health System“Building a safer system means designing processes of care to ensure that patients are safe from accidental injury.”Dosing errors comprise more than 40% of fatal medication errors14Phillips, J., et al (2001). Retrospective analysis of mortalities associated with medication errors. American Journal of Health-System Pharmacy, 58(19), 1835–1841.

15. Factors Associated with Increased Risk of Medical ErrorMultiple individuals involved in careHigh acuity illness or injurySevere time constraintsHigh volume of patients Unpredictable patient flowCommunication barriersMultiple types of diagnostic or treatment technologiesKizer KW. Patient safety: a call to action. A consensus statement from the National Quality Forum. Medscape General Medicine 2001; 3:1-11

16. Future of Emergency Care: Hospital-Based Emergency Care At the Breaking PointED visits grew by 26% between 1993 and 2003 (90  114 million)Number of EDs declined by 425Critical shortages of healthcare providers (MDs, RNs, etc)Substantial ED overcrowdingAmbulances frequently diverted from overcrowded EDs~ 500,000 diversions in 2003Overcrowding associated with poor care quality & medical error Institute of Medicine. Future of Emergency Care in the US Healthcare System. National Academies Press, 2006.

17. Future of Emergency Care:Emergency Care for Children “Growing Pains”Although children constitute ~1/4 of all ED visits nationwideMost general EDs and EMS agencies do not require specialized pediatric training for clinical staffMost EDs do not have the full scope of pediatric equipment, medications, and supplies for childrenPaucity of research on best practices, clinical outcomes, and patient safety

18. 2006 IOM Report “If there is one word to describe the current state of pediatric emergency care in 2006 it is UNEVEN.”“a regionalized, coordinated, and accountable system”

19. June 15, 2006Emergency medical care in the United States is on the verge of collapse… …As a system…it provides care of variable and often unknown quality…

20. Patient Safety Risks Unique to Children in the EDWeight-based rather then standardized dosingMeasurements in pounds requires calculationInability of young children to communicatePoor localization of pain Unaccompanied by a parentLimited experience with critically ill and injured childrenFailure/delay in recognizing signs of illness or injuryChildren with special health care needs

21. Pediatric Readiness and Emergency DepartmentsThe average ED sees < 13 children a day>80% are cared for in general EDsFew critical pediatric patients stimulate the ED to ensure readinessMultiple factors associated with increased risk for medical errorUnique pediatric characteristicsKnown gaps in day-to-day readiness

22. The Perfect StormAcute illness or injury + OvercrowdingIncreased risk for error Unique characteristics and needs of childrenFurther increased risk for errorDeficiencies: Pediatric readiness Pediatric experience Pediatric competencies of pre-hospital and hospital-based emergency care providers

23. Pediatric Patients and Medication ErrorsChildren at increased risk for errors 5-27% of medication orders in children contain errors across the spectrum of the entire delivery process100-400 prescribing errors per 1000 pediatric patientsPediatric errors tend be greater (2-100X the correct dose)23Miller, et al. Qual Saf Health Care, 2007: 16(2): 116-126.

24. Epidemiology of Pediatric Medication ErrorsHighest risks for medication errors occur during pediatric resuscitations 25% of errors due to “confusion between pounds and kilograms; and simply having the option to weigh in either unit contributed to wrong weight entries.”A single incorrect weight may lead to multiple medication dosing errors 24Emergency Nurse Association Policy Statement (2016) Policy Statement for Weighing All Patients in KilogramsKaji AH, Gausche-Hill M, Conrad H, et al. Pediatrics. 2006;118:1493-1500)

25. Recommendations for Improving Medication SafetyUse kilogram-only weight-based dosingStandardize measurement systems throughout the institutionOptimize computerized physician order entry (CPOE) by using: Clinical decision supportElectronic processes to check dose, dosage schedule, drug interactions, allergies, and duplicate therapiesEmbedded templates or clinical pathway order sets with alert systems25

26. Joint Commission Recommendations“Since patient weight is used to calculate most dosing, all pediatric patients should be weighed in kilograms at the time of admission (including outpatient and ambulatory clinics) or within four hours of admission in an emergency situation”Kilograms should be the standard nomenclature for weight on prescriptions, medical records and staff communications.26

27. Pediatric Readiness and Best Practices in Family Centered Care27Conversion sheet for parents – Kilograms to PoundsScript:“Mom / Dad / Caregiver, I’m going to weigh your child now.   The number you hear me call out as the weight will sound odd to you, because in the hospital, we weigh in the metric system.  The reason we do that is because, everything we do for your child will be based on his/her metric weight.  That means medication dosing, and everything.  Now, I’m going to give you a card which will help you convert that number to pounds and ounces.  DO NOT TELL ME WHAT THAT  IS!  I don’t want to take the chance of entering your child’s weight into the record incorrectly, and possibly cause someone to make an error.  That card is for your information only.”

28. 28Aim StatementBy December 2019, at least 85%of pediatric patients, treated at sites adopting the weight measurementbundle, will have their weight measured and recorded exclusively in kilograms.

