Reductions in invasive device use and care costs after institution of a daily safety checklist in a pediatric critical care unit

Training of Pediatric Critical Care Providers in Developing Countries in Evidence Based Medicine Utilizing Remote Simulation Sessions

Background. Remote simulation training provides a unique opportunity to captivate providers despite language, distance, and cultural barriers. Previously we developed a novel electronic decision support and rounding tool, the Checklist for Early Recognition and Treatment of Acute Illness in Pediatrics (CERTAINp). This study was conducted to determine the feasibility and impact of remote simulation training of international PICU providers using CERTAINp. Methods. We conducted train-the-trainer sessions in 7 hospitals based in 5 countries (China, Congo, Croatia, India, and Turkey) between 11/2015 and 11/2016. Providers first took part in a base line simulation session to assess their clinical performance. They had structured hands-on training using CERTAINp, which was done remotely using video conference with recording capabilities. Performance in PICU “admission” and “rounding” scenarios was assessed by their adherence to standard of care guidelines using CERTAINp. After this training, the providers were re-evaluated for performance using a validated instrument by 2 independent trained reviewers. Results. A total of 7 hospitals completed both baseline and post simulation sessions. We observed improved critical task (total 14) completion in the admission scenarios where pre training task completion was 8.2 ± 2.6, while after remote training was 11.2 ± 1.8, P = .01. In rounding scenarios, compliance to standard of care guidelines improved overall from 45% to 95% (P < .01). Conclusion. We observed an improvement in compliance for measures determined as best practice guidelines in simulation rounding and overall improvement in critical tasks for simulated admission cases after remote training.

Communication in Pediatric Critical Care Units: A Review of the Literature

TOPIC

Current communication styles in pediatric critical care units do not often consider the needs of providers, patients, or family members.

CLINICAL RELEVANCE

The Child Hospital Consumer Assessment of Healthcare Providers and Systems score has begun real-world testing and soon will be mandatory and tied to reimbursement. Poor communication in pediatric critical care units can lead to reduced continuity of care, escalated or unnecessary care, and poor outcomes for patients and hospitals. Improving communication in pediatric critical care units is imperative.

PURPOSE OF PAPER

Extant literature was reviewed to assess communication in pediatric critical care from the provider, parent, and patient perspectives. Communication tools were also reviewed.

CONTENT COVERED

Twenty-eight articles met inclusion criteria and were analyzed according to study focus (provider, parent/caregiver, patient, or tool). This review links communication to outcomes related to providers, parents, and patients. Current tools are reviewed to evaluate their effectiveness in addressing communication barriers and to guide future research in communication. Findings indicate that effective communication is challenging in intensive care units despite robust evidence that effective communication improves patient outcomes and quality metrics. Repeated and varied forms of communication, especially written reinforced with verbal communication, seem to have the strongest effect and show promising results. Common barriers nurses face on their units are identified, and solutions are suggested. This review adds to current knowledge by linking communication to measurable outcomes and examining communication barriers and needs specific to pediatric critical care populations from the provider, parent, and patient perspectives.

Prompting Rounding Teams to Address a Daily Best Practice Checklist in a Pediatric Intensive Care Unit

BACKGROUND

Implementation of best practices for pediatric ICU (PICU) patients is challenging. The objective of this project was to improve process of care outcomes and clinical outcomes by having a dedicated person (quality champion [QC]) prompt PICU rounding teams to address a daily best practice rounding checklist.

METHODS

A prospective cohort study was performed in an academic tertiary referral PICU, which implemented a daily rounding checklist, including reminders to assess central line/urinary catheter need, sedation goals, sedative/paralytic need, enteral nutrition readiness, and extubation readiness. Data were collected on patient characteristics, process of care outcomes, and clinical outcomes over three periods: before and after the checklist was implemented and after the practice of prompting for checklist use was instituted.

RESULTS

Over nine months, 444 patients were included. The QC was present on rounds 94 of 139 (67.6%) days. Checklist adherence (all checklist items discussed daily) improved from 75.7% to 86.6% of patients. There was a reduction in urinary catheter days across all time periods (p = 0.001), and post hoc analysis showed fewer blood draws (p = 0.049) among patients for whom the QC was present consistently during rounds. There was also a decrease in PICU length of stay after the checklist was implemented (p = 0.008), although this may be due to less severity of illness in the prompted cohort.

