Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events

Risk Factors for Deterioration Events in the Pediatric Acute Care Setting

OBJECTIVES

Rapid response system (RRS) activations resulting in emergency transfers (ETs) and codes outside the ICU are associated with increased mortality and length of stay. We aimed to evaluate the patient and care team characteristics of RRS activations resulting in ETs and codes outside the ICU (together classified as "deterioration events") versus those that did not result in a deterioration event.

METHODS

For each RRS activation at our institution from 2019 to 2021, data were gathered on patient demographics and medical diagnoses, care team and treatment factors, and ICU transfer. Descriptive statistics, bivariate analyses, and multivariable logistic regression using a backward elimination model selection method were performed to assess potential risk factors for deterioration events.

RESULTS

Over the 3-year period, 1765 RRS activations were identified. Fifty-three (3%) activations were deemed acute care codes, 64 (4%) were noncode ETs, 921 (52%) resulted in nonemergent transfers to an ICU, and 727 (41%) patients remained in an acute care unit. In a multivariable model, any complex chronic condition (adjusted odds ratio, 6.26; 95% confidence interval, 2.83-16.60) and hematology/oncology service (adjusted odds ratio, 2.19; 95% confidence interval, 1.28-3.74) were independent risk factors for a deterioration event.

CONCLUSIONS

Patients with medical complexity and patients on the hematology/oncology service had a higher risk of deterioration events than other patients with RRS activations. Further analyzing how our hospital evaluates and treats these specific patient populations is critical as we develop targeted interventions to reduce deterioration events.

Implementation of a critical care outreach team in a children's hospital

Introduction

Proactive surveillance by a critical care outreach team (CCOT) can promote early recognition of deterioration in hospitalized patients but is uncommon in pediatric rapid response systems (RRSs). After our children's hospital introduced a CCOT in 2019, we aimed to characterize early implementation outcomes. We hypothesized that CCOT rounding would identify additional children at risk for deterioration.

Methods

The CCOT, staffed by a dedicated critical care nurse (RN), respiratory therapist, and attending, conducts daily in-person rounds with charge RNs on medical-surgical units, to screen RRS-identified high-risk patients for deterioration. In this prospective study, observers tracked rounds discussion content, participation, and identification of new high-risk patients. We compared 'identified-patient-discussions' (IPD) about RRS-identified patients, and 'new-patient-discussions' (NPD) about new patients with Fisher's exact test. For new patients, we performed thematic analysis of clinical data to identify deterioration related themes.

Results

During 348 unit-rounds over 20 days, we observed 383 discussions - 35 (9%) were NPD. Frequent topics were screening for clinical concerns (374/383, 98%), active clinical concerns (147/383, 39%), and watcher activation (66/383, 17%). Most discussions only included standard participants (353/383, 92%). Compared to IPD, NPD more often addressed active concerns (74.3% vs 34.8%, p < 0.01) and staffing resource concerns (5.7% vs 0.6%, p < 0.04), and more often incorporated extra participants (25.7% vs 6%, p < 0.01). In thematic analysis of 33 new patients, most (29/33, 88%) had features of deterioration.

Conclusion

A successfully implemented CCOT enhanced identification of clinical deterioration not captured by existing RRS resources. Future work will investigate its impact on operational safety and patient-centered outcomes.

Patterns of interactions among ICU interprofessional teams: A prospective patient-shift-level survey approach

BACKGROUND

The Awakening, Breathing Coordination, Delirium monitoring and Early mobility bundle (ABCDE) is associated with lower mortality for intensive care unit (ICU) patients. However, efforts to improve ABCDE are variably successful, possibly due to lack of clarity about who are the team members interacting when caring for each patient, each shift. Lack of patient shift-level information regarding who is interacting with whom limits the ability to tailor interventions to the specific ICU team to improve ABCDE.

OBJECTIVE

Determine the number and types of individuals (i.e., clinicians and family members) interacting in the care of mechanically ventilated (MV) patients, as reported by the patients' assigned physician, nurse, and respiratory therapist (RT) each shift, using a network science lens.

METHODS

We conducted a prospective, patient-shift-level survey in 2 medical ICUs. For each patient, we surveyed the assigned physician, nurse, and RT each day and night shift about who they interacted with when providing ABCDE for each patient-shift. We determined the number and types of interactions, reported by physicians, nurses, and RTs and day versus night shift.

RESULTS

From 1558 surveys from 404 clinicians who cared for 169 patients over 166 shifts (65% response rate), clinicians reported interacting with 2.6 individuals each shift (physicians: 2.65, nurses: 3.33, RTs: 1.86); this was fewer on night shift compared to day shift (1.99 versus 3.02). Most frequent interactions were with the bedside nurse, attending, resident, intern, and RT; family member interactions were reported in less than 1 in 5 surveys (12.2% of physician surveys, 19.7% of nurse surveys, 4.9% of RT surveys).

INTERPRETATION

Clinicians reported interacting with 3-4 clinicians each shift, and fewer on nights. Nurses interacted with the most clincians and family members. Interventions targeting shift-level teams, focusing on nurses and family members, may be a way to improve ABCDE delivery and ICU teamwork.

