Children’s Hospital of Orange County | Davies Enterprise Award

Children’s Hospital of Orange County (CHOC) is a 2016 winner of the HIMSS Davies Enterprise Award. For over 20 years, CHOC has been committed to providing the highest quality medical care to children. Affiliated with the University of California, Irvine, CHOC’s regional pediatric healthcare network includes a state-of-the-art 279-bed main hospital facility in the City of Orange, and a hospital-within-a-hospital in Mission Viejo.

CHOC also offers many primary and specialty care clinics, more than 100 additional programs and services, a pediatric residency program, and four centers of excellence – The CHOC Children’s Heart, Neuroscience, Orthopaedic and Hyundai Cancer Institutes.

CHOC received the award from HIMSS based on four case studies that detailed how the use of health information technology and standardized clinical processes have improved patient care and the bottom line. The case studies included:

  • Through education, a standardized care bundle, and EHR-enabled best practice guidance to minimize urinary catheter use and duration, CHOC significantly reduced catheter associated infections and urinary catheter use.
  • Since the implementation of the revised evidence-based guideline and order set and portal-enabled home management plan care documentation for asthma, CHOC drove down the average length of stay for asthma patients from 2.14 days to 1.72 days. Asthma readmissions within 30 days also fell from an average of 1.7 per quarter to 0.7 per quarter.
  • CHOC implemented an EHR-enabled Pediatric Early Warning System (PEWS) to trigger a rapid response team for rapidly deteriorating patients. As result, some 369 children have avoided resuscitation, with potentially as many lives saved.
  • CHOC implemented centralized breastmilk preparation including barcoding to effectively eliminate feedings of the wrong breastmilk. Efficiencies associated with the centralized processes for breast milk preparation resulted in annual savings of approximately $30,000.

CHOC has found that one of the most common hospital-acquired infection is Urinary tract infection (UTI). These infections are attributable to indwelling urethral catheter. CHOC Children’s recognized the need for a more comprehensive approach to documentation and education of urinary catheter care and Catheter Associated Urinary Tract Infections (CAUTI) prevention.  CHOC researched and developed recommendations for CAUTI prevention based on jointly published guidelines from the Society for Healthcare Epidemiology of America, Infectious Disease Society of America, American Hospital Association, Association for Professionals in Infection Control, and the Joint Commission.

Guided by these recommendations, a multidisciplinary team was formed to develop the catheter insertion and maintenance documentation tools and workflows. The combined efforts of the clinical and technical groups resulted in the development of two PowerForms within the EHR to more comprehensively capture documentation for catheter insertion and maintenance.

These forms guide nurses to indicate the catheter insertion aseptic techniques, as well as catheter function and care for every shift. Additionally, the team created and administered a staff education module, which provided didactic knowledge around evidence-based practices for CAUTI prevention.

The visibility of clinical and adoption data from the top down reinforces an organizational commitment to reducing serious patient harm and preventing HACs, including CAUTIs. Hospital-wide, CAUTI rates dropped from a mean pre-project rate of 1.86 per 1000 catheter days to 0.9 per 1000 catheter days in 2015, a 51.2% reduction.

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In 2009, leadership at CHOC Children’s decided to review and rewrite existing care guidelines, as well as develop care guidelines for previously uncovered clinical diagnoses and conditions. The hospital had a modest number of care guidelines in place, but saw an opportunity to utilize their EHR to embed clinical guidelines-and their associated order sets- directly within existing workflows and, when necessary, incorporate automated alerts.

All potential guidelines were assessed using three established criteria: 1) high volume conditions, 2) high risk conditions, or 3) high variability diagnoses or conditions. Over the next two years, CHOC Children’s went from approximately five active care guidelines to 20+ evidence-based care guidelines – all embedded directly within the EHR and easily accessible during care.

Currently there are more than 35 CHOC care guidelines. Asthma is the most common chronic condition in pediatrics, the second to third highest volume inpatient diagnosis at CHOC Children’s, and the only condition identified by The Joint Commission (TJC) for pediatric core measures; therefore, the pre-existing evidence-based care guideline for asthma was an obvious and early guideline identified for review.

Since the implementation of the revised evidence-based guideline and order set and portal-enabled home management plan care documentation for asthma, CHOC drove down the average length of stay for asthma patients from 2.14 days to 1.72 days. Asthma readmissions within 30 days also fell from an average of 1.7 per quarter to 0.7 per quarter.

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In 2008, after an internal review of three years of data, CHOC Children’s leadership found that more than 80 percent of patients in non-ICU areas who eventually coded displayed early, identifiable signs of clinical deterioration up to eight hours prior to arrest. Leadership thus decided to deploy a Rapid Response program.

In addition to the RRTs, CHOC Children’s decided to develop an electronic physiologic assessment tool, referred to as Pediatric Early Warning System (PEWS), to standardize language and process of clinical deterioration observation in non-ICU areas. The system leverages patient data from the electronic health record (EHR) to assess all children for risk of deterioration.

CHOC implemented an EHR-enabled Pediatric Early Warning System (PEWS) to trigger a rapid response team for rapidly deteriorating patients. As result, some 369 children have avoided resuscitation, with potentially as many lives saved.

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The use of breastmilk is common on the CHOC Children’s campus. While the majority of breastmilk use is within the 67 bed level IV NICU, infants receiving breastmilk may be admitted to any unit within the facility. The concept of using quality improvement measures with regards to safe breastmilk handling is not new and current emphasis throughout the industry has been focused on preventing breastmilk misadministration.

The primary concern of a breastmilk administration error is the health of the infant. While the risk of infection is low, breastmilk is a bodily fluid and concerns about transmission of Hepatitis B, Hepatitis C, and HIV exist. In addition, breastmilk could result in an infant being exposed to medications or illicit drugs from another mother.

Based on the analysis of potential failure points in breastmilk handling, the PI team determined the safest course of action would be to change processes in two phases. Phase I would consist of changing to a model of centralized breastmilk handling where dedicated milk technicians would do all of the thawing, fortifying, and labeling of breastmilk and deliver the prepared feedings to the bedside nurse.Phase II would involve implementation of breastmilk bar code scanning.

CHOC implemented centralized breastmilk preparation including barcoding to effectively eliminate feedings of the wrong breastmilk. Efficiencies associated with the centralized processes for breast milk preparation resulted in annual savings of approximately $30,000.

Read the Case Study