CONCLUSION

Prompting PICU rounding teams to address a daily best practice rounding checklist may improve some process of care outcomes. Further study is needed to delineate long-term effects of this initiative.

Review article: Current literature on surgical checklists and handoff tools and application for orthopaedic surgery

Despite the adaptation of checklists for specific surgeries being developed, there remains a lack of an available standard for an orthopaedic-specific checklist. Benefits of implementing checklists include cost-effectiveness as well as the ability to significantly reduce both mortality and complication rates in a variety of healthcare settings. The aim of this review is to analyze the evidence surrounding the effectiveness of checklists as well as recommend for the development of a standard checklist for specific orthopaedic surgeries such as total joint arthroplasty (TJA).

Improving Reliability to a Care Goal Rounding Template in the Pediatric Intensive Care Unit

Background:

Effective pediatric intensive care requires addressing many important aspects of care delivery during morning rounds, often achieved using a rounding checklist. Our objective was to develop a care goal rounding template and then double the reliability of discussion of rounding topics during morning rounds without the use of a checklist.

Methods:

The Institute for Healthcare Improvement Model for Improvement was used for this initiative. A care goal rounding template was established through discussions and consensus with pediatric intensive care unit (PICU) faculty. Rounds were audited in a blinded fashion over a 3-month period to obtain baseline data on rounding topic discussion. Three interventions were then trialed (plan, do, study, act cycles) over a 12-month period. Weekly reliability in rounding topic discussion was tracked.

Results:

Baseline reliability with discussion of rounding topics was 36%. The first intervention included the use of a standardized progress note in the electronic health record, which contained topics and served to prompt the discussion on rounds. The second intervention was implementation of laminated cards provided to PICU fellows highlighting the elements of the care goal rounding template. The third intervention addressed a standardized handoff sheet often used during rounds. Mean reliability for discussion of rounding topics improved to 52% shortly following the second intervention. Reliability was sustained more than 1 year later.

Conclusions:

Following the establishment of a PICU care goal rounding template and various interventions, the reliability in discussing important care goal elements on patient rounds improved.

Impact of a Daily PICU Rounding Checklist on Urinary Catheter Utilization and Infection

INTRODUCTION

In critically ill children, inappropriate urinary catheter (UC) utilization is associated with increased morbidity, including catheter-associated urinary tract infections (CAUTIs). Checklists are effective for reducing medical errors, but there is little data on their impact on device utilization in pediatric critical care. In this study, we evaluated UC utilization trends and CAUTI rate after implementing a daily rounding checklist.

METHODS

A retrospective review of our checklist database from 2006 through 2016 was performed. The study setting was a 36-bed pediatric intensive care unit in a quaternary-care pediatric hospital. Interventions included the "Daily QI Checklist" in 2006, ongoing education regarding device necessity, and a CAUTI prevention bundle in 2013. UC utilization and duration were assessed via auto-correlated time series models and Cochran-Armitage tests for trend. Changes in CAUTI rate were assessed via Poisson regression.

RESULTS

UC utilization decreased from 30% of patient-days in 2006 to 18% in 2016 (P < 0.0001, Cochran-Armitage trend test), while duration of UC use (median, 2.0 days; interquartile range, 1-4) did not change over time (P = 0.18). CAUTI rate declined from 9.49/1,000 UC-days in 2009 to 1.04 in 2016 (P = 0.0047).

CONCLUSIONS

Implementation of the checklist coincided with a sustained 40% reduction in UC utilization. The trend may be explained by a combination of more appropriate selection of patients for catheterization and improved timeliness of UC discontinuation. We also observed an 89% decline in CAUTI rate that occurred after stabilization of UC utilization. These findings underscore the potential impact of a checklist on incorporating best practices into daily care of critically ill children.

WE CARE 4 KIDS: Use of a Rounding Tool in the Pediatric Intensive Care Unit

OBJECTIVE

To implement a daily rounding tool in a pediatric intensive care unit (PICU) to improve the discussion performance of identified clinical elements. We hypothesized that a semi-structured rounding tool created by a multidisciplinary team would be successfully implemented and sustained in the PICU.

PATIENTS AND METHODS

A pre-post interventional study was conducted in a multidisciplinary medical-surgical PICU. Baseline data collection of undisclosed clinical elements was performed by covert observers, which resulted in the development of a comprehensive, nurse-driven rounding checklist. Frequencies of pre- and postintervention metrics were assessed after implementation, and sustainability was assessed at 5 years.