Evaluation of a Course to Teach Medical Students Latent Hazard Identification in the Operating Room

INTRODUCTION

To improve situational awareness in the operating room (OR), a virtual online operating room of hazards (ROH) with deliberately placed risks was created. We hypothesized that subjects first participating in the virtual online ROH would identify more hazards during an in-person ROH exercise in a physical OR than those in the control group who only received didactic training.

METHODS

We conducted a randomized controlled trial at a major academic medical center, enrolling 48 pre-clinical medical students with no previous OR exposure during their classes. Control and experimental group subjects participated in a brief, online didactic orientation session conducted live over Zoom (Zoom Video Communications, Inc., San Jose, CA) to learn about latent hazards in the OR. Experimental group subjects further interacted with a virtual online operating ROH in which latent hazards were present. The fraction of deliberately created latent hazards placed in a physical, in-person OR identified by subjects was calculated.

RESULTS

Experimental group subjects identified a significantly larger fraction of the created hazards (41.3%) than the control group (difference = 16.4%, 95% CI: 11.3% to 21.4%, P < 0.0001). There was no difference in the number of non-hazards misidentified as hazards between the groups.

CONCLUSIONS

Participation in the virtual online environment resulted in greater recognition of latent operating room hazards during a simulation conducted in a physical, in-person OR than in a didactic experience alone. Because creating an in-room experience to teach the identification of latent hazards in an OR is resource-intensive and requires removing the OR from clinical use, we recommend the virtual online approach described for training purposes. Adding items most misidentified as hazards is suggested for future implementation.

Exploring eye-tracking data as an indicator of situational awareness in nursing students during a cardiorespiratory arrest simulation

AIM

To examine the components of visual attention that maintain situational awareness during simulation training in undergraduate nursing students with different instruction levels.

BACKGROUND

Eye-tracking can provide deep insight into the nurses' attention during simulated practice. Knowing which gaze patterns promote situational awareness can significantly improve nurse instruction.

DESIGN

A comparative observational study investigated the role of visual attention on the performance quality, psychophysiological parameters (vital signs, anxiety and stress) and socioemotional competencies (cognitive workload, motivation and self-efficacy) of nursing students with various experience levels.

METHODS

Thirty nursing students divided into two groups according to their academic level: first cycle (n=14) and second-cycle (n=16) faced a clinical simulation scenario to resolve a cardiorespiratory arrest event. Eye tracking-based analysis required the selection of six areas of interest. The monitorization of vital signs included measuring blood pressure, heart rate, respiratory rate and oxygen saturation before and after the simulation practice. Participants completed the socioemotional questionnaire (NASA-TLX). They answered the state subscale of the State-Trait Anxiety Inventory (STAI), the Visual Analogue Scale (VAS) of stress, the Situational Motivation Scale (SIMS) and the Baessler and Schwarzer General Self-Efficacy Scale.

RESULTS

The first-cycle group displayed higher vital sign scores than the second cycle, apart from the post-simulation respiratory rate. All physiological parameters increased in mean value after the clinical simulation, except oxygen saturation. Anxiety was the only parameter in the socioemotional domain to present a statistically significant difference between the groups. First-year nursing students showed greater anxiety, stress, mental workload, identified regulation and intrinsic motivation, while second-year students showed higher levels of amotivation, external regulation and perceived self-efficacy. Eye-tracking data (revisits, gaze and duration of fixations) exhibited statistically significant differences depending on the area of interest in both groups (p =. 05). The performance outcomes showed a negative and moderate association with gaze the total number of gazes in the second-cycle group (rho = -0.640, p = 0.010).

CONCLUSION

Eye-tracking-based analysis can help to predict performance quality while maintaining situational awareness during nursing instruction.

Could Spatial Awareness Affect Situation Awareness: A Conceptual Examination

PURPOSE

The purpose of this study was to explore the relationship between situation awareness (SA) and the physical environment in patient rooms through building a conceptual model.

BACKGROUND

Nurses work in very complicated and dynamic environments where having high levels of SA could be critical for their performance. Studies have also shown that nurses' awareness of the physical environment and patient room is a part of their awareness of dynamic situations in which nurses' spatial awareness may play a role in SA. Despite literature outlining the importance of SA, there is a lack of studies exploring the relationship between the two.

METHOD

A literature review was conducted for the study from nursing and psychology databases. Thirty-three articles, books, and dissertations from a scoping review were included for in-depth review.

RESULTS

An in-depth review of the harvested literature indicated that there is in fact a relationship between these two phenomena. Founded on Endsley's model of SA, the literature review in this study offers a conceptual model that articulates a plausible causal pathway between the physical environment and SA.

CONCLUSIONS

There are a lot of studies focusing on SA and various aspects of it related to nursing, but almost none mention the physical environment and its impact on SA. The current inquiry suggests that spatial awareness plays a prominent role in SA.

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.

