Comparing Two Proximal Measures of Unrecognized Clinical Deterioration in Children

A Quality Improvement Project to Promote Interdisciplinary Communication Using the Pediatric Early Warning System

Introduction

In August 2020, residents and nurses lacked awareness and knowledge of the pediatric early warning system (PEWS). Residents and nurses infrequently performed interdisciplinary bedside huddles for patients with critical scores, and residents did not document assessments and plans despite these patients being at higher risk for clinical deterioration. We aimed to increase the mean rate of documented huddles from 0% to 50% within 4 months.

Methods

We piloted this quality improvement project on 1 floor of a pediatric hospital and included patients admitted to the pediatric hospital medicine service. Key drivers included buy-in and trust in PEWS, understanding of critical scores, a reliable scoring algorithm, and a culture where interdisciplinary communication is routine. Interventions included physician and nurse education, improving the scoring algorithm, and promoting a shared understanding of PEWS. Our outcome measure was the percentage of documented huddle notes for each patient with a critical score, a proxy for huddles occurring. We entered data into a control chart and analyzed it for changes in response to interventions.

Results

The mean baseline rate of note completion was 0%. After 4 months, the mean increased to 100%, associated with multiple educational interventions and efforts to improve the scoring algorithm.

Conclusions

Implementing multimodal interventions was associated with an increased rate of documented huddles. Scoring algorithm changes and personalized education galvanized physician and nurse support for PEWS. Institutions can use the lessons we have learned to implement PEWS and promote huddles and interdisciplinary communication.

Association between mortality and critical events within 48 hours of transfer to the pediatric intensive care unit

Introduction

Critical deterioration in hospitalized children, defined as ward to pediatric intensive care unit (PICU) transfer followed by mechanical ventilation (MV) or vasoactive infusion (VI) within 12 h, has been used as a primary metric to evaluate the effectiveness of clinical interventions or quality improvement initiatives. We explore the association between critical events (CEs), i.e., MV or VI events, within the first 48 h of PICU transfer from the ward or emergency department (ED) and in-hospital mortality.

Methods

We conducted a retrospective study of a cohort of PICU transfers from the ward or the ED at two tertiary-care academic hospitals. We determined the association between mortality and occurrence of CEs within 48 h of PICU transfer after adjusting for age, gender, hospital, and prior comorbidities.

Results

Experiencing a CE within 48 h of PICU transfer was associated with an increased risk of mortality [OR 12.40 (95% CI: 8.12-19.23, P < 0.05)]. The increased risk of mortality was highest in the first 12 h [OR 11.32 (95% CI: 7.51-17.15, P < 0.05)] but persisted in the 12-48 h time interval [OR 2.84 (95% CI: 1.40-5.22, P < 0.05)]. Varying levels of risk were observed when considering ED or ward transfers only, when considering different age groups, and when considering individual 12-h time intervals.

Discussion

We demonstrate that occurrence of a CE within 48 h of PICU transfer was associated with mortality after adjusting for confounders. Studies focusing on the impact of quality improvement efforts may benefit from using CEs within 48 h of PICU transfer as an additional evaluation metric, provided these events could have been influenced by the initiative.

Use of design thinking and human factors approach to improve situation awareness in the pediatric intensive care unit

BACKGROUND

Optimal design of healthcare spaces can enhance patient care. We applied design thinking and human factors principles to optimize communication and signage on high risk patients to improve situation awareness in a new clinical space for the pediatric ICU.

OBJECTIVE

To assess the impact of these tools in mitigating situation awareness concerns within the new clinical space. We hypothesized that implementing these design-informed tools would either maintain or improve situation awareness.

DESIGN, SETTINGS, AND PARTICIPANTS

A 15-week design thinking process was employed, involving research, ideation, and refinement to develop and implement new situation awareness tools. The process included engagement with interprofessional clinical teams, scenario planning, workflow mapping, iterative feedback collection, and collaboration with an industry partner for signage development and implementation.

INTERVENTION

Improved and updated communication devices and bedside mitigation plans.

MAIN OUTCOME AND MEASURES

Process metrics included individual and shared situation awareness of PICU care teams and our patient outcome metric was the rate of cardiopulmonary resuscitation (CPR) events pre- and post-transition.

RESULTS

When evaluating all patients, shared situation awareness for accurate high-risk status improved from 81% pre-transition to 92% post-transition (p = .006). When assessing individual care team roles, accuracy of patient high-risk status improved from 88% to 95% (p = .05) for RNs, 85% to 96% (p = .003) for residents, and 88% to 95% (p = .03) for RTs. There was no change in the rate of CPR events following the transition.

