Sepsis is a significant cause of PICU admissions

Sepsis is a significant cause of PICU admissions and is associated with the high infant morbidity and mortality rates at the Morton Plant Hospital. Internal assessment results suggest that close to half a decade of work at the hospital has achieved too little with regards to alleviating sepsis in the pediatric intensive care unit- a disappointment which has pushed the organization to develop a quality improvement plan aimed at alleviating the problem of medical errors within the pediatric intensive care unit. This article provides the details of the quality improvement plan that will be taken as a basis of Morton Plant Hospital’s obligation to constantly enhance the value of treatment services it delivers in the pediatric intensive care unit (PICU). 

Background 

Since 2015, Morton Plant Hospital has been setting numerous trials and procedures on alleviating sepsis, focusing majorly on how to improve the management and the prevention of infant sepsis-related complications. During this time, the facility has largely emphasized the need for the caregivers to focus on therapeutic measures with positive impacts. However, based on a 2019 quality assessment survey at the Morton Plant Hospital’s pediatric unit, 75 % of all sepsis incidents between 2015 and 2019 are associated with medical errors. These findings have inspired a shift of attention towards medical errors as a key cause of sepsis in the hospital’s PICU. 

Project Aim 

By January 2021, incidents of sepsis associated with medical errors will be reduced by 20%, based on the current incident data. 

Theoretical Change 

Many healthcare organizations rely on Lewin's change management theory in understanding how human behavior affects the patterns of change. The theory provides that any change encompasses three distinctive phases, including unfreezing, moving, and refreezing ( Udod & Wagner, 2018) . The purpose of applying this theory in Morton Plant’s QI plan is to identify factors and circumstances which will likely facilitate or impede the anticipated change. Only when the organization fully understands the behaviors that oppose change, then work to fortify the positive forces, will the change come about successfully. 

The unfreezing phase of the theory will entail the identification of the key players in the PICU who will be affected by the change. The main component of this stage is communicating with all the stakeholders involved in the PICU, including nurses, physicians, managers, and the hospital leadership. It is important that communication remains honest and open so that the feeling of security and trust is maintained by all the parties taking part in the proposed change ( Connelly, 2016) . The forces that will likely oppose the change in the facility include staff resistance to the use of computerized devices in delivering sepsis care, the possibility of workarounds, limited computer experience among the staff, aversion to the use of new patient care protocols, and a lack of trust among the caregivers. 

The moving phase will represent a period of the actual change, which involves the actual implementation of the care plan. 

The refreezing phase in Lewin’s theory will require that the quality improvement (QI) committee verifies the stability of the pediatric sepsis care. The ongoing quality improvement practices ought to proceed until the change is considered complete, and all the statistics show a drop in the medical errors that lead to sepsis. 

Quality Improvement Tool 

Root Cause Analysis 

The root cause analysis (RCA) will be utilized as a tool for identifying the causes of the high numbers of infant sepsis in the PICU. RCA comprises five basic steps, including problem identification, data collection, possible causa factors, root causes, and recommendations. Accordingly, all the five identifiable steps of RCA will be followed in improving care in the PICU: 

Problem definition. Objective evidence from a recent survey indicates that even with the best medical procedures, PICU still continues to register high scores of sepsis morbidity and mortality. Medical errors are among the reasons behind the inherent high numbers of infant sepsis in PICU ( Plunkett & Tong, 2015) . At this facility, the medical errors fall into the categories of the wrong dosage, missed medication, and the wrong route. Regarding missed medication, data from Morton Plant's PICU reveal of incidents where the infants have missed their routine medication ultimately developed sepsis and associated complications. Regarding the wrong dosage, infants who were mistakenly subjected to overdose prescriptions have been identified to be twice as likely to develop sepsis as the normally treated infants ( Boeddha et al., 2018) . Also, tubing misconnections in the pediatric ICU have had devastating effects on the patients' lives. There have been instances of negligence, such as failure to sterilize the medical equipment that has reportedly resulted in infant sepsis in the ICU ( Hood, 2018) . Cases of intravenous administration of drugs meant for oral use have also caused sepsis among the infants. 