How do we detect and respond to clinical deterioration in hospitalized children? Results of the Pediatric Care BefOre Deterioration Events (CODE) survey

Systems to detect and respond to deteriorating hospitalized children are common despite little evidence supporting best practices. Our objective was to describe systems to detect/respond to deteriorating hospitalized children at Pediatric Resuscitation Quality Collaborative (pediRES-Q) institutions. We performed a cross-sectional survey of pediRES-Q leaders. Questionnaire design utilized expert validation and cognitive interviews. Thirty centers (88%) responded. Most (93%) used ≥1 system to detect deterioration: most commonly, early warning scores (83%), watcher lists (55%), and proactive surveillance teams (31%). Most (90%) had a team to respond to deteriorating patients and the majority of teams could be activated by clinician or family concerns. Most institutions (90%) collect relevant data, including number of rapid responses (88%), arrests outside intensive care units (100%), and serious safety events (88%). In conclusion, most pediRES-Q institutions utilize systems to detect/respond to deteriorating hospitalized children. Heterogeneity exists among programs. Rigorous evaluation is needed to identify best practices.

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.

Pediatric vital signs monitoring in hospital wards: Recognition systems and factors influencing nurses' attitudes and practices

AIMS

To describe: 1) systems in place for recognition and response to deteriorating children in Italy, 2) attitudes and practices of registered nurses (RN) towards vital signs (VS) monitoring in pediatric wards, 3) the associations of nurses attitudes and pratices with nurses' and organizational characteristics.

DESIGN AND METHODS

A multicentre cross-sectional correlational study. Data were collected between January-May 2020 using: an adapted version of the 'Survey on Recognition and Response Systems in Australia', and the 'Ped-V Scale'. Descriptive and adjusted linear regression analysis was performed, accounting for clustering.

RESULTS

Ten Italian hospitals participated, 432 RNs responded to the Ped-V scale (response rate = 52%). Five (50%) hospitals had a VS policy in place, three hospitals (30%) had a Pediatric Early Warning System (PEWS), almost all hospitals had a system in place to respond to deteriorating children. Following multivariate regression analysis, having a PEWS was significantly associated with Ped-V scale 'Workload', 'Clinical competence', 'Standardization' dimensions; gender was associated with 'key indicators' and pediatric surgical ward with 'Clinical competence'.

CONCLUSIONS

The use of VS policies and PEWS was not consistent across hospitals caring for children in Italy. Nurses' attitudes and practices (i.e., perception of workload, and clinical competence) were significantly lower in hospitals with increased complexity of care/PEWS. Gender was significantly associated with knowledge scores.

PRACTICE IMPLICATIONS

System strategies to improve nurses' attitudes and practices towards VS monitoring and education are warranted to support effective behaviors towards VS monitoring, their interpretation, and appropriate communication to activate the efferent limb of the rapid response system.

The Predictive Value of Vital Signs for Morbidity in Pregnancy: Evaluating and Optimizing Maternal Early Warning Systems

OBJECTIVE

Vital sign scoring systems that alert providers of clinical deterioration prior to critical illness have been proposed as a means of reducing maternal risk. This study examined the predictive ability of established maternal early warning systems (MEWS)-as well as their component vital sign thresholds-for different types of maternal morbidity, to discern an optimal early warning system.

STUDY DESIGN

This retrospective cohort study analyzed all patients admitted to the obstetric services of a four-hospital urban academic system in 2018. Three sets of published MEWS criteria were evaluated. Maternal morbidity was defined as a composite of hemorrhage, infection, acute cardiac disease, and acute respiratory disease ascertained from the electronic medical record data warehouse and administrative data. The test characteristics of each MEWS, as well as for heart rate, blood pressure, and oxygen saturation were compared.

RESULTS

Of 14,597 obstetric admissions, 2,451 patients experienced the composite morbidity outcome (16.8%) including 980 cases of hemorrhage (6.7%), 1,337 of infection (9.2%), 362 of acute cardiac disease (2.5%), and 275 of acute respiratory disease (1.9%) (some patients had multiple types of morbidity). The sensitivities (15.3-64.8%), specificities (56.8-96.1%), and positive predictive values (22.3-44.5%) of the three MEWS criteria ranged widely for overall morbidity, as well as for each morbidity subcategory. Of patients with any morbidity, 28% met criteria for the most liberal vital sign combination, while only 2% met criteria for the most restrictive parameters, compared with 14 and 1% of patients without morbidity, respectively. Sensitivity for all combinations was low (maximum 28.2%), while specificity for all combinations was high, ranging from 86.1 to 99.3%.

CONCLUSION

Though all MEWS criteria demonstrated poor sensitivity for maternal morbidity, permutations of the most abnormal vital signs have high specificity, suggesting that MEWS may be better implemented as a trigger tool for morbidity reduction strategies in the highest risk patients, rather than a general screen.

KEY POINTS

· MEWS have poor sensitivity for maternal morbidity.. · MEWS can be optimized for high specificity using modified criteria.. · MEWS could be better used as a trigger tool..

