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Patient safety, process improvement, and quality management

The Patient Safety & Quality (PSQ) Program in the Boston Children’s Hospital Department of Urology aims to ensure the quality of care in all facets, including inpatient and outpatient consultation as well as surgical services. Process and quality improvement initiatives play a crucial role in enhancing patient care, safety, and outcomes in pediatric urology. Our efforts are led by PSQ Director Dr. Julia Finkelstein, who is committed to ongoing program evaluation and driving a number of projects aimed at providing high-quality, reliable, and safe care.

Here are some of our recent and ongoing initiatives.

Opioid stewardship

Opioids are often indicated for postoperative pain management in pediatric urology patients, but there is limited evidence regarding best practices. Opioid overdoses have increased among children and adolescents, and this is sometimes related to overprescribing. Providers who use institutional guidelines prescribe fewer opioids, and this does not necessarily cause an increase in patient pain scores. Therefore, a multidisciplinary quality improvement initiative was established to develop and implement an opioid-prescribing guideline for postoperative pediatric urology patients, determining the optimal number of doses for specific surgeries. Our goal was to reduce the procedure-adjusted rate of opioid prescriptions. In September 2022, our prescribing guideline was integrated into Boston Children’s opioid-prescribing clinical pathway, distributed to clinical staff, and incorporated into our trainee handbook. There has been high compliance with these recommendations, as well as a low rate of prescription refills and high patient-reported satisfaction, suggesting clinically appropriate recommendations. We continue to monitor compliance with opioid prescribing and to assess the appropriateness of the opioid guideline dosing recommendations by surgery.

  • Implementation of an Opioid Prescribing Guideline for Postoperative Pediatric Urology Patients/Platform, Pediatric Urology Nurse Specialists Annual Meeting 2023, Houston, TX

Investigation of virtual care in pediatric urology: Assessing the feasibility, safety, and equity

Prior to the COVID-19 pandemic, we evaluated the feasibility of telemedicine for postoperative encounters in pediatric urology and demonstrated that telemedicine can be successfully implemented in postoperative care. In a subsequent study, we compared virtual visits with conventional in-person visits and found that, for pediatric urological postoperative care, virtual visits are associated with shorter wait times, decreased absence from work and school, and clinical outcomes like those of in-person visits. This work laid the foundation for telemedicine use within pediatric urology at Boston Children’s and across the country. It was far-sighted in its relevance, since we did not know that the COVID-19 pandemic would create an urgent need to limit in-person care.

Given the emergency conditions and accelerated use of telemedicine during the pandemic, there was not time to fully evaluate the value of telemedicine in the clinical environment. Thus, we sought to assess the diagnostic accuracy of telemedicine visits, compared to subsequent in-person encounters for pediatric penile conditions. While the exact concordance between the initial telemedicine and subsequent in-person visit penile diagnoses was low, this did not necessarily result in a change in the surgical procedure performed. With this in mind, we then investigated the clinician-determined efficacy of virtual visits performed for pediatric urologic encounters. In more than 3,200 pediatric urology virtual visits during a one-year period, we found telemedicine to be quite effective for management, with almost 97 percent of patients being deemed by clinicians as receiving complete case management. We continue to evaluate which patients may be best suited for telemedicine, and the patient/family and clinician experiences with telemedicine, along with implementation lessons learned, to inform and optimize future telemedicine practice for pediatric urology patient at Boston Children’s and beyond.

Peer-reviewed telemedicine scholarship:

Research and invited telemedicine presentations:

  • Telemedicine is as Effective as In-Person Visits for Pediatric Urologic Postoperative Care/Platform: Annual Meeting of the American Urological Association 2019, Chicago, IL
  • Virtual Visits, Real Benefits: Family Experience and Satisfaction with Telemedicine in Pediatric Urology/Poster: Annual Meeting of the American Urological Association 2019, Chicago, IL
  • Emerging Concepts in Pediatric Urology: Telehealth/Dr. Finkelstein: Societies for Pediatric Urology 2021, Fall Congress, Miami, FL
  • Pediatric Urological Provider Use and Comfort Level with Telemedicine/Poster: Societies for Pediatric Urology 2021, Fall Congress, Miami, FL
  • Environmental Impact of a Pediatric Telemedicine Program: A Lesson from the COVID-19 Pandemic/Platform: Pediatric Academic Societies Meeting 2022, Denver, CO
  • Characterizing Digital Access in Pediatric Urology/Platform: Societies for Pediatric Urology 2022, Fall Congress, Las Vegas, NV
  • The Accuracy of Telemedicine for Pediatric Penile Anatomy/Platform: Societies for Pediatric Urology 2022, Fall Congress, Las Vegas, NV
  • Concordance of planned versus actual penile surgery when using telemedicine for pre-operative assessment of children/Platform: European Societies for Pediatric Urology 2023, Lisbon, Portugal 
  • Factors Contributing to Effective Telemedicine Use in Pediatric Urology/Moderated Poster: Annual Meeting of the American Urological Association 2023, Chicago, IL
  • Telemedicine in Urology/Dr. Finkelstein: Young Urologists Forum, New England Section of the American Urological Association 2022, Portland, ME
  • The Future of Telemedicine in Pediatric Urology/Dr. Finkelstein: Annual Meeting of the American Urological Association 2023, Chicago, IL 
  • How to Effectively Incorporate Telehealth into Pediatric Urology Practice/Dr. Finkelstein: American Urological Association, 2023 Quality Improvement Summit, Linthicum, MD