Data collection. Data will be collected and evaluated as indicated in the table below 

Possible Causal Factors. Healthcare professionals , patients , medicines, hospital tasks , c omputerized information systems , and primary-secondary care interface are key areas that contribute to the high number of medical errors. 

Root Causes. Below is a list of possible root causes of sepsis that relate directly to the causal factors highlighted above. 

Little justifications of the recommendations for secondary care 

Inadequate therapeutic training/ drug knowledge/ knowledge of patient/ perception of risks 

Fatigue and emotional issues 

Poor communication with infant parents ( Helo & Moulton, 2017) 

The complexity of the clinical case such as comorbidities and polypharmacy. 

Naming, Labelling, and packaging of medicines ( Robertson & Long, 2018) 

Repetitive computing systems 

Inaccurate patient records 

Inadequate design that permits medical errors 

Difficult process for generating correct prescriptions 

Recommended Solutions. As a recommendation, the hospital should ensure that: 

The treatments offered to the infants under the age of 1 year in the pediatric intensive care unit incorporates evidence-based practices. 

The treatments to be offered to each patient must be suitable for every consumer's needs 

The treatments and services provided at the pediatric intensive care unit are fully available whenever they are needed 

There are prevention mechanism for ensuring that the probability of occurrence of medical errors is significantly reduced 

The risks to medical personnel are equally lessened, as is the risk to the patient. 

The medical procedures, treatments, and services at the pediatric intensive care unit will be provided in a timely and efficient manner. It would require suitable synchronization and stability across all segments of patient care. 

The providers of pediatric care must consider principles for quality improvement during their practice. 

Quality Improvement Model 

Plan-Do-Check-Act (PDCA) model 

Morton Plant Hospital will either design measures to enhance the quality of the current services or to create new ones. The improvement process will be undertaken through the Plan-Do-Check-Act (PDCA) model. 

Plan. This will be the first step, entailing the determination of the affected staff, compiling the data, and using the trends to come up with the most appropriate solution. 

Do. Testing the new solution, and if successful, implementing it as a conventional practice in the department. 

Check. Again, data will be collected to make comparisons between the new results and the preceding results 

Act . This stage will rewrite that the affected staff and those whose support would be required to execute the changes brought overboard to design a new routine of operations that reduced the likelihood of occurrence of sepsis at the PICU. The process will end with the documenting and reporting the findings for follow-up or evaluation. 

Budget 

As the resources allow, the budget allocation for this QI project will be dedicated to the line of activities described in the table below. 

Donabedian’s Measures 

Outcome Measures 

By August 2020, medical errors caused by the wrong route will reduce by 7%. By November 2020, these errors will reduce by another 7% (14% overall). By January 2021. These errors will reduce by an additional 6% (20% total) based on the current incident data. By September 2020, medical errors associated with the administration of the wrong dosage will reduce by 11%. By December 2020, this category of errors will be reduced by an additional 5% (16% overall). By January 2021, the errors will reduce by another 4% (20% total) based on the current incident statistics. By October 2020, the medical errors caused by insufficient administration of medication or missed medication will reduce by 14%. By December 2020, the medial errors of this category will reduce by another 4% (18% overall). By January 2021, the incidence of insufficient prescription or missed medication will reduce by an additional 2% (20% in total) based on the current data. 

Process Measures 

All pediatric staff to undertake training in multicomponent quality programs and practices of pediatric care quality enhancement by June 29, 2020. The hospital to adopt a computerized provider entry (PCOE) with decision support as a replacement of human monitoring of patient conditions. The PCOE will reduce the burden of alerts from inappropriate medications, thereby giving the caregivers chance to focus on the clinically relevant warning signs only. 

Structure Measures 

Create a medication reconciliation unit within the first month of the approval of this QI plan. The unit will formally establish and document a consistent, definitive list of medications across transitions of care by rectifying any prescription discrepancies. The accuracy of medical information during the transition from normal care to intensive care will reduce the possibility of medication clash ( World Health Organization, 2016) . 

Balancing Measures 

The computerized system will be reviewed within the next three months to establish areas of difficulty and develop multicomponent solutions to each challenge. However, the organization must first start by taking the pediatric professionals through IT training to better familiarize with the current digital system. Morton Plant Hospital will also recruit at least three pediatric professionals to reduce the burden of employee overworking by August 29, 2020. 

