Nathan C. Kraynack, M.D. (center), director of the Children's Hospital Medical Center of Akron visits the Antonio J. and Janet Palumbo CF Center in Pittsburgh to enrich his center's quality improvement efforts through the pediatric benchmarking initiative designed to explore practices at high performing centers.
When is a patient sick enough to receive aggressive treatment? A group of health care professionals in Akron asked themselves this very question and learned, to their surprise, that their answers varied.
Pulmonary exacerbations occur periodically in individuals with CF, often requiring hospitalization and at times causing irreversible lung damage. Identifying and aggressively treating exacerbations can help maintain lung function, but until recently it was difficult for care teams to agree on how to define them.
“The general assumption was that everyone was doing the same things the same way, but we found that this simply was not true. The key to this project was that we had to really accept that things were being done differently,” said Nathan Kraynack, M.D., director of the cystic fibrosis center at the Children’s Hospital Medical Center of Akron. Kraynack believed that understanding these differences could eventually lead to a common path.
In 2004, Akron’s quality improvement team decided to standardize the center’s practice. They reached consensus in defining exacerbations for patients aged 6 to 18 years old by using a uniform scoring system that tallies several factors including cough, shortness of breath, weight loss, abnormal chest X-rays and lung function.
Once an exacerbation is identified, the general strategy is to provide early and aggressive treatment. How and when to treat a patient, however, is still ultimately decided by the patient’s health care professional. The Akron team also worked closely with a council comprised of CF patients and families.
Using the standardized scoring system has paid off. An analysis of the center’s pulmonary data showed that on average patients had significantly improved their lung function. The good news spread fast, and other centers are now exploring the use of a scoring system, including the Children’s Hospital and Regional Medical Center in Seattle and the Women and Children’s Hospital of Buffalo.
To help pass it on, staff from the Akron center volunteered to serve as “improvement coaches” in this year’s Fifth Leadership and Learning Collaborative sponsored by the CF Foundation and led by its vice president of clinical affairs, Bruce Marshall, M.D.
“The collaborative is one of many ways the Foundation works to ensure that people with CF and their families benefit from the best possible research and care,” said Marshall. “The idea is to share what works at one center with other centers by offering support while they are trying new approaches.”
Through a standardized curriculum, face-to-face meetings, teambuilding and yearlong training, the collaborative and Akron’s improvement coaches are supporting the implementation of several strategic ideas to improve pulmonary care elsewhere, including standardizing the definition of pulmonary exacerbations.
“Foundation support has been huge,” said Kraynack. “An earlier collaborative laid the groundwork for us to understand how to affect change in our center and gave us very formalized training in quality improvement. Without that training, I doubt that we would’ve been able to take this project to completion or be able to sustain it.”
Kraynack hopes to continue to see improvement in the center’s patients. Scoring systems have expanded to other aspects of care, and health care providers at Akron are now using them to standardize the way they approach nutrition.