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Physician-Driven QI Projects Enhancing Patient Outcomes and Experience
Key Takeaways
Orthopaedic surgeons and other specialists from Cincinnati Children’s are teaming up on quality improvement projects, and some of their efforts have been implemented across the health system.
To ensure as many surgical patients as possible are given prophylactic cefazolin—the gold standard in preventing post-op infections—they implemented an antibiotic allergy testing process and fixed a medication ordering issue in EPIC.
The Division of Orthopaedic Surgery is also piloting a patient-reported outcomes survey about treatment success that provides actionable, electronic data in real time.
Two quality improvement projects initiated within the Cincinnati Children’s Division of Orthopaedics have the potential to optimize patient safety, satisfaction and outcomes across all of the health system’s surgical subspecialties.
First, a recently completed effort to ensure all eligible orthopaedic surgery patients receive preoperative cefazolin led to an organization-wide order change that removes barriers to cefazolin access. And a patient-reported outcomes project currently being piloted by the health system’s orthopaedic surgeons eventually could be replicated by any surgical or interventional specialty, at any pediatric medical center.
Improving Antibiotic Prophylaxis Through Allergy Testing
Even though an ever-growing body of evidence consistently confirms cefazolin is the safest and most effective antibiotic for preventing postoperative infections, there’s a long-standing misconception throughout the medical community that people with penicillin allergies can’t take cefazolin.
Jaime Rice Denning, MD, MS
“For various reasons, cefazolin has been incorrectly labeled as unsafe for people who are allergic to penicillin,” says Jaime Rice Denning, MD, MS, a Cincinnati Children’s orthopaedic surgeon who serves as both associate director and safety officer for the Division of Orthopaedics. “Although there isn’t any data supporting this theory, many patients with penicillin allergies receive alternative antibiotics that aren’t as effective at preventing post-op infections.”
Cincinnati Children’s providers were previously unable to prescribe cefazolin to any patients without a hard stop in the order set. So, several orthopaedic providers decided to explore whether they could match patients with the right antibiotic through allergy testing.
Since this process was implemented, our data shows a 27.5% increase in prophylactic cefazolin use without adverse effects and patient referrals for allergy testing increased from 14.1% to 31.6%.
Jaime Rice Denning, MD, MS
They teamed up with other experts—including allergy and immunology specialists, pharmacists and anesthesiologists—to create and perfect a process that is now in use across the health system: Before having elective surgery, any patient flagged as having a penicillin allergy is referred to the Cincinnati Children’s Pediatric Antibiotic Allergy Testing service. There, they have a simple test that confirms whether they’re truly allergic to penicillin, and whether they can take cefazolin.
“Since this process was implemented, our data shows a 27.5% increase in prophylactic cefazolin use without adverse effects and patient referrals for allergy testing increased from 14.1% to 31.6%,” Denning says. “We were also successful in removing the block from our ordering system that automatically prevented patients with penicillin allergies from receiving cefazolin.”
Evaluating Patients’ Perceptions of Successful Treatment
Denning and some of her colleagues also have been working on a process for collecting measurable (and actionable) patient-reported outcomes.
Their goal? To track whether patients think they’re getting better after having orthopaedic treatment at Cincinnati Children’s—and to quickly follow up with those who aren’t satisfied with their outcome.
“During a quality improvement discussion a couple years ago, we wondered whether our definition of a ‘good outcome’ matches up with our patients’ perceptions of how they’re doing after treatment,” Denning says. “We often use imaging scans and other physician-centric clinical measures to determine whether someone’s surgery was successful, but what does success mean to that patient? We decided to see if this was something we could measure and track.”
The health system didn’t have any existing tools to collect this data without using lengthy questionnaires. Knowing patients and families get tired of filling out forms, the team didn’t want to create yet another long survey. So, they turned to the literature and found something they could potentially repurpose: a validated, one-question survey measuring patient satisfaction related to specific orthopaedic treatments such as hip replacement surgery.
The division’s surgeons spent the next two years testing and refining their version of the survey and the data collection process, ensuring they were asking the right questions at the right time. Today, they’re collecting data at all eight Cincinnati Children’s orthopaedic surgery clinics—and are working on making that data as useful as possible.
“Our current process is running quite smoothly,” Denning explains. “Each eligible patient who checks in for a follow-up appointment is given an iPad with a simple, three-question survey. We’re basically asking them to confirm whether they’ve completed the treatment for their condition, which specific treatment they had and whether they’ve gotten better. So we can see, for example, that the majority of patients who received orthotics report that they’re happy with their treatment, while patients with casts are less satisfied.”
Denning says providers can act upon this high-yield information in real time during the patient’s visit, probing the reasons why they feel their treatment hasn’t helped and discussing next steps.
“We’re still in the troubleshooting phase with the survey, and still exploring how best to use the collective data to continuously improve the care we offer,” Denning adds. “But because we have a great mechanism for extending quality improvement work at Cincinnati Children’s, I can see this tool being rolled out to other surgical divisions in the near future. In fact, because this project is so standardized and spreadable, I think it could easily be adopted at other medical centers as well.”