The Need for a Standard Outcome for Clinical Deterioration in Children's Hospitals

Unrecognized clinical deterioration is a common and significant source of preventable harm to hospitalized children. Yet, unlike other sources of preventable harm, clinical deterioration outside of the ICU lacks a clear, "gold standard" outcome to guide prevention efforts. This gap limits multicenter learning, which is crucial for identifying effective and generalizable interventions for harm prevention. In fact, to date, no coordinated safety/quality initiative currently exists targeting prevention of harm from unrecognized clinical deterioration in hospitalized pediatric patients, which is startling given the morbidity and mortality risk patients incur. In this article, we compare existing outcomes for evaluating clinical deterioration outside of the ICU, highlighting sources of variation and vulnerability. The broader aim of this article is to highlight the need for a standard, consensus outcome for evaluating clinical deterioration outside of the ICU, which is a critical first step to preventing this type of harm.

Sepsis Prediction in Hospitalized Children: Clinical Decision Support Design and Deployment

BACKGROUND

Following development and validation of a sepsis prediction model described in a companion article, we aimed to use quality improvement and safety methodology to guide the design and deployment of clinical decision support (CDS) tools and clinician workflows to improve pediatric sepsis recognition in the inpatient setting.

METHODS

CDS tools and sepsis huddle workflows were created to implement an electronic health record-based sepsis prediction model. These were proactively analyzed and refined using simulation and safety science principles before implementation and were introduced across inpatient units during 2020-2021. Huddle compliance, alerts per non-ICU patient days, and days between sepsis-attributable emergent transfers were monitored. Rapid Plan-Do-Study-Act (PDSA) cycles based on user feedback and weekly metric data informed improvement throughout implementation.

RESULTS

There were 264 sepsis alerts on 173 patients with an 89% bedside huddle completion rate and 10 alerts per 1000 non-ICU patient days per month. There was no special cause variation in the metric days between sepsis-attributable emergent transfers.

CONCLUSIONS

An automated electronic health record-based sepsis prediction model, CDS tools, and sepsis huddle workflows were implemented on inpatient units with a relatively low rate of interruptive alerts and high compliance with bedside huddles. Use of CDS best practices, simulation, safety tools, and quality improvement principles led to high utilization of the sepsis screening process.

Sepsis Prediction in Hospitalized Children: Model Development and Validation

BACKGROUND AND OBJECTIVES

Early recognition and treatment of pediatric sepsis remain mainstay approaches to improve outcomes. Although most children with sepsis are diagnosed in the emergency department, some are admitted with unrecognized sepsis or develop sepsis while hospitalized. Our objective was to develop and validate a prediction model of pediatric sepsis to improve recognition in the inpatient setting.

METHODS

Patients with sepsis were identified using intention-to-treat criteria. Encounters from 2012 to 2018 were used as a derivation to train a prediction model using variables from an existing model. A 2-tier threshold was determined using a precision-recall curve: an "Alert" tier with high positive predictive value to prompt bedside evaluation and an "Aware" tier with high sensitivity to increase situational awareness. The model was prospectively validated in the electronic health record in silent mode during 2019.

RESULTS

A total of 55 980 encounters and 793 (1.4%) episodes of sepsis were used for derivation and prospective validation. The final model consisted of 13 variables with an area under the curve of 0.96 (95% confidence interval 0.95-0.97) in the validation set. The Aware tier had 100% sensitivity and the Alert tier had a positive predictive value of 14% (number needed to alert of 7) in the validation set.

CONCLUSIONS

We derived and prospectively validated a 2-tiered prediction model of inpatient pediatric sepsis designed to have a high sensitivity Aware threshold to enable situational awareness and a low number needed to Alert threshold to minimize false alerts. Our model was embedded in our electronic health record and implemented as clinical decision support, which is presented in a companion article.

Improving Situational Awareness to Decrease Emergency ICU Transfers for Hospitalized Pediatric Cardiology Patients

Introduction

Failure to recognize and mitigate critical patient deterioration remains a source of serious preventable harm to hospitalized pediatric cardiac patients. Emergency transfers (ETs) occur 10-20 times more often than code events outside the intensive care unit (ICU) and are associated with morbidity and mortality. This quality improvement project aimed to increase days between ETs and code events on an acute care cardiology unit (ACCU) from a baseline median of 17 and 32 days to ≥70 and 90 days within 12 months.

Methods

Institutional leaders, cardiology-trained physicians and nurses, and trainees convened, utilizing the Institution for Healthcare Improvement model to achieve the project aims. Interventions implemented focused on improving situational awareness (SA), including a "Must Call List," evening rounds, a visual management board, and daily huddles. Outcome measures included calendar days between ETs and code events in the ACCU. Process measures tracked the utilization of interventions, and cardiac ICU length of stay was a balancing measure. Statistical process control chart methodology was utilized to analyze the impact of interventions.

Results

Within the study period, we observed a centerline shift in primary outcome measures with an increase from 17 to 56 days between ETs and 32 to 62 days between code events in the ACCU, with sustained improvement. Intervention utilization ranged from 87% to 100%, and there was no observed special cause variation in our balancing measure.

