QuIIN: Home to national pediatric improvement networks.
Value in Inpatient Pediatrics Network Improving Community-Acquired Pneumonia Management Quality Improvement Project (ICAP)
The Quality Collaborative for Improving Community-Acquired Pneumonia Management (ICAP) provided hospitalist-led teams with strategies, tools, and resources necessary to assess and improve the quality of care delivered to pediatric patients admitted with community acquired pneumonia (CAP). The project aimed to improve care delivery for pediatric patients hospitalized with community-acquired pneumonia (CAP) by measures identified in the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America's guidelines - The Management of Community Acquired Pneumonia in Infants and Children Older than 3 Months of Age: Clinical Practice Guidelines.
ICAP Change Package: Strategies and Tools for Change
Improving Community-Acquired Pneumonia (ICAP) Project
(Quality Improvement Tookit)
Take a look at the ICAP Change Package that is organized by the project measures and includes helpful resources and tools for each area; |
1. Clinical Pathway
2. Order sets
3. Antibiotic Stewardship Programs and other tools and resources. Participating hospital teams shared resources, tools and templates that they use or had developed via the project listserv.
The goal of this project was to improve the care of children with CAP by increasing compliance with the 2011 IDSA/PIDS clinical practice guideline on community-acquired pneumonia.
The specific aim of the project was to improve the care of children with CAP by increasing compliance with the 2011 IDSA/PIDS clinical practice guideline on community-acquired pneumonia, specifically including the following goals:
- Increase overall usage of narrow-spectrum antibiotics for inpatients with uncomplicated CAP to 80% for eligible population
- Decrease overall usage of macrolides for inpatients with uncomplicated CAP
- to less than 5% for children under age 5, and
- to less than 25% for children age 5-18
- Decrease overall usage of complete blood counts for inpatients with uncomplicated CAP to less than 10%
- Decrease overall usage of more than one inpatient chest radiograph for patients with uncomplicated CAP to less than 10%
- Decrease overall usage of CT to less than 5%
- Increase overall usage of Pulmonary Ultrasound in treatment of CAP to 10%
- Measure the rate of concurrent inpatient treatment for asthma in patients admitted with uncomplicated CAP and decrease this treatment to less than 10%
The overall usage of Ultrasound will be assessed as the evidence does not suggest what an appropriate baseline utilization percentage should be.
Teams also worked to improve systems, workflow and team communication as it relates to community acquired pneumonia care in the in-patient setting.
Chart Review Tool and Balancing Measures
The data for these measures were captured through the online Quality Improvement Data Aggregator (QIDA) system.
Several questions on the various dynamics of the project were assessed with the monthly progress report survey.
Fifty two hospital site teams participated in this quality improvement project representing 26 US states and one international site in Pakistan.
It was suggested that the local improvement team consist of 3 members, to be led by a physician and to include a respiratory therapist and a nurse. Click here to see a list of all of the
hospital site teams
Pediatric hospital teams were responsible for:
Physician leader only: serve as Local Leader in the attestation process required by the American Board of Pediatrics (ABP) for Part 4 Maintenance of Certification (if approved). Includes providing each hospitalist interested in participating for MOC credit a document describing the requirements of their participation, monitoring physician participation, and attesting that they met the project's completion criteria.
- Devoting necessary resources and time to testing and implementing changes over the specified intervention period, while collecting data from 20 patient charts per month for 9 months, and working to obtain buy-in from all members in their hospital.
- Seeking necessary institutional approval for participation in the project prior to any data collection.
- Completing pre-work activities (over one month) including:
- Completing pre-survey (via SurveyMonkey)
- Participating in an orientation conference call, as well as a call regarding chart data entry into the online Quality Improvement Data Aggregator (QIDA) for "Group Administrators."
- Participating in live learning session #1: Project Orientation, QIDA Introduction, & Metric Evidence
- Learning the Model for Improvement and implement Plan, Do, Study, Act (PDSA) cycles.
- Making appropriate changes in the structure of how inpatient pneumonia care is delivered to patients.
- Regularly collecting and submitting clinical measurements pertinent to the aims of the project.
- One core team member (identified as the Group Administrator) will enter chart review data into QIDA retrospectively for the months September 2013 – May 2014 (every three months, so 3 data points total over a 9-month action period)
- Every 3 months for 9 months total (9 months' baseline and 9 months' post intervention), review charts of 5 patients minimum/20 patients maximum (or 100% of eligible patients that month if fewer than 5 eligible patients) 3 months (90 days) to 18 years of age hospitalized for community acquired pneumonia and collect data on project measures. Chart review was completed using the AAP Quality Improvement Data Aggregator (QIDA).
- Completing a narrative progress report periodically throughout the action/intervention phase via SurveyMonkey.
- Testing innovations in care delivery to improve care of children with community acquired pneumonia.