Antibiotic stewardship for pediatric urologic surgeries

Perioperative surgical antibiotic prophylaxis may decrease postoperative morbidity including surgical site infections and urinary tract infections. However, surgical antibiotic prophylaxis use may also contribute to the rising prevalence of antibiotic resistance, adverse drug reactions, and health care costs. Guidelines for surgical antibiotic prophylaxis are lacking within pediatric urology, and prior literature has shown that surgical antibiotic prophylaxis is widely used by pediatric urologists with great variation in practices. At Boston Children’s we recognized that postoperative intravenous (IV) surgical antibiotic prophylaxis utilization following common pediatric urological procedures might not be necessary. Accordingly, we initiated a quality improvement effort aimed to reduce potentially unnecessary IV surgical antibiotic prophylactic use after pediatric urological surgeries. In June 2022, in collaboration with Boston Children's antibiotic stewardship and clinical informatics teams, IV antibiotic prophylaxis was eliminated from most pediatric urological postoperative order sets in our electronic medical record. After this intervention, there was a significant decrease in the use of postoperative IV antibiotic prophylaxis from 69.1 percent to 31.9 percent. We did not observe a change in the surgical site infection rate.

  • Minimizing the Use of Intravenous Antibiotic Prophylaxis after Pediatric Urologic Surgeries/Platform, Pediatric Urology Nurse Specialists Annual Meeting 2023, Houston, TX
  • Minimizing the Use of Intravenous Antibiotic Prophylaxis after Pediatric Urologic Surgeries/Poster, Societies for Pediatric Urology 2023, Fall Congress, Houston, TX

Enhanced recovery after surgery (ERAS) in pediatric urology

Management of bladder exstrophy involves complex multidisciplinary perioperative and surgical care. Historically, complete primary repair of bladder exstrophy (CPRE) has included postoperative recovery in the Intensive Care Unit and extended length of hospital stay. ERAS protocols are implemented to optimize perioperative care and expedite surgical recovery. At Boston Children’s, we applied ERAS principles to CPRE in an iterative fashion with refinements made to meet the needs of our specific patient population. This program has led to decreased variations in care, optimized patient outcomes, and catalyzed more effective resource utilization, with significant decreases in both overall hospital and intensive care unit lengths of stay

Timeliness of care and outcomes in patients with acute testicular torsion

Testicular torsion is a common pediatric urological emergency that poses a time-sensitive risk to the testicle. Timely diagnosis and management of acute testicular torsion is a benchmark for quality of care. Delays may occur due to protracted presentation, need for transfer to a children’s hospital, or hospital processes. Delays in management and treatment of this condition can result in loss of the testicle. At Boston Children’s, we prospectively track all patients who were treated for acute testicular torsion, tracking patient flow from ED presentation to arrival in the operating room. Our aim is to identify factors associated with the timeliness of acute testicular torsion management.

Additionally, the American College of Surgeons National Surgical Quality Improvement Program Pediatric (NSQIPP) tracks hospital processes related to testicular torsion. With the goal of assessing and identifying quality improvement practices, the Testicular Torsion Collaborative was convened, consisting of approximately 30 NSQIPP hospitals participating in the voluntary testicular torsion process measure collection. Co-led by Dr. Finkelstein, the Testicular Torsion Collaborative aims to assess factors associated with favorable testicular torsion process metrics, potentially identifying performance improvement opportunities. The collaborative also seeks to define longitudinal outcomes in testicular torsion. This multi-institutional quality improvement effort provides a forum to share and disseminate best practices that may contribute to the advancement of testicular torsion care at Boston Children’s.

  • Variation and Opportunities to Improve Testicular Torsion Care: The National Surgical Quality Improvement Program Pediatric Testicular Torsion Collaborative/Platform, Societies for Pediatric Urology 2023, Fall Congress, Houston, TX
  • Acute Testicular Torsion: Put the Pedal to the Metal/Moderated Poster
  • Annual Meeting of the American Urological Association 2024, San Antonio, TX
  • Leveraging NSQIPP Testicular Torsion Process Measures: Initial Survey of the NSQIPP Testicular Torsion Collaborative. American College of Surgeons, Quality and Safety Conference 2024, Denver, CO

Clinical care pathways

We highly prioritize the construction of care pathways, which play a critical role in optimizing the specialty resources within our department as well as standardizing and enhancing the quality of care provided. These pathways aim to incorporate up-to-date evidence, standardize patient experience, and minimize variation in processes when feasible. Our PSQ team most recently focused their efforts on standardizing nursing evaluation of new urology patients to optimize intake and evaluation. Our live nursing triage line is unique at Boston Children’s, allowing immediate response to clinical questions or concerns, and ensures information escalated to providers is comprehensive. “Real-time” advisement can also be provided for call center scheduling agents who have questions about how to optimally schedule patients in clinic.

Furthermore, the PSQ team has created and/or is developing clinical pathways to guide evidence-based care for common urological diagnoses and to enhance patient care outcomes. Besides the Urology recommendations within the institutional opioid prescribing guideline, there are two urology-specific pathways included in the Clinical Pathways Program at Boston Children’s Hospital: nocturnal enuresis and urinary tract dilation. There are ongoing efforts to develop additional clinical pathways, such as for vesicoureteral reflux and recurrent urinary tract infections, to achieve highly reliable care with optimal patient outcomes.

Integrating a culture of safety

Our PSQ team is dedicated to integrating a culture of safety and quality in the Department of Urology. This team has empowered all staff in the department to speak up for patient safety via Safety Stories and submission of safety event reports. There are monthly Morbidity & Mortality Conferences, led by Dr. Finkelstein along with our clinical pediatric urology fellows. These serve as a safe venue with opportunities for inter- and multi-disciplinary reflection and collaborative learning. Furthermore, our PSQ team seeks to align our departmental efforts with the institutional aim of expanding and sustaining use of high reliability principles.