Conclusions

Interventions focused on improving SA in a particularly vulnerable patient population led to sustained improvement with reduced ETs and code events outside the ICU.

Using the Endsley Model to Evaluate Simulation-Based Situation Awareness Training for Medical and Nursing Students in India: A Qualitative Analysis

INTRODUCTION

Situation awareness (SA) training is a vital part of healthcare training, and opportunities to provide SA training to healthcare workers are limited in low- and middle-income countries. We aimed to analyze undergraduate medical and nursing students' perception of their understanding of SA through an interprofessional obstetric neonatal emergency simulation workshop (ONE-Sim) and subsequently evaluate their perceived changes in SA understanding using the Endsley model ( Hum Factors 1995;37(1):32-64).

METHODS

Feedback on SA before and after the workshop was collected through questionnaire-based surveys. Thematic analysis was performed, with themes emerging from an inductive analysis followed by a deductive analysis using the Endsley model.

RESULTS

The themes emerging from the inductive analysis included environmental awareness, evolving knowledge, skill development, and applicability to practice. These aligned with the 3 levels of SA in the Endsley model in the deductive analysis suggesting that participants transformed their perception, comprehension, and projection of SA after the workshop.

CONCLUSION

Simulation-based education enhanced SA perception in obstetric and neonatal emergencies for medical and nursing students in a low- and middle-income country, and the Endsley model is a feasible framework to measure learner perceived changes in SA understanding through simulation-based education.

Pediatric Septic Shock Care Pathways in General Emergency Departments: A Qualitative Study Targeting How to Really Make it Work

OBJECTIVES

Many academic pediatric emergency departments (PEDs) have successfully implemented pediatric septic shock care pathways. However, many general emergency departments (GEDs), who see the majority of pediatric ED visits, have not. This study aims to compare the workflow, resources, communication, and decision making across these 2 settings to inform the future implementation of a standardized care pathway for children with septic shock in the GED.

METHODS

We used the critical incident technique to conduct semistructured interviews with 24 ED physicians, nurses, and technicians at one PED and 2 GEDs regarding pediatric septic shock care. We performed a thematic analysis using the Framework Method to develop our coding schema through inductive and deductive analyses. We continued an iterative process of revising the schema until we reached consensus agreement and thematic saturation.

RESULTS

We identified the following 6 themes: (1) functioning like a "well-oiled machine" may be key to high performance; (2) experiencing the sequence of care for children with sepsis as invariant and predictable may be essential to high-quality performance; (3) resilience and flexibility are characteristic of high levels of performance; (4) believing that "the buck stops here" may contribute to more accountability; (5) continuous system learning is essential; and (6) computerized clinical decision support may not be optimized to drive decision-making at the point of care. Commentary from GED and PED participants differed across the 6 themes, providing insight into the approach for standardized care pathway implementation in GEDs.

CONCLUSIONS

Pediatric septic shock workflow, decision making, and system performance differ between the PED and GEDs. Implementation of a standardized care pathway in GEDs will require a tailored approach. Specific recommendations include (1) improving shared situation awareness; (2) simulation for knowledge, skill, and team-based training; and (3) promoting a culture of continuous learning.

Guidelines on human factors in critical situations 2023

OBJECTIVE

To provide guidelines to define the place of human factors in the management of critical situations in anaesthesia and critical care.

DESIGN

A committee of nineteen experts from the SFAR and GFHS learned societies was set up. A policy of declaration of links of interest was applied and respected throughout the guideline-producing process. Likewise, the committee did not benefit from any funding from a company marketing a health product (drug or medical device). The committee followed the GRADE® method (Grading of Recommendations Assessment, Development and Evaluation) to assess the quality of the evidence on which the recommendations were based.

METHODS

We aimed to formulate recommendations according to the GRADE® methodology for four different fields: 1/ communication, 2/ organisation, 3/ working environment and 4/ training. Each question was formulated according to the PICO format (Patients, Intervention, Comparison, Outcome). The literature review and recommendations were formulated according to the GRADE® methodology.

RESULTS

The experts' synthesis work and application of the GRADE® method resulted in 21 recommendations. Since the GRADE® method could not be applied in its entirety to all the questions, the guidelines used the SFAR "Recommendations for Professional Practice" A means of secured communication (RPP) format and the recommendations were formulated as expert opinions.

CONCLUSION

Based on strong agreement between experts, we were able to produce 21 recommendations to guide human factors in critical situations.

Opportunities to improve diagnosis in emergency transfers to the pediatric intensive care unit

BACKGROUND

Late recognition of in-hospital deterioration is a source of preventable harm. Emergency transfers (ET), when hospitalized patients require intensive care unit (ICU) interventions within 1 h of ICU transfer, are a proximal measure of late recognition associated with increased mortality and length of stay (LOS).

OBJECTIVE

To apply diagnostic process improvement frameworks to identify missed opportunities for improvement in diagnosis (MOID) in ETs and evaluate their association with outcomes.