Rapid response events with multiple triggers are associated with poor outcomes in children

Objective

We describe the characteristics and outcomes of pediatric rapid response team (RRT) events within a single institution, categorized by reason for RRT activation (RRT triggers). We hypothesized that events with multiple triggers are associated with worse outcomes.

Patients and Methods

Retrospective 3-year study at a high-volume tertiary academic pediatric hospital. We included all patients with index RRT events during the study period.

Results

Association of patient and RRT event characteristics with outcomes including transfers to ICU, need for advanced cardiopulmonary support, ICU and hospital length of stay (LOS), and mortality were studied. We reviewed 2,267 RRT events from 2,088 patients. Most (59%) were males with a median age of 2 years and 57% had complex chronic conditions. RRT triggers were: respiratory (36%) and multiple (35%). Transfer to the ICU occurred after 1,468 events (70%). Median hospital and ICU LOS were 11 and 1 days. Need for advanced cardiopulmonary support was noted in 291 events (14%). Overall mortality was 85 (4.1%), with 61 (2.9%) of patients having cardiopulmonary arrest (CPA). Multiple RRT trigger events were associated with transfer to the ICU (559 events; OR 1.48; p < 0.001), need for advanced cardiopulmonary support (134 events; OR 1.68; p < 0.001), CPA (34 events; OR 2.36; p = 0.001), and longer ICU LOS (2 vs. 1 days; p < 0.001). All categories of triggers have lower odds of need for advanced cardiopulmonary support than multiple triggers (OR 1.73; p < 0.001).

Conclusions

RRT events with multiple triggers were associated with cardiopulmonary arrest, transfer to ICU, need for cardiopulmonary support, and longer ICU LOS. Knowledge of these associations can guide clinical decisions, care planning, and resource allocation.

Leveraging EHR Data to Evaluate the Association of Late Recognition of Deterioration With Outcomes

OBJECTIVES

Emergency transfers (ETs), deterioration events with late recognition requiring ICU interventions within 1 hour of transfer, are associated with adverse outcomes. We leveraged electronic health record (EHR) data to assess the association between ETs and outcomes. We also evaluated the association between intervention timing (urgency) and outcomes.

METHODS

We conducted a propensity-score-matched study of hospitalized children requiring ICU transfer between 2015 and 2019 at a single institution. The primary exposure was ET, automatically classified using Epic Clarity Data stored in our enterprise data warehouse endotracheal tube in lines/drains/airway flowsheet, vasopressor in medication administration record, and/or ≥60 ml/kg intravenous fluids in intake/output flowsheets recorded within 1 hour of transfer. Urgent intervention was defined as interventions within 12 hours of transfer.

RESULTS

Of 2037 index transfers, 129 (6.3%) met ET criteria. In the propensity-score-matched cohort (127 ET, 374 matched controls), ET was associated with higher in-hospital mortality (13% vs 6.1%; odds ratio, 2.47; 95% confidence interval [95% CI], 1.24-4.9, P = .01), longer ICU length of stay (subdistribution hazard ratio of ICU discharge 0.74; 95% CI, 0.61-0.91, P < .01), and longer posttransfer length of stay (SHR of hospital discharge 0.71; 95% CI, 0.56-0.90, P < .01). Increased intervention urgency was associated with increased mortality risk: 4.1% no intervention, 6.4% urgent intervention, and 10% emergent intervention.

CONCLUSIONS

An EHR measure of deterioration with late recognition is associated with increased mortality and length of stay. Mortality risk increased with intervention urgency. Leveraging EHR automation facilitates generalizability, multicenter collaboratives, and metric consistency.

Pediatric rapid response system innovations

Rapid Response Systems (RRSs) are an organizational approach to support the timely recognition and treatment of decompensating patients and are used in many pediatric hospitals. These systems are comprised of afferent and efferent Limbs, as well as oversight arms. When incorporated into an RRS, standardized care algorithms can be helpful in identifying deteriorating patients and improving behaviors of the multidisciplinary team. The aim of this paper is to provide an overview of pediatric RRS and provide an example in which standardized care algorithms developed for the efferent limb of a pediatric RRS were associated with improvement in early escalation of care.PLAIN LANGUAGE SUMMARYThe Rapid Response System (RRS) is used in hospitals to recognize and care for hospitalized patients that are decompensating outside of an Intensive Care Unit. RRSs are made up of two main response components. The afferent limb focuses on the recognition and calls for help; the efferent limb focuses on correcting the deteriorating patient's physiology. Much energy has been put into afferent limb development to identify worsening patients before they progress to full cardiac or respiratory arrest. Standardization of efferent limb care algorithms can assist in developing and maintaining a shared mental model of care to improve communication and function of the multidisciplinary team.