Making Pediatric Care Safer and Higher Quality

“AHRQ funding has enabled me to contribute knowledge to the field of pediatric medicine, helping to improve patient safety for children.”

Protecting pediatric patients from unintended medical harm is a top priority for Michael Rinke, M.D., Ph.D., who is the Medical Director of Pediatric Quality at the Children’s Hospital at Montefiore and Associate Professor of Pediatrics and Director of Dissemination and Implementation Science at Albert Einstein College of Medicine in the Bronx, New York. That’s why his research focuses on improving the quality of care delivered to children in both the hospital and ambulatory settings.

Dr. Rinke established a foundation for his research through a career development grant from AHRQ in 2012 that allowed him to investigate the causes of central line-associated bloodstream infections (CLABSIs), as well as barriers and approaches to preventing them in children with cancer. These pediatric patients are particularly vulnerable to infection, because they are very sick and often have central lines in place to receive medications. They are also often cared for in ambulatory settings, including in their homes, where patients are generally less sick and care processes can be more relaxed.

Dr. Rinke’s research revealed that CLABSIs occur three times more frequently in ambulatory settings than in hospitals and that the differences in care policies between home care agencies and inpatient facilities were a contributing factor. In a 2013 AHRQ-funded study published in Pediatrics, he and a multidisciplinary team showed that implementation of a central-line maintenance bundle reduced CLABSIs in ambulatory oncology pediatric patients by 48 percent. This and other studies demonstrated that a central-line maintenance care bundle used in both inpatient and ambulatory settings could lower CLABSIs and significantly reduce these dangerous infections. Dr. Rinke’s team also discovered that educating family and medical outpatient caregivers on these CLABSI prevention interventions can improve compliance with best-practice care, which can reduce infections.

Building on this initial work, Dr. Rinke received additional AHRQ funding to conduct multisite epidemiological studies focused on healthcare-associated infections that occur in all types of ambulatory pediatric patients. These kinds of studies help researchers better understand the scope and cause of a problem, and risk factors so that future research efforts can be better defined and future prevention efforts can have high-yield targets. Preliminary data suggest that CLABSIs occur at comparable rates in inpatient and ambulatory settings. In addition, Dr. Rinke’s analysis found that risk factors for ambulatory catheter-associated urinary tract infections include anti-infective bladder irrigation and public medical insurance.

In another study, Dr. Rinke investigated the epidemiology of diagnostic errors and whether a quality improvement (QI) collaborative can reduce these harmful events in a national group of pediatric primary care practices. He found that diagnostic errors and missed opportunities for diagnosis occur often in pediatric primary care. Among the pediatricians surveyed, 35 percent reported making a diagnostic error monthly. This group of 30 primary care practices reduced missed diagnoses of pediatric elevated blood pressure and adolescent depression via the implementation of a QI collaborative. A QI collaborative intervention collects high-quality data using standardized methodologies, uses those data to provide feedback to physicians, and employs an “all-teach, all-learn” strategy to accelerate change across practices who work to improve patient outcomes. Additionally, Dr. Rinke’s research showed that missed or delayed actions for laboratory tests with abnormal results improved during his study when additional time was given for follow-up. This AHRQ-funded research is the basis for a toolkit to help reduce diagnostic errors in primary care.

Currently, Dr. Rinke is expanding on this work in further AHRQ-funded research in which he is identifying evidence-based strategies to improve the screening, diagnosis, and management of hypertension in children. Working with 57 primary care practices across the country, he and his team are bringing together primary and subspecialty care practitioners to ensure guideline-compliant care is being delivered to all children to reduce the harmful effects of pediatric hypertension. Dr. Rinke’s project will be completed in 2021.

He also leads an AHRQ Learning Healthcare System (LHS) grant that trains Einstein/Montefiore faculty in LHS research, including QI methods and health information technology, and brings together operational and research leaders to ensure the creation of effective LHSs.

Dr. Rinke is a member of the American Academy of Pediatrics (AAP). He has had several recent articles published in the AAP’s journal, Pediatrics.

Principal Investigator: Michael Rinke, M.D., Ph.D.
Institution: Children’s Hospital at Montefiore
Grantee Since: 2012
Type of Grant: Various

Consistent with its mission, AHRQ provides a broad range of extramural research grants and contracts, research training, conference grants, and intramural research activities. AHRQ is committed to fostering the next generation of health services researchers who can focus on some of the most important challenges facing our Nation's health care system.

To learn more about AHRQ's Research Education and Training Programs, please visit https://www.ahrq.gov/training.

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