System Level Prevention

The Breathing Institute at Children's Hospital Colorado Helps Identify Infants at Risk for RSV

What happens when your team doesn’t own a process...but the process needs to be improved? A team from the Breathing Institute​ at Children’s Hospital Colorado is proving that it’s possible to impact the health of your patients, even when the process isn’t yours.

Respiratory syncytial virus, or RSV, causes lung infections. The Centers for Disease Control and Prevention estimate​ upwards of 125,000 children under age 1 are hospitalized each year. It’s a common childhood illness, but it can be deadly for some babies—in particular, preterm infants.

The incidence of RSV infections can be reduced in high-risk patients through the administration of the injectable prescription drug Synagis (palivizumab). When the drug was first released, CHCO had a process of identifying which patients were most likely to benefit. However, in the early 2000s, the system for Synagis administration changed. Primary care providers now owned the process for ordering Synagis and delivering it to patients.

CHCO was no longer able to administer the drug to its pulmonary patients.

Initial Steps

Three years ago, as CHCO observed the U.S. News and World Report metrics​ on reducing admissions, Wendy Berry, a Certified Pediatric Nurse Practitioner at the Breathing Institute, recognized that many patients who might benefit from Synagis were not receiving it. She started a campaign aimed at providers to identify high-risk patients and identified a nurse champion within the Breathing Institute to own this process.  

“It was a very manually driven process,” said Denise Chacon, BSN, RN, MHA.

The nurse champion received a report that indicated which patients receiving care at the Breathing Institute met the minimum criteria associated with Synagis. She would then work with providers to determine whether patients met criteria for bronchopulmonary dysplasia (BPD), which meant Synagis was recommended. If a patient met this criteria, the patient’s primary care provider would be contacted to ensure the patient would be administered Synagis as indicated: five injections over five months during RSV season. 

Thirty four patients were identified in 2012 who met the criteria for BPD and contacted each patient’s PCP to encourage Synagis administration. After RSV season, it was determined that 88% received all five doses. Cost was a barrier for patients not receiving all doses.

To refine the process, the electronic health record alert was updated with more clearly-defined criteria. The team also addressed some of the financial barriers patients in 2012 experienced. They worked with the Synagis manufacturer’s patient assistance program. The team also helped deal with insurance company denials by providing PCPs with appeal letters to send should a patient’s coverage be denied.

The Breathing Institute identified 55 patients in 2013 meeting Synagis criteria and contacted each patient’s PCP to encourage Synagis administration. Follow up revealed that 91% of the 55 patients received all doses.

New Perspectives Gained From Certificate Training Program

A Breathing Institute team, now consisting of Berry, Chacon and Gwendolyn Kerby, MD​, entered the certificate training program of the Institute of Healthcare Quality, Safety and Efficiency (IHQSE) in 2013.  They continued working on this initiative throughout 2014.

During this time, the team identified another barrier to proper Synagis administration. Patients in the neonatal intensive care unit at Children’s Hospital were given their first dose of Synagis prior to being discharged.

Without a process in place to proactively communicate with the PCP, the second dosage could be delayed. The IHQSE team developed a process in which the neonatal ICU would notify an internal case management team when the first dose was administered. Case managers would then contact the PCP to begin the ordering process.

The IHQSE team also began contacting patients midway through RSV season to ensure they were receiving their doses and identify any barriers. “In some cases, insurance was the challenge—parents didn’t understand that they could appeal a single insurance company denial and receive the necessary dosages,” says Chacon.

Their results: 95% of the 76 patients they identified received all doses of their medication.

Looking Ahead to 2015

The Breathing Institute team faces a challenging year, as the American Academy of Pediatrics changed its guidelines criteria​ for the qualifications and age range of patients who should receive Synagis.

“Our identification numbers may go down because the guidelines are stricter,” says Dr. Kerby. “Of course, we hope to be just as successful with the patients who do qualify.”

Other departments at CHCO may be able to learn from the experiences of the Breathing Institute. The team has plans to help their peers in the cardiac care and neonatal units develop similar identification processes for infants at increased risk of RSV.

Dr. Kerby will continue to play a role with the IHQSE to stay connected and receive ongoing support and training. “As more and more people at CHCO are trained, we can begin to work together across our areas to improve patient care,” says Dr. Kerby.