RESULTS

Six months after implementation, 70% (7/10) of checklist elements demonstrated significant improvement. Five years after implementation, 172 of a possible 222 (74%) checklists were collected. Eighty percentage (8/10) of the measures sustained discussion frequency after 5 years of use. Nursing presence significantly improved at year 5 compared with the preimplementation period. Nursing satisfaction surveys distributed at year 5 showed that the rounding tool was useful and nurses were confident in understanding care plans at the end of rounds. Ninety-eight percentage of checklists revealed discrete transcription of qualitative daily goals.

CONCLUSIONS

A semi-structured rounding tool created by a multidisciplinary team was successfully implemented, and performance was sustained at 5 years. This initiative led to improved bedside nursing presence during patient care rounds.

Promoters and Barriers to Implementation of Tracheal Intubation Airway Safety Bundle: A Mixed-Method Analysis

OBJECTIVES

To describe promoters and barriers to implementation of an airway safety quality improvement bundle from the perspective of interdisciplinary frontline clinicians and ICU quality improvement leaders.

DESIGN

Mixed methods.

SETTING

Thirteen PICUs of the National Emergency Airway Registry for Children network.

INTERVENTION

Remote or on-site focus groups with interdisciplinary ICU staff. Two semistructured interviews with ICU quality improvement leaders with quantitative and qualitative data-based feedbacks.

MEASUREMENTS AND MAIN RESULTS

Bundle implementation success (compliance) was defined as greater than or equal to 80% use for tracheal intubations for 3 consecutive months. ICUs were classified as early or late adopters. Focus group discussions concentrated on safety concerns and promoters and barriers to bundle implementation. Initial semistructured quality improvement leader interviews assessed implementation tactics and provided recommendations. Follow-up interviews assessed degree of acceptance and changes made after initial interview. Transcripts were thematically analyzed and contrasted by early versus late adopters. Median duration to achieve success was 502 days (interquartile range, 182-781). Five sites were early (median, 153 d; interquartile range, 146-267) and eight sites were late adopters (median, 783 d; interquartile range, 773-845). Focus groups identified common "promoter" themes-interdisciplinary approach, influential champions, and quality improvement bundle customization-and "barrier" themes-time constraints, competing paperwork and quality improvement activities, and poor engagement. Semistructured interviews with quality improvement leaders identified effective and ineffective tactics implemented by early and late adopters. Effective tactics included interdisciplinary quality improvement team involvement (early adopter: 5/5, 100% vs late adopter: 3/8, 38%; p = 0.08); ineffective tactics included physician-only rollouts, lack of interdisciplinary education, lack of data feedback to frontline clinicians, and misconception of bundle as research instead of quality improvement intervention.

CONCLUSIONS

Implementation of an airway safety quality improvement bundle with high compliance takes a long time across diverse ICUs. Both early and late adopters identified similar promoter and barrier themes. Early adopter sites customized the quality improvement bundle and had an interdisciplinary quality improvement team approach.

Design and α-testing of an electronic rounding tool (CERTAINp) to improve process of care in pediatric intensive care unit

Increasing process complexity in the pediatric intensive care unit (PICU) can lead to information overload resulting in missing pertinent information and potential errors during morning rounds. An efficient model using a novel electronic rounding tool was designed as part of a broader critical care decision support system-checklist for early recognition and treatment of acute illness and injury in pediatrics (CERTAINp). We aimed to evaluate its impact on improving the process of care during rounding. Prospective pre- and post-interventional data included: team performance baseline assessment, patient safety discussion, guideline adherence, rounding time, and a survey of Residents' and Nurses' perception using a Likert scale. Attending physicians were blinded to the components of the assessment. A total of 113 pre-intervention and 114 post-intervention roundings were recorded by direct observation. Pre-intervention (108) and post-intervention staff surveys (80) were obtained. Adherence to standard of care guidelines improved to >97 % in all data points, with maximum increase seen in discussions of ulcer prophylaxis, bowel protocol, DVT prophylaxis, skin care, glucose control and head of bed elevation (2-28 % pre-vs. 100 % for all post-intervention, p < 0.01). Significant improvement was noticed in spontaneous breathing trials, sedation breaks and need for devices (45-57 % pre- vs. 100 % for all post-intervention, p < 0.01). Rounding time (mean ± SD) increased by 2 min/patient (8.0 ± 5.8 min pre-intervention vs. 9.9 ± 5.7 min post-intervention, p = 0.002). Staff reported improved perception of all aspects of rounding. Utilization of the CERTAINp rounding tool led to perfect compliance to the discussion of best practice guidelines; had minimal impact on rounding time and improved PICU staff satisfaction.