DESIGN, SETTINGS, AND PARTICIPANTS

A single-center retrospective cohort study of ETs, January 2015 to June 2019. ET criteria include intubation, vasopressor initiation, or≥ $\ge \phantom{\rule{}{0ex}}$ 60 mL/kg fluid resuscitation 1 h before to 1 h after ICU transfer. The primary exposure was the presence of MOID, determined using SaferDx. Cases were screened by an ICU and non-ICU physician. Final determinations were made by an interdisciplinary group. Diagnostic process improvement opportunities were identified.

MAIN OUTCOME AND MEASURES

Primary outcomes were in-hospital mortality and posttransfer LOS, analyzed by multivariable regression adjusting for age, service, deterioration category, and pretransfer LOS.

RESULTS

MOID was identified in 37 of 129 ETs (29%, 95% confidence interval [CI] 21%-37%). Cases with MOID differed in originating service, but not demographically. Recognizing the urgency of an identified condition was the most common diagnostic process opportunity. ET cases with MOID had higher odds of mortality (odds ratio 5.5; 95% CI 1.5-20.6; p = .01) and longer posttransfer LOS (rate ratio 1.7; 95% CI 1.1-2.6; p = .02).

CONCLUSION

MOID are common in ETs and are associated with increased mortality risk and posttransfer LOS. Diagnostic improvement strategies should be leveraged to support earlier recognition of clinical deterioration.

Reduction of Very Rapid Emergency Transfers to the Pediatric Intensive Care Unit

Introduction

Emergency transfers are associated with increased inpatient pediatric mortality. Therefore, interventions to improve system-level situational awareness were utilized to decrease a subset of emergency transfers that occurred within four hours of admission to an inpatient medical-surgical unit called very rapid emergency transfers (VRET). Specifically, we aimed to increase the days between VRET from non-ICU inpatient units from every 10 days to every 25 days over 1 year.

Methods

Using the Model for Improvement, we developed an interdisciplinary team to reduce VRET. The key drivers targeted were the admission process from the emergency department and ambulatory clinics, sepsis recognition and communication, and expansion of our situational awareness framework. Days between VRET defined the primary outcome metric for this improvement project.

Results

After six months of interventions, our baseline improved from a VRET every 10 days to every 79 days, followed by another shift to 177 days, which we sustained for 3 years peaking at 468 days between events.

Conclusion

Interventions targeting multiple admission sources to improve early recognition and communication of potential clinical deterioration effectively reduced and nearly eliminated VRET at our organization.

Paediatric early warning systems: not a simple answer to a complex question

Paediatric early warning systems (PEWS) to reduce in-hospital mortality have been a laudable endeavour. Evaluation of their impact has rarely examined the internal validity of the components of PEWS in achieving desired outcomes. We highlight the assumptions made regarding the mode of action of PEWS and, as PEWS become more commonplace, this paper asks whether we really understand their function, process and outcome.

The Deterioration Risk Index: Developing and Piloting a Machine Learning Algorithm to Reduce Pediatric Inpatient Deterioration

OBJECTIVES

Develop and deploy a disease cohort-based machine learning algorithm for timely identification of hospitalized pediatric patients at risk for clinical deterioration that outperforms our existing situational awareness program.

DESIGN

Retrospective cohort study.

SETTING

Nationwide Children's Hospital, a freestanding, quaternary-care, academic children's hospital in Columbus, OH.

PATIENTS

All patients admitted to inpatient units participating in the preexisting situational awareness program from October 20, 2015, to December 31, 2019, excluding patients over 18 years old at admission and those with a neonatal ICU stay during their hospitalization.

INTERVENTIONS

We developed separate algorithms for cardiac, malignancy, and general cohorts via lasso-regularized logistic regression. Candidate model predictors included vital signs, supplemental oxygen, nursing assessments, early warning scores, diagnoses, lab results, and situational awareness criteria. Model performance was characterized in clinical terms and compared with our previous situational awareness program based on a novel retrospective validation approach. Simulations with frontline staff, prior to clinical implementation, informed user experience and refined interdisciplinary workflows. Model implementation was piloted on cardiology and hospital medicine units in early 2021.

MEASUREMENTS AND MAIN RESULTS

The Deterioration Risk Index (DRI) was 2.4 times as sensitive as our existing situational awareness program (sensitivities of 53% and 22%, respectively; p < 0.001) and required 2.3 times fewer alarms per detected event (121 DRI alarms per detected event vs 276 for existing program). Notable improvements were a four-fold sensitivity gain for the cardiac diagnostic cohort (73% vs 18%; p < 0.001) and a three-fold gain (81% vs 27%; p < 0.001) for the malignancy diagnostic cohort. Postimplementation pilot results over 18 months revealed a 77% reduction in deterioration events (three events observed vs 13.1 expected, p = 0.001).

CONCLUSIONS

The etiology of pediatric inpatient deterioration requires acknowledgement of the unique pathophysiology among cardiology and oncology patients. Selection and weighting of diverse candidate risk factors via machine learning can produce a more sensitive early warning system for clinical deterioration. Leveraging preexisting situational awareness platforms and accounting for operational impacts of model implementation are key aspects to successful bedside translation.