29. 29WEIGHT IN KILOGRAMS BUNDLEGuideline StatementsInfrastructure ChangesEMR OptimizationEducationBy December 2019, at least 85%of pediatric patients, treated at sites adopting the weight measurement bundle, will have their weight measured and recorded exclusively in kilograms.Medication Ordering PatternsKnowledge Reinforcement for Care TeamPatient & Family Engagement

30. 30Intervention Strategieskey driver 1: guideline statementsChange Strategies: Weight should be recorded at every ED encounter: scale/gurney (electronic) preferred over length-based tapeActual weight should be obtained whenever possible. When it is not possible, weight should beestimated using a standard method of estimating weight in metric units (e.g., length-based system)Ensure that length-based tape is used for all resuscitationsInclude family-centered care elements within guidelines document (i.e., informing families prior toweighing children and medication administration the importance of weighing children in kilograms as a method for reducing pediatric medication errors.

31. 31Intervention Strategieskey driver 2: infrastructure changes Change StrategiesUtilize a scale that only weighs pediatric patients in kilograms or a scale that can be locked in kilograms modeUtilize a length-based tape and ensure that it is available/secured in resuscitation bay as wellUtilize a single formulation for each medication

32. 32Intervention Strategieskey driver 3: emr optimization Change StrategiesEMR alerts care team when weight is not recorded in correct unitEMR alerts care team that weight does not coincide with patient’s height and ageFor resuscitation, weight is a required entry in the patient’s medical recordConsider using standard weight nomograms (e.g., World Health Organization)EMR automatically calculates medication dosing based on weight entered in medical record

33. 33Intervention Strategieskey driver 4: education Change StrategiesDevelop training/educational content for care teamLearning objectives should include: proper use of length-based tape, necessity of weight measurement required in cases of resuscitation, safety issues (e.g., number of reported medication errors), methods of measuring weight, nomograms, family engagement, your site’s guidelines, and reinforce that weight should not be estimated but measuredIdentify training modality (e.g., online, in-person, staff-meetings, peer to peer, electronic medical record alerts)Identify strategies to increase families’ engagement

34. 34Intervention Strategieskey driver 5: knowledge reinforcement for care team Change StrategiesPosters in triage areaDirect feedback to care team following chart auditsDevelop script/cards (weight conversion for families) for use by triage nurse

35. 35Intervention Strategieskey driver 6: medication ordering patterns Change StrategiesIntegrate a process to track the number of incidences when an incorrect dose of a medication was ordered for a patient based on their weightTrack high risk conditions with common errors in prescribing and administrationMonitor family engagement in medication administration

36. 36Intervention Strategieskey driver 6: medication ordering patterns Change StrategiesIntegrate a tool that nurses can reference to ensure that medication dosing is appropriate (use standard nomograms as reference)Integrate a nurse to nurse cross-check to ensure that medication dosing is appropriate. If site has bandwidth to accommodate this effort, consider cross-check for high-risk patients/medications or cross-checks during off-peak hours in the ED.Work with pharmacy team to develop notification system in the event that a prescribed medication does not coincide with standard practice

37. 37Intervention Strategieskey driver 7: patient & family engagement Change StrategiesInclude process where family are advised of medication and dose prior to administrationDisseminate weight infographic/conversion chart to empower caregiver engagement

38. 38Quality MeasuresStructural Measure #1: Presence of a policy that outlines standards for weighing pediatric patients inKilogramsProcess Measure #1: Percentage of pediatric patients presenting to the emergency department that areexclusively weighed in kilogramsProcess Measure #2: Percentage of pediatric patients presenting to the emergency department whoseweight is exclusively documented in the medical records in kilogramsOutcome Measure #1: Percentage of medication dosing errors identified during the reporting period 

39. 39Variables  Site-Specific InformationWeight Policy 1 – Yes (Upload) / 2 – NoDoes the policy specify that weight be measured in kg only? 1 – Yes / 2 – NoDoes the policy specify that weight be recorded in kg only? 1 – Yes / 2 – No

40. 40Variables  Patient-Specific InformationDate of BirthDate/Time of ArrivalMode of ArrivalTriage LevelWeight in Medical Record (unit/value)Target Medication AdministeredMedication GivenMedication Dosage

41. DATA COLLECTIONData Use Agreements Must Be Established Data Portal in Development”How-To” guide for data submission will be released this summerEach site will have ownership of their own data Dashboards available – control charts; run chartsIntervention-Specific (benchmarking purposes)Site-Specific (based on selected intervention bundle at site)Comprehensive PRQC Dashboard (all intervention bundle progress)41

42. RESOURCESFile-Sharing SitePre-Readings; Checklists; Pertinent Articleshttps://bcm.box.com/v/prqc42

43. Action Items:Administrative: Establish data use agreementsCollaborative-Specific: Site Visit Survey #1 (if not already completed)Dates:July 1: Anticipated completion of DUA process; Collect contact information for data portal users (2 users max) and sites will receive registration information for QI education upon completion of DUA (IHI Modules) September 1: Go Live for Piloting Phase & Baseline Data Collection43HOUSEKEEPING

44. BUNDLE RELEASE DATES44Disaster Planning Part II Focus on implementation of disaster bundle (workflows; data submission)Anticipated Release of Process Maps: Friday, July 27Bundle Deep Dive Part II: Tuesday, July 31Release Date: All Content Available OnlineDeep Dive Webinar: In-Depth Description of Bundle with Subject Matter Experts, Data Support Team, & Admin Team

45. Sign Up for CreditPRQC members joining today’s deep dive can earn Continuing Nursing Education or Continuing Medical Education credit. Please complete the following survey to receive additional information: https://tch-redcap.texaschildrens.org/REDCap/surveys/?s=LWHMXA44R8Name of Learning Session Attending: WEIGHT IN KG DEEP DIVE45CNE | CME CREDITS