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Learning From a National Quality Improvement Collaborative for Brief Resolved Unexplained Events
Daniela Hochreiter1, Erin Sullivan2, Amy M DeLaroche3
1Division of Hospital Medicine, Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut.
Insights
A quality improvement collaborative improved adherence to clinical guidelines for Brief Resolved Unexplained Events (BRUE) in infants. While testing and hospitalization rates did not further improve, risk classification and documentation were enhanced.
Area of Science:
- Pediatric Emergency Medicine
- Quality Improvement Science
- Clinical Practice Guidelines
Background:
- The American Academy of Pediatrics published clinical practice guidelines (CPG) for Brief Resolved Unexplained Events (BRUE) in 2016.
- A quality improvement (QI) collaborative was initiated across 15 hospitals to enhance adherence to these BRUE guidelines.
Purpose of the Study:
- To improve adherence to the BRUE CPG, focusing on testing, hospitalization of lower-risk infants, diagnostic criteria, and risk classification.
- To evaluate the impact of a multicenter QI collaborative on BRUE care processes and outcomes.
Main Methods:
- A QI collaborative involving 15 hospitals implemented interventions including CPG education, updated documentation, clinical pathways, and EHR integration.
- Medical record review analyzed care for 1756 infants meeting BRUE criteria across three periods: pre-CPG, post-CPG, and the collaborative period.
- Collaborative learning sessions were used to identify and address barriers to improvement.
Main Results:
- Following CPG publication, testing adherence increased from 56% to 64%, and hospitalization of lower-risk infants decreased from 49% to 27%.
- During the collaborative, correct risk classification improved significantly (26% to 49% in ED, 15% to 33% inpatient).
- Documentation of BRUE risk factors improved from 84% to 91% in the ED setting.
Conclusions:
- The national BRUE QI collaborative successfully enhanced hospital processes and outcomes related to BRUE care.
- While testing and hospitalization rates did not surpass initial post-CPG gains, the collaborative improved risk classification and definition adherence.
- Future improvements may involve integrating caregiver perspectives and shared decision-making tools.
Objective:
In 2016, the American Academy of Pediatrics published the Brief Resolved Unexplained Event (BRUE) Clinical Practice Guideline (CPG). A multicenter quality improvement (QI) collaborative aimed to improve CPG adherence.
Methods:
A QI collaborative of 15 hospitals aimed to improve testing adherence, the hospitalization of lower-risk infants, the correct use of diagnostic criteria, and risk classification. Interventions included CPG education, documentation practices, clinical pathways, and electronic medical record integration. By using medical record review, care of emergency department (ED) and inpatient patients meeting BRUE criteria was displayed via control or run charts for 3 time periods: pre-CPG publication (October 2015 to June 2016), post-CPG publication (July 2016 to September 2018), and collaborative (April 2019 to June 2020). Collaborative learning was used to identify and mitigate barriers to iterative improvement.
Results:
A total of 1756 infants met BRUE criteria. After CPG publication, testing adherence improved from 56% to 64% and hospitalization decreased from 49% to 27% for lower-risk infants, but additional improvements were not demonstrated during the collaborative period. During the collaborative period, correct risk classification for hospitalized infants improved from 26% to 49% (ED) and 15% to 33% (inpatient) and the documentation of BRUE risk factors for hospitalized infants improved from 84% to 91% (ED).
Conclusions:
A national BRUE QI collaborative enhanced BRUE-related hospital outcomes and processes. Sites did not improve testing and hospitalization beyond the gains made after CPG publication, but they did shift the BRUE definition and risk classification. The incorporation of caregiver perspectives and the use of shared decision-making tools may further improve care.
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