Developing a machine learning model to detect diagnostic uncertainty in clinical documentation

BACKGROUND AND OBJECTIVE

Diagnostic uncertainty, when unrecognized or poorly communicated, can result in diagnostic error. However, diagnostic uncertainty is challenging to study due to a lack of validated identification methods. This study aims to identify distinct linguistic patterns associated with diagnostic uncertainty in clinical documentation.

DESIGN, SETTING AND PARTICIPANTS

This case-control study compares the clinical documentation of hospitalized children who received a novel uncertain diagnosis (UD) diagnosis label during their admission to a set of matched controls. Linguistic analyses identified potential linguistic indicators (i.e., words or phrases) of diagnostic uncertainty that were then manually reviewed by a linguist and clinical experts to identify those most relevant to diagnostic uncertainty. A natural language processing program categorized medical terminology into semantic types (i.e., sign or symptom), from which we identified a subset of these semantic types that both categorized reliably and were relevant to diagnostic uncertainty. Finally, a competitive machine learning modeling strategy utilizing the linguistic indicators and semantic types compared different predictive models for identifying diagnostic uncertainty.

RESULTS

Our cohort included 242 UD-labeled patients and 932 matched controls with a combination of 3070 clinical notes. The best-performing model was a random forest, utilizing a combination of linguistic indicators and semantic types, yielding a sensitivity of 89.4% and a positive predictive value of 96.7%.

CONCLUSION

Expert labeling, natural language processing, and machine learning methods combined with human validation resulted in highly predictive models to detect diagnostic uncertainty in clinical documentation and represent a promising approach to detecting, studying, and ultimately mitigating diagnostic uncertainty in clinical practice.

Optimizing Recognition and Management of Patients at Risk for Infection-Related Decompensation Through Team-Based Decision Making

INTRODUCTION

Pediatric sepsis is a leading cause of death among children. Electronic alert systems may improve early recognition but do not consistently result in timely interventions given the multitude of clinical presentations, lack of treatment consensus, standardized order sets, and inadequate interdisciplinary team-based communication. We conducted a quality improvement project to improve timely critical treatment of patients at risk for infection-related decompensation (IRD) through team-based communication and standardized treatment workflow.

METHODS

We evaluated children at risk for IRD as evidenced by the activation of an electronic alert system (Children at High Risk Alert Tool [CAHR-AT]) in the emergency department. Outcomes were assessed after multiple improvements including CAHR-AT implementation, clinical coassessment, visual cues for situational awareness, huddles, and standardized order sets.

RESULTS

With visual cue activation, initial huddle compliance increased from 7.8% to 65.3% ( p < .001). Children receiving antibiotics by 3 hours postactivation increased from 37.9% pre-CAHR-AT to 50.7% posthuddle implementation ( p < .0001); patients who received a fluid bolus by 3 hours post-CAHR activation increased from 49.0% to 55.2% ( p = .001).

CONCLUSIONS

Implementing a well-validated electronic alert tool did not improve quality measures of timely treatment for high-risk patients until combined with team-based communication, standardized reassessment, and treatment workflow.

A multidisciplinary safety briefing for acutely ill and deteriorating patients: A quality improvement project

BACKGROUND

Safety briefings can help promoting situational awareness, interprofessional communication and improve patient safety.

LOCAL PROBLEM

A clinical survey highlighted that 90% of the participants including the medical team and the critical care outreach team nurses perceived the meeting for escalating acutely ill and deteriorating patients during the out-of-hours period (20.00 to 08.00) to have unconstructive and unwelcoming atmosphere with belittling, hostility and unhelpful criticisms. The participants reported that the communication across teams lacked in structure and clear information given; but staff also self-reported lacking confidence in communicating key issues.

METHOD

A quality improvement project with Plan-Do-Study-Act was adopted to design and implement a dedicated multidisciplinary safety briefing with a structured format.

RESULTS

The multidisciplinary safety briefing was to 90% of clinicians, and it took a median of 10 min to complete. Delayed referrals to the critical care outreach team were reduced by 46%. Positive changes included increased situational awareness and clearer communication across teams. Barriers identified were variable usage and need for face-to-face presence. Considering all the findings and the time constraint during the SARS-CoV-2 pandemic, we changed to a telephonic safety briefing directly to the team leaders.

CONCLUSION

A structured multidisciplinary safety briefing can improve patient safety and support management of deteriorating and acutely ill patients on the wards during the out-of-hours period.

Validation of a modified bedside Pediatric Early Warning System score for detection of clinical deterioration in hospitalized pediatric oncology patients: A prospective cohort study

BACKGROUND

Hospitalized pediatric oncology patients are at risk of severe clinical deterioration. Yet Pediatric Early Warning System (PEWS) scores have not been prospectively validated in these patients. We aimed to determine the predictive performance of the modified BedsidePEWS score for unplanned pediatric intensive care unit (PICU) admission and cardiopulmonary resuscitation (CPR) in this patient population.

