Practical quality improvement changes for a low-resourced pediatric unit

Abstract

Background: This work describes a sustainable and replicable initiative to optimize multi-disciplinary care and uptake of clinical best practices for patients in a pediatric intensive care unit in Low/Middle Income Countries and to understand the various factors that may play a role in the reduction in child mortality seen after implementation of the Quality Improvement Initiative.

Methods: This was a longitudinal assessment of a quality improvement program with the primary outcome of intubated pediatric patient mortality. The program was assessed 36 months following implementation of the quality improvement intervention using a t-test with linear regression to control for co-variates. An Impact Pathway model was developed to describe potential pathways for improvement, and context was added with an exploratory analysis of adoption of the intervention and locally initiated interventions.

Results: 147 patients were included in the sustainability cohort. Comparing the initial post-implementation cohort to the sustainability cohort, the overall PICU unexpected extubations per 100 days mechanical ventilation decreased significantly from baseline (6.98) to the first year post intervention (3.52; p < 0.008) but plateaued without further significant decrease in the final cohort (3.0; p = 0.73), whereas the mortality decreased from 22.4 (std 0.42) to 9.5% (std 0.29): p value: 0.002 (confidence intervals: 0.05;0.21). The regression model that examined age, sex, diagnosis and severity of illness (via aggregate Pediatric Risk of Mortality (PRISM) scores between epochs) yielded an adjusted R-squared (adjusting for the number of predictors) value of 0.046, indicating that approximately 4.6% of the variance in mortality was explained by the predictors included in the model. The overall significance of the regression model was supported by an F-statistic of 3.198 (p = 0.00828). age, weight, diagnosis, and severity of illness. 15 new and locally driven quality practices were observed in the PICU compared to the initial post-implementation time period. The Impact Pathway model suggested multiple unique potential pathways connecting the improved patient outcomes with the intervention components.

Conclusion: Sustained improvements were seen in the care of intubated pediatric patients. While some of this improvement may be attributable to the intervention, it appears likely that the change is multifactorial, as evidenced by a significant number of new quality improvement projects initiated by the local clinical team. Although currently limited by available data, the use of Driver Diagram and Impact Pathway models demonstrates several proposed causal pathways and holds potential for further elucidating the complex dynamics underlying such improvements.

Keywords: Mass General Brigham; institutional review; low/middle income country; pediatric intensive care unit; quality improvement; unplanned extubations.

Figure 1

Timeline of pre-post intervention study. Timepoint 0 indicates start of 18-month pre-intervention period of data collection. Timepoint 1 indicates implementation of multi-media, in-person education-based intervention. Timepoint 2 when short-term post-intervention data collection period occurred. Timepoint 3 indicates 18-month period when no research staff visited the Bloom Hospital and relied on light-touch, internet-based support of the Bloom Hospital PICU team. Timepoint 4 indicates repeat post-intervention data collection during the same season as Timepoint 2. Timepoint 5 indicates return visit to the Bloom Hospital 18 months later.

Figure 2

QR code for Spanish-Language Educational Video. Example of one of many QR codes posted in the PICU linking providers to 2–4 min Spanish-language instructional videos addressing safe airway management procedures and practices such as proper securement of the ETT, proper ETT selection, safe suctioning practices and safe management of cuff pressure in cuffed ETTs.

Figure 3

Careways Impact Pathway Model. The Careways Impact Pathway Model elucidates the pathways through which the planned Quality Improvements intervention attains its specified objectives, delineates the causal mechanisms by which the intervention operates, as well as demonstrates the interconnectedness and mutual reinforcement among its constituent elements. Within this framework, balancing factors are elements that might counteract or moderate the effects of the intervention, helping to maintain equilibrium within the system.

Figure 4

Impact Pathway Model used to comprehend and monitor changes to the causal pathway that we believe will lead to the desired outcomes.