Continuous Quality Improvement Project

Baystate Medical Center, Springfield, CT

Lauren Timmerman & Grace Lo

Identification of Problem and Study Rationale

Baystate Children’s Hospital, located in Springfield, CT, is a 110-bed and 35-bassinette center
located within Baystate Medical Center. It is the only accredited full-service children’s hospital
in Western Massachusetts (1). It includes an infants and children floor (INFCH), pediatric
intensive care unit (PICU), and a neonatal intensive care unit (NICU) (1). Baystate caters to
patients in both inpatient and outpatient settings. For the purpose of this study, the inpatient
center was the focus for quality improvement.

When pediatric patients are admitted to the medical center, if appropriate, their height or length
is measured in order to chart growth patterns by measuring weight-for-length. This is important
because according to the World Health Organization (WHO), weight-for-length/height reflects
body weight in proportion to attained growth in length or height (3). This value can be useful in
multiple instances; for example, in situations where children’s ages are unknown, it can identify
children with low weight-for-height who may be wasted from chronic undernutrition or an
illness, or it can identify children with a potential risk of becoming overweight or obese (3).
This is particularly important for patients 2 years and younger, since this age range is rapidly
growing and gaining weight, patients can become undernourished relatively quickly compared to
adult patients (3). So, faulty length measurement in this population can sometimes falsely signal
failure to thrive or malnutrition (3). However, it can be difficult to obtain an accurate
measurement for many reasons; a child may be too ill, it may be painful for them to fully stretch
out, or the hospital staff may have more pressing priorities.

Measurable Indicators
The length of children between the ages of 0-2 is plotted on the growth chart standards that are
set by the World Health Organization (WHO) (3). All children at Baystate are measured to the
nearest tenth of a centimeter by nurses and are documented on the electronic medical record
(CIS). Growth curves are plotted as low as the 10th percentile, and as high as the 95th percentile
(3). To determine if a patient is an outlier ​(measurements deviated from normal growth patterns)​,
all measurements that are recorded are analyzed, as they are displayed on the growth chart. For
children who are considered to be growing along a “normal curve” are required to meet the
following criteria:
1. The patient must be plotted along the established curve set by the WHO standards within
the 10th-95th percentile.
2. A patient is only allowed to be plotted outside of the 10th-95th percentile if they prove to
be following a similar upward trend, similar to the curve established by the WHO. The
 reasoning is some patients have underlying conditions that may skew their length,
however are otherwise healthy.
For a patient to be considered an outlier, they must meet the following criteria:
1. If the infant decreased in recorded length from a previous admission upon measurement.
2. If the infant increased in length of +4cm within 1-2 days when measured (measurement
can be done in two different places, such as outpatient vs emergency department).
3. If the patient has a continuation of oscillating values when measurements are depicted on
a growth chart.

Data Collection
Over the course of two weeks, a list of pediatric patients from the PICU and the ​INFCH​ unit
were reviewed. The patients that were older than two years of age were automatically omitted
from the study. We then recorded the lengths of the remaining patients’ under two years of age
(from day of screening)​ from the electronic charting system (CIS). New admissions were
recorded and noted if there was a length outlier. For patient’s that lengths were already recorded
on our list, we added new lengths and took note if there was a decrease in length.

Data Analysis
Of the 96 patients lengths that were obtained from CIS, 43% of patients were between
birth-3 months old; 16% of patients were 4-6 months old; 11% of patients were 7-9 months old;
6% of patients were 10-12 months old; and 24% of patients were 1-2 years old (Image 1). There
were 19 of 96 (20%) patients that were found to have a form of error in measurement within the
measurable indicators determined (Image 2). Within the 20% of patients who were measured
incorrectly, 53% of the patients were found to be between the ages of birth-3 months; 16%
between 4-6 months; 5% between 7-9 months and 10-12 months; and 21% between 1-2 years
(Image 3).
When comparing the number of errors against the patients measured within each age
group, 24% of patients between birth-3 months were incorrectly measured; 20% between 4-6
months; 9% between 7-9 months; and 17% between 10-12 months and 1-2 years.
Overall, the highest population of incorrectly measured patients is between the ages of
birth-3 months, the second highest population is 4-6 months.

Image 1​: Image shows the

percentage of patients
measured within each age
groups separated by 3
months.
 Image 2​: Of 96 patients
measured, there were 19
patients whose lengths were
measured incorrectly. Thus,
approximately 20% of all
measured patients resulted
in an error in measurement.

Image 3​: Percentage of

patients with an error in
measurement by each age
group.