Variability in the structure and care processes for critically injured children: A multicenter survey of trauma bay and intensive care units

PURPOSE

Evaluate national variation in structure and care processes for critically injured children.

METHODS

Institutions with pediatric intensive care units (PICUs) that treat trauma patients were identified through the Virtual Pediatric Systems (n=72). Prospective survey data were obtained from PICU and Trauma Directors (n=69, 96% response). Inquiries related to structure and care processes in the PICU and emergency department included infrastructure, physician staffing, team composition, decision making, and protocol/checklist use.

RESULTS

About one-third of the 69 institutions were ACS-verified Level-1 Pediatric Trauma Centers (32%); 36 (52%) were state-designated Level 1. The surgeon was the primary decision maker in the trauma bay at 88% of sites, and in the PICU at 44%. The intensivist was primary in the PICU at 30% of sites and intensivist consultation was elective at 11%. Free-standing pediatric centers used checklists more often than adult/pediatric centers for DVT prophylaxis (75% vs. 50%, p=0.039), cervical spine clearance (75% vs. 44%, p=0.011), and pain control (63% vs. 34%, p=0.024). Otherwise, protocols/checklists were infrequently utilized by either center type.

CONCLUSION

Variability exists in structure and care processes for critically injured children. Further investigation of variation and its causal relationship to outcomes is warranted to provide optimal care.

Interprofessional team management in pediatric critical care: some challenges and possible solutions

BACKGROUND

Aiming for and ensuring effective patient safety is a major priority in the management and culture of every health care organization. The pediatric intensive care unit (PICU) has become a workplace with a high diversity of multidisciplinary physicians and professionals. Therefore, delivery of high-quality care with optimal patient safety in a PICU is dependent on effective interprofessional team management. Nevertheless, ineffective interprofessional teamwork remains ubiquitous.

METHODS

We based our review on the framework for interprofessional teamwork recently published in association with the UK Centre for Advancement of Interprofessional Education. Articles were selected to achieve better understanding and to include and translate new ideas and concepts.

FINDINGS

The barrier between autonomous nurses and doctors in the PICU within their silos of specialization, the failure of shared mental models, a culture of disrespect, and the lack of empowering parents as team members preclude interprofessional team management and patient safety. A mindset of individual responsibility and accountability embedded in a network of equivalent partners, including the patient and their family members, is required to achieve optimal interprofessional care. Second, working competently as an interprofessional team is a learning process. Working declared as a learning process, psychological safety, and speaking up are pivotal factors to learning in daily practice. Finally, changes in small steps at the level of the microlevel unit are the bases to improve interprofessional team management and patient safety. Once small things with potential impact can be changed in one's own unit, engagement of health care professionals occurs and projects become accepted.

CONCLUSION

Bottom-up patient safety initiatives encouraging participation of every single care provider by learning effective interprofessional team management within daily practice may be an effective way of fostering patient safety.

Development of evidence-based clinical algorithms for prescription of exercise-based cardiac rehabilitation

Background

Guideline adherence with respect to exercise-based cardiac rehabilitation (CR) is hampered by a large variety of complex guidelines and position statements, and the fact that these documents are not specifically designed for healthcare professionals prescribing exercise-based CR programs. This study aimed to develop clinical algorithms that can be used in clinical practice for prescription and evaluation of exercise-based CR in patients with coronary artery disease (CAD) and chronic heart failure (CHF).

Methods

The clinical algorithms were developed using a systematic approach containing four steps. First, all recent Dutch and European cardiac rehabilitation guidelines and position statements were reviewed and prioritised. Second, training goals requiring a differentiated training approach were selected. Third, documents were reviewed on variables to set training intensity, modalities, volume and intensity and evaluation instruments. Finally, the algorithms were constructed.

Results

Three Dutch guidelines and three European position statements were reviewed. Based on these documents, five training goals were selected and subsequently five algorithms for CAD patients and five for CHF patients were developed.

Conclusions

This study presents evidence-based clinical algorithms for exercise-based CR in patients with CAD and CHF according to their training goals. These algorithms may serve to improve guideline adherence and the effectiveness of exercise-based CR.