Measures of Effectiveness 

Qualitative 

A computerized system will review the performance of PICU within the next three months to establish areas of difficulty and develop multicomponent solutions to each difficulty. 

Quantitative 

A quantitative evaluation of the state of care in the PICU will be completed by comparing the number of sepsis cases related to medical errors at the start of the project and the total number of these cases after the full implementation of the QI plan. 

Visual Displays for Reporting Outcome Data 

The improvement outcome will be displayed using line graphs and pie charts. Graphs and charts will be effective in condensing large amounts of information into easily understandable formats to highlight vital points in the progress of the QI plan. The data on the percentage reductions on the number of medical errors are termed as categorical because they have non-overlapping statistics ( CDC, 2018) . It is easier to use line graphs and pie charts to represent this set of data, unlike the histograms, which are best used for displaying continuous data such as test scores and weight. 

Line graphs are used to display the relationship between two sets of information ( CDC, 2018) . In the current quality improvement plan, the graphs will be used to display a progressive drop in the number of medical errors by year. 

Pie charts are used to make comprehensive comparisons of different parts of related data ( CDC, 2018) . In the current quality improvement plan, the pie charts will be used to compare the trends of the different types of medical errors, such as wrong dosage errors, missed medication errors, and wrong route errors. 

Conclusion 

The Morton Plant Hospital quality improvement plan exists within the context of the organization’s mission, values, and priorities to become a premier pediatric care destination in the country. The plan is created to enable the pediatric intensive care unit to more effectively achieve a reduction in the cases of sepsis caused by medical errors in the unit. The project aims to see a 20% reduction in total medical error and, ultimately, a reduction in the cases of PICU. This development will call for the application of the principles of Lewin’s change theory model to ensure that the project is completed in time and within budget. 

References 

Boeddha, N. P., Schlapbach, L. J., Driessen, G. J., Herberg, J. A., Rivero-Calle, I., Cebey-López, M., ... & Nadel, S. (2018). Mortality and morbidity in community-acquired sepsis in European pediatric intensive care units: a prospective cohort study from the European Childhood Life-threatening Infectious Disease Study (EUCLIDS).  Critical care ,  22 (1), 143. 

CDC. (2018).  Evaluation Briefs: Using Charts and Graphs to Illustrate Quantitative Data . Centers for Disease Control and Prevention.  https://www.cdc.gov/healthyyouth/evaluation/pdf/brief12.pdf 

Connelly, M. (2016, November 15).  The Kurt Lewin model of change . Change Management Coach.  https://www.change-management-coach.com/kurt_lewin.html 

Helo, S., & Moulton, C. A. E. (2017). Complications: acknowledging, managing, and coping with human error.  Translational andrology and urology ,  6 (4), 773. 

Hood, R. (2018).  Sepsis can be caused by medical malpractice . McGowan, Hood & Felder, LLC.  https://www.mcgowanhood.com/2018/03/20/sepsis-can-be-caused-by-medical-malpractice/ 

Hussain, S. T., Lei, S., Akram, T., Haider, M. J., Hussain, S. H., & Ali, M. (2018). Kurt Lewin's change model: A critical review of the role of leadership and employee involvement in organizational change.  Journal of Innovation & Knowledge ,  3 (3), 123-127. 

Plunkett, A., & Tong, J. (2015). Sepsis in children.  Bmj ,  350 , h3017. 

Robertson, J. J., & Long, B. (2018). Suffering in silence: medical error and its impact on health care providers.  The Journal of emergency medicine ,  54 (4), 402-409. 

Udod, S., & Wagner, J. (2018, June 30).  Common change theories and application to different nursing situations – Leadership and influencing change in nursing . Leadership and Influencing Change in Nursing – Simple Book Publishing.  https://leadershipandinfluencingchangeinnursing.pressbooks.com/chapter/chapter-9-common-change-theories-and-application-to-different-nursing-situations/ 

World Health Organization. (2016).  Medication Errors: Technical Series on Safer Primary Care .  https://apps.who.int/iris/bitstream/handle/10665/252274/9789241511643-eng.pdf;jsessionid=FDB1BE2683396D2DA592F947714EBF5E?sequence=1