Age Range #Errors/#Pts Measured

Birth-3 months 24%

4-6 months 20%

7-9 months 9%

10-12 months 17%

1-2 years 17%

Table 1​: The percentage of patients with an error in
measurement compared to the number of patients
measured within each age group.
Discussion
Overall, the data that was collected shows 19 outliers signaling a faulty measurement at
one point during the patient’s admission to the hospital, over half of which were under three
months old. Each patient that triggered as an outlier may have their own specific reasoning for a
faulty height measurement.
Measuring infants who are under three months may pose as a challenge as many like to
remain in a fetal position, versus older toddlers who may not fuss over being stretched out.
During an infant’s first three months of life, they are recommended to be feeding every three
hours, which can be a challenge for nurses and dietitians to find a convenient time to correctly
measure the infant with a stadiometer. A bigger challenge to correctly measure infants can arise
when they have a chronic condition, such as cystic fibrosis or muscular dystrophy. A patient who
is intubated may also pose a challenge, as there is an increased risk of a tube dislodging while
moving the patient from the bed to the stadiometer. In other cases, the nurses may choose not to
use the stadiometer in the acute inpatient setting. When speaking to nurses, most choose not to
use the stadiometer because it is time consuming, parents may be intimidated by the equipment,
or they simply were not trained to use the device.
The stadiometer is great for acquiring very accurate measurements of infants ​(4)​.
Unfortunately, the tool is large, cumbersome, and usually requires two individuals to properly
measure an infant (4). In an acute setting such as the PICU or when patients are intubated, using
a stadiometer and two health care professionals to hold down the infant only to obtain a length
can be simply dangerous for the infant, and overall an inappropriate use of a health
professional’s time. Nurses often have more pressing issues such as administering medications,
setting tube feeds, d​ressing wounds, and speaking with patients’ families.
Additionally, certain conditions, such as muscular dystrophy, in which a child can
experience pain when stretched out on the stadiometer, may create inaccurate length
measurements, and a prediction in growth could deem to be more accurate and safe. At times, a
child is admitted into the hospital for another reason that may take priority than the growth of the
child, so a length measurement may not be taken as priority, especially if the team is short on
time (5).
Unfortunately, not all healthcare professionals even know how to properly use the
stadiometer and may not have the time to learn on the spot or from the certified educator. In
some cases, since there is only one stadiometer on the floor at Baystate, it may not be easily
accessible and some may not know where it is. Therefore, when an infant is being cared for in an
acute situation, a estimated height using a tape measure may be suitable for the sake of time,
health of the infant, and overall convenience.

Suggested Remedies
 When discussing with multiple healthcare professionals for potential solutions (dietitians,
nurses, medical assistants), it was discovered that the nurse manager who trained the nurses on
how to use the stadiometers is no longer present at the hospital. As a result, the stadiometers are
no longer being used to the fullest potential. A ​possible​ way to increase the use of the
stadiometer could be to re-train the current nurses on using the stadiometer, and allow them to
train those who don’t know how to use the device. Training the new nurse managers can also be
beneficial as they could supervise and make sure the stadiometer is being used correctly. This
could be an efficient alternative rather than retraining the entire staff at once (as nurses are
always going to be needed on the floors).
Another suggestion to ensure accurate lengths are being measured is for dietitians to
re-measure patients as appropriate when they notice an outlier. Since dietitians often look at
growth curves to see if a patient is growing appropriately ​or estimate energy needs, ​it can be a
quick and easy way to notify the healthcare team if a measurement doesn’t seem correct.
Lastly, in addition to simply teaching nurses and dietitians on how to use the stadiometer,
it is also important to explain and demonstrate the benefits on using the device. Outlining the
importance for use of the stadiometer and equipping employees with the knowledge of using it
may empower the entire team to increase the usage. It may be important to highlight the
appropriate times to use the stadiometer and note if the patient is in need of an accurate
measurement.

References

1.Baystate Children’s Hospital. Fast Facts. Retrieved on Feb. 2018.

https://www.baystatehealth.org/locations/childrens-hospital

2. ​D.J.Secker, Khursheed N.​ ​(2012).How to Perform Subjective Global Nutritional Assessment

in Children.​Journal of the Academy of Nutrition and Dietetics.​March 2012.​112(3),​ 424-431.

3. Department of Nutrition for Health and Development by the World Health Organization.
WHO Child Growth Standards: Length/height-for-age, weight-for-age, weight-for-length,
weight-for-height and body mass index-for-age, Methods and development. ​Retrieved on: Feb.
2018. http://www.who.int/childgrowth/standards/Technical_report.pdf

4. ​Indian Health Service: The Federal Health Program for the National Reserve. Selecting and
Using Equipment. Retrieved Feb. 2018. ​https://www.ihs.gov/HWM/selectingequipment/

5. ​Q.W. Spender, C.E. Cronk,E. B. Charney, V.A. Stallings. (2008). Assessment of Linear
Growth of Children with Cerebral Palsy: Use Of Alternative Measures To Height Or Length.
31(2), 206-214.
6. Waterlow, J. C., Buzina, R., Keller, W., Lane, J. M., Nichaman, M. Z., & Tanner, J. M.
(1977). The presentation and use of height and weight data for comparing the nutritional status of
groups of children under the age of 10 years. ​Bulletin of the World Health Organization​, ​55​(4),
489–498.

7. World Health Organization (WHO). ​Training Course on Child Growth Assessment: WHO
Child Growth Standards. ​Retrieved on Feb. 2018.
http://www.who.int/childgrowth/training/module_c_interpreting_indicators.pdf

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2366685/?page=1

http://www.who.int/childgrowth/training/module_c_interpreting_indicators.pdf​ -

https://www.ihs.gov/HWM/selectingequipment/ 
 
http://onlinelibrary.wiley.com/doi/10.1111/j.1469-8749.1989.tb03980.x/full

http://www.sciencedirect.com/science/article/pii/S0002822311015057?via%3Dihub