1. Experts believe that a stunning 20 to 40 percent of the $2.4 trillion America spends on health care in 2008 will be wasted on misuse (including harmful and fatal errors), overuse (care thats unnecessary) or underuse ( effective care thats not provided). The Overuse and Misuse of Health Care Resources: Reduction of Bronchodilator Utilization in the Management of Acute Bronchiolitis in Children

2. Finding Value in Health Cares : Our Escape Fire….. The Five Domains of Value: Access Technical Quality Functional Status Service Satisfaction Cost/price Value (V) == A + TQ +FS + SS C

3. Core Conclusions of the IOM Report.. Every system is perfectly designed to achieve exactly the results it gets. The problems come from poor systems…not bad people

4. Redesign Care Based on Best Practices Use Information Technology to Improve Access to Information and to Support Clinical Decision Making Develop Effective Teams Coordinate Care Among Services and Settings Measure Performance and Outcomes Changing the System…..

5. Bronchiolitis A self-limited condition; viral mediated associated with URI symptoms, cough, and wheezing; most commonly dx age <2. #1 discharge ICD-9 diagnosis, excluding birth #2 in aggregate costs incredible degree of variation New evidence-based AAP guidelines

6. The Evidence From the American Academy of Pediatrics… Bronchodilators should not be used routinely for management. An optional trial of an - or ß-agonist should be continued only if objective evaluation indicates a clinical response. Most positive studies of bronchodilators for management of bronchiolitis show transient improvement of unclear clinical significance.

7. Specific AIM: To reduce the utilization of bronchodilators for bronchiolitis by 20% when comparing 1 st Q2010 data to 4 th Q 2008 and 1 st Q 2009 data in the Pediatric Inpatient Ward and in the Pediatric Emergency Room Global Aims: To Improve Effectiveness of Care (IOM)

8. Timeline

9. Plan…… Create the Team Clinical Physicians: Pediatric Hospitalists; Pediatric ED Physicians, Community Pediatricians, and Pediatric Pulmonologists Respiratory Therapists Nurse Managers from the Inpatient and Pediatric ED Physician Liaison to IS Department (order set creation)

10. Plan ….

11. ) Respiratory Rate0 (normal)1 (infant>50; child >40, adolescent>20) Accessory Muscles 0 (normal)1 (supra/sub/inter costal retractions 2 (neck/abdominal muscles) Air Exchange0 (normal)1 (localized decrease) 2 (diffuse decreased) Wheeze0 (none/end-exp)1 (entire expiration) 2 (entire expiration/inspir ation) I: E Ratio0 (less than 1:2)1 (greater than 1:3) Do: The Intervention An Objective Respiratory Acuity Scoring Tool

12. Do: The Intervention

13. Do: The Intervention A Standardized Bronchiolitis Order Set in ED and Inpatient settings IF Score is 4 or greatertrial of Racemic Epinephrine (evidence demonstrates some modest improvement in Resp Scoreso will wait for scores to be clearly indicative of respiratory distress) IF one wants an Albuterol Trial ( should be based on primary FH of Atopy/Asthma)must specify Asthma Protocol with albuterol (and albuterol will be given after a post suction score of 4) There will be 2 orders on the Bronchiolitis Order Set Bronchiolitis Protocol (start with Racemic Epinephrine) Bronchiolitis Protocol (start with Albuterol)

14. Bronchiolitis Protocol Monday, October 12, 2009 @ 10:30am - 11:00am in the PEDS Conference Room Wednesday, October 14, 2009 @ 7am - 7:30am in the Playroom Do: The Intervention– Education and Changing Culture

15. Check

18. ACT LESSONS LEARNEDNEXT STEPS Every system is perfectly designed to get the results it gets. If we want different results, we must change the system Culture eats strategy for lunch. Effective leaders help others to understand the necessity of change and to accept a common vision of the desired outcome Monitor Control Charts for next 3 months to ensure stable process Sustaining Change Integrate in to Physician Report Cards Development of a Balanced Score EBM Lunch Series (CM E)

19. Closing the Gap……