Creating a Standardized Angle Tolerance Testing Process for the Pediatric Ambulatory Care Setting

The purpose of this project is to improve patient safety through the creation and implementation of standardized angle tolerance testing in the outpatient setting.

Safe transportation of preterm, low birth weight, or hypotonic infants requires testing at inpatient discharge to ensure the infant can tolerate traditional car seat angles without decompensation. Patients exhibiting cardio-respiratory compromise during angle tolerance testing are discharged lying in a flat lying car bed. Post-discharge outpatient testing, while necessary, is often not available to safely transition infants from the car bed to a traditional car seat. This poster will address how our facility implemented outpatient angle tolerance testing to address this gap in care, including administrative pre-work, data collection, marketing plans, and case studies.

There are no published guidelines to perform outpatient angle tolerance testing. To determine best practice guidelines, a multidisciplinary team of physicians, nurse educators, and injury prevention experts formed to establish procedures.

Administrative work was done to determine logistical aspects of outpatient testing. A series of electronic medical record (EMR) updates were developed to identify patients sent home in a car bed and prompt referral for outpatient testing. Engagement of inpatient units revealed gaps in testing throughout the system. A best practice advisory was built into the EMR to ensure all at-risk infants are identified and tested. Also, to address these gaps, an in-person, hands-on training and competency was developed and implemented.

Prior to implementation, data was collected to determine volume, need, and demographic characteristics of children requiring outpatient testing. First, data was gathered from the hospital system EMR to determine the number of inpatient angle tolerance studies and children discharged home in a car bed. Second, engagement of outpatient clinics servicing at-risk populations revealed groups of children displaying signs of angle intolerance who are outside traditional testing parameters, for example by age or diagnosis. One large group identified in our system are older children with spinal muscular atrophy (SMA) who present outpatient or who are seen at outside facilities.

To communicate the availability of outpatient testing, we developed a three-tiered model to market this service to needed children: inpatient, ambulatory, and primary care/community pediatricians. Additionally, a staff education model to address new processes for internal identification and referral will be shared.

Initial outpatient angle tolerance studies provided lessons learned and additional work needed, such as engagement of other services like the emergency department and physical therapy. We will provide case studies and best practice testing guidelines as a starting point for other institutions to replicate.