Transcript The Pediatric Cardiology National Quality Improvement Collaborative

The Pediatric Cardiology
National Quality Improvement
Collaborative
To Improve Care and Outcomes for Children
with Cardiovascular Disease
Pediatric Cardiology
QI Collaborative
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Brief Background
Current Status
Near-term Plans
Long-term Challenges
Characteristics of Pediatric Cardiology
That Underscore the Need for QI Collaboratives
• Cardiac surgical mortality has largely been conquered
(since the 1980-90’s), and now an emphasis must be
placed on reducing morbidities
• Provides care for many, rare congenital cardiac defects
• Ability to study & improve outcomes is limited by small
volumes at any center
• Few evidence-based treatment guidelines
• Formal QI Science is foreign to our specialty
• Clear need for multicenter collaboratives/registries to
study clinical processes and outcomes
The JCCHD National QI Initiative
Goals
• To improve care & outcomes for children with
cardiovascular disease
• To do so in a multi-institutional, collaborative
fashion
• To develop a sustainable national registry to
study care processes & outcomes
• To apply formal Quality Improvement methods to
test changes, rapidly identify and spread
improvements
Cardiology QI Collaborative
2005
The JCCHD committed to developing a National
QI Collaborative for Pediatric Cardiology
Task Force Assembled in 2006:
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Rob Beekman – Cincinnati Children’s Hospital Medical Center
Kathy Jenkins –Children’s Hospital Boston
Tom Klitzner – Mattel Children’s Hospital at UCLA
John Kugler – Children’s Hospital, Omaha, Nebraska
Gerard Martin – Children’s National Medical Center, DC
Steve Neish – Texas Children’s Hospital, Houston
Geoff Rosenthal – Children’s Hospital at Cleveland Clinic
Center for Health Care Quality
– Carole Lannon
– Laura Brown
The JCCHD National QI Initiative
Guiding Principles
Cardiology QI Collaborative
Project Selection Criteria
• Clinically important
• Potential for improvement
• Under purview of Pediatric Cardiology
• Specific and measurable
• Generates enthusiasm
Cardiology QI Collaborative
Initial Project Aim
To improve survival and quality of life in
infants with a single ventricle during the
“interstage” period between Discharge after
Neonatal Cardiac Surgery and Admission
for Bidirectional Glenn.
Cardiology QI Collaborative
Key Drivers
Possible Changes to Test
Assure appropriate discharge
communication /
coordination
AIM
Improve survival &
quality of life in infants
with a single ventricle
during the interstage
between discharge from
neonatal surgery and
admission for the Glenn.
Optimize nutritional status
during the interstage
period
Improve interstage
surveillance and response to
changes in cardiovascular
status
Patient Characteristics
Surgical Outcome
Medical Management
Under Development
with input from
families
Cardiology QI Collaborative
Examples of Possible
Changes to be Tested
• Detect and Respond to Changes in
Cardiac Status at Home
– Specific surveillance protocols: 4 levels of vigilance
• Home measurement of O2 sat and weight daily
• Home measurement of O2 sat daily
• Weekly measurement of O2 sat and weight by pediatrician or
visiting nurse
• “Usual” care with cardiology clinic follow-up visits per routine
– Red Flag System
• To clearly define for parents what changes to look for in their child
• To define exactly what they should do in response
Cardiology QI Collaborative
Examples of Possible
Changes to be Tested
• Optimize Nutritional Status
– Specific feeding protocols
– Explicit caloric goals identified and updated at each clinic visit
– System to track weights at frequent intervals
– Regular involvement of Nutritionist in outpatient care
– Better systems to communicate/teach feeding plan to family
Cardiology QI Collaborative
Parent / Family Input
• Parent survey underway Summer-Fall 2007
• Will involve 20-30 families of infants with a
single ventricle from 7 centers
• Survey translated into Spanish for Latino
families
• IRB approval obtained in May 2007
Cardiology QI Collaborative
Parent Survey
• Most questions are open-ended
– An opportunity for parents to enlighten the
project in unexpected ways
• Major Topics:
– What do parents need to better care for their infant?
– How can we incorporate parents into the healthcare team?
– How to better monitor infant at home (e.g. “red flags”)
– Parent knowledge/skills re: Feedings & Medications
– Discharge communications (handoffs) with other caregivers
Cardiology QI Collaborative
Database & Measures Are
Under Development
• Kathy Jenkins (Boston), Geoff Rosenthal (CCF)
and Rob Beekman (Cincinnati) are working on
definition of database elements and measures
• Measures required to establish a Multicenter Registry
of infants with a single ventricle
• To support the initial QI project, and future projects as
well
• Will be coordinated with existing database
measures/definitions as possible (e.g. STS congenital
heart surgery database)
Cardiology QI Collaborative
Funding
• Pilot Funding ($360,000) obtained from the
Cincinnati Children’s Heart Association
– Support for initial 2-3 years.
• Grant Application submitted June 2007 to
the Children’s Heart Foundation
– Support for an additional 2 years
Project Timeline
Cardiology QI Collaborative
When might this effort improve
the 1st child’s care?
• February 2008: Tests of Change will
begin in at least 7 Cardiology centers.
– Rapid cycle, iterative tests of change (rapid data
feedback, assessment & revision of changes,
reassessment – i.e. PDSA cycles)
– Based on the Model for Improvement
– Probably using a Factorial Design (testing several
levels of home surveillance and nutritional
interventions)