- Sharing lessons learned and problem-solve with other participating hospitals via the project e-mail listserv.
- Engaging with assigned expert coaches regularly to discuss successes and challenges.
- Using e-mail and the Internet on a regular basis for ongoing support, information, and communication among hospital site teams.
- Participating in 5 live learning session/webinar learning sessions during the action period covering the following topics:
- Webinar #3: Overuse and Review of Baseline Data
- Webinar #4: Review of Baseline Data, Data Cycle #4, & Periodic Progress Report 1
- Webinar #5: Leading Change
- Webinar #6: ICAP Progress to Date
- Webinar #7: Review and compare 2014-2015 data to 2013-2014 baseline data; plan sustainability and next steps
- Completing a post-survey at the end of the project and participating in a project report-out webinar.
Baseline assessments: Hospital teams assessed their current level of performance with respect to the project measure (utilization and process measures) via a Pre-Project Survey and in the chart review of up to 60 charts over a 9-month period (September 2013 – May 2014) that served as baseline data.
Expert coaches from the field
were assigned to each hospital team based on the area of expertise and experience of the coach in hospital-based improvement projects. Coaches were matched with hospital sites that had an interest in improving their baseline data in areas that coaches have expertise and a knowledge base. The Coaches were flexible in the number of times and the method of interaction with their assigned hospital teams but were encourages to communicate on a monthly basis.
Webinar-based Learning Sessions:
Hospital teams were oriented to the project as well at quality improvement basis and pneumonia evidence via webinars. The method of data collection (AAP Quality Improvement Data Aggregator) and change package tools were also outlined in webinars at the outset of the project (during the pre-work phase).
9-month testing phase:
Hospital teams developed a plan to increase overall usage of narrow-spectrum antibiotics and decrease use of macrolides, CBCs, Chest X-rays, and CTs; utilized PDSA cycles to test tools, process, measures, and introduce protocols and pathways; and reviewed run charts.
Periodic webinars: Hospital teams participated in seven live periodic educational learning session webinars to learn about project metric evidence, antibiotic stewardship, how to safely do less, achieving change, progress across the project, and ideas for sustainability.
Sustainability and Report Out Webinar-based Learning Session:
Project leaders shared the data trends from the chart review data entered for the September 2013 – May 2014 pneumonia season (baseline) to the September 2014 – May 2015 season and summarized the improvement in behaviors that were made in aggregate.
The webinar also included a presentation on how to sustain and hold the gains made during the project on certain measures.
One-year post-Action Period Data Entry – for Sustainability:
In order to assess how the improvements were sustained, hospital teams had the opportunity to submit chart review data for a third pneumonia season reflecting winter 2015.
This was an optional data entry for the hospital sites.
Qualitative Interviews: A qualitative interview consultant performed 20-30-minute phone qualitative interviews with the hospital teams. The qualitative interviews were optional. The data retained from the interviews is being coded; data from the interviews will be used to inform the direction and next models for the VIP Network projects.
Project Data Collection Included:
Resources for Hospital Site Teams
- Pre-work: 9 months retrospective baseline chart review data (5 charts minimum or 20 charts maximum every 3 month between September 2013 – May 2014 entered into QIDA)
- Action Period: 9 months intervention chart review data (5 charts minimum or 20 charts maximum every 3 months between September 2014 – May 2015 entered into QIDA)
- Pre- and Post-Project Survey: At pre- and post-, teams were asked to assess existing practices, beliefs and systems in place for providing inpatient pneumonia care and team collaboration.
- Periodic Progress Reports: Periodic progress reports allowed clinical teams to describe specific changes and tools they have tested. They helped faculty to monitor progress and needs of practice teams.
Webinar-based Learning Sessions: Power Point Presentations
Special Thanks to the Expert Group
- Kavita Parikh, MD, FAAP (co-Chairperson)
- Eric Biondi, MD, FAAP (co-Chairperson)
- Joanne Nazif, MD, FAAP
- Shawn L. Ralston, MD, MS, FAAP (Project Coach)
- Mary Ann Queen, MD, FAAP (Project Coach)
- Ricardo Quinonez, MD, FAAP
- Samir Shah, MD, MSCE, FAAP
- Derek Williams, MD, FAAP (Project Coach)
Thank You to the Project Coaches
- Matthew Garber, MD, FHM, FAAP
- Michael Koster, MD, FAAP
- JoAnna Leyenaar, MD
- Michelle Marks, DO, FAAP
- Russell McCulloh, MD, FAAP
- Vineeta Mittal, MD
- Angela Myers, MD, MPH, FAAP
- Jason Newland, MD, MEd, FAAP
- Natalia Paciorkowski, MD, PhD, FAAP
- Emily Thorell, MD, MSCI, FAAP
- Illana Waynik, MD, FAAP