METHODS

We performed a prospective cohort study in an 80-bed pediatric oncology hospital in the Netherlands, where care has been nationally centralized. All hospitalized pediatric oncology patients aged 0-18 years were eligible for inclusion. A Cox proportional hazard model was estimated to study the association between BedsidePEWS score and unplanned PICU admissions or CPR. The predictive performance of the model was internally validated by bootstrapping.

RESULTS

A total of 1137 patients were included. During the study, 103 patients experienced 127 unplanned PICU admissions and three CPRs. The hazard ratio for unplanned PICU admission or CPR was 1.65 (95% confidence interval [CI]: 1.59-1.72) for each point increase in the modified BedsidePEWS score. The discriminative ability was moderate (D-index close to 0 and a C-index of 0.83 [95% CI: 0.79-0.90]). Positive and negative predictive values of modified BedsidePEWS score at the widely used cutoff of 8, at which escalation of care is required, were 1.4% and 99.9%, respectively.

CONCLUSION

The modified BedsidePEWS score is significantly associated with requirement of PICU transfer or CPR. In pediatric oncology patients, this PEWS score may aid in clinical decision-making for timing of PICU transfer.

HeartWatch: Implementing a Pediatric Heart Center Program to Prevent Cardiac Arrests Outside the ICU

Pediatric patients with cardiovascular disease are at increased risk of cardiopulmonary arrest. Despite utilization of Cardiac Pediatric Early Warning Scores to identify patients at risk of decompensation, our institution had a twofold increase in cardiac arrests (CAs) in the acute care cardiology unit (ACCU) over 2 years. Through a quality improvement initiative, we developed a watcher program, HeartWatch, to reduce the CA arrest rate in the ACCU by 50% over the first year of implementation.

METHODS

HeartWatch aims to identify patients not adequately captured by Cardiac Pediatric Early Warning Scores who are at high risk for sudden decompensation. Inclusion criteria were developed and evaluated during pilot and implemented phases (April 2020-April 2021) and then monitored in a sustained phase through June 2022. Our primary outcome was the reduction in the out-of-ICU CA rate.

RESULTS

During the 13 months, we enrolled 169 patients, and the CA rate decreased from 0.7 to 0.33 per 1,000 patient days, a 53% reduction. The CA rate further decreased to 0.28 events per 1,000 patient days, a 60% reduction, by June 2022. The most common indications for HeartWatch inclusion were high-risk single-ventricle patients (31%) and patients with diminished ventricular function (20%).

CONCLUSIONS

Implementation of HeartWatch was associated with a meaningful reduction in CA in the ACCU. Creating shared mental models for high-risk patients is essential for patient safety. Future work will optimize local processes that focus on the sustainability of our gains. We will also evaluate opportunities to adapt and implement a similar framework in other institutions to assess reproducibility.

Interventions Into Reliability-Seeking Health Care Organizations: A Systematic Review of Their Goals and Measuring Methods

OBJECTIVES

Within the last 2 decades, numerous interventions making use of high-reliability theory have been implemented to increase reliability in healthcare organizations. This systematic literature review first explores the concrete goals on which such interventions focus. Second, the review captures how the achievement of these goals, or alternatively a change, generally an increase in organizational reliability, is measured across different contexts.

METHODS

Searches were conducted in PubMed, Academic Search Ultimate, Business SourcePremier, CINAHL, Communication Source, EconLit, ERIC, Medline, Political Science Complete, PsycArticles, APA PsycInfo, PSYNDEX, SocINDEX (via the resource hosterEbscoHost), and Web of Science (through November 22, 2021). Peer-reviewed, English language studies were included, reporting on the implementation of a concrete intervention to increase reliability in a medical context and referring to high-reliability theory.

RESULTS

The search first yielded 8896 references, from which 75 studies were included in the final sample. Important healthcare goals stated by the seminal report "Crossing the Quality Chasm" guided the analysis of the included studies. Most of the studies originated from the United States and report on interventions to increase reliability of either organizational units or whole organizations when aiming for safety (n = 65). Other goals reported on include effectiveness, and much less frequently timeliness, patient centeredness, and efficiency. Fifty-eight studies use quantitative measurement exclusively to account for the achievement of these goals; 7 studies use qualitative measurement exclusively, and 10 studies use a mixed-method approach. The operationalization of goals, including the operationalization of organizational reliability, and measurement methods do not follow a unified approach, despite claiming to be informed by a coherent theory. Instead, such operationalizations strongly depend on the overall objective of the study and the respective context.

CONCLUSIONS

Measuring the outcomes of high-reliability interventions into healthcare organizations is challenging for different reasons, including the difficult operationalization of partly overlapping goals, the complex, processual nature of achieving reliability, and the limited ability of organizations striving for more reliability if they are already performing on a high level. This review critically assesses the adoption of the goals stated in the seminal report "Crossing the Quality Chasm" and provides insights for organizations and funding providers that strive to evaluate more reliable service provision.

Optimizing Pediatric Patient Safety in the Emergency Care Setting

Patient safety is the foundation of high-quality health care and remains a critical priority for all clinicians caring for children. There are numerous aspects of pediatric care that increase the risk of patient harm, including but not limited to risk from medication errors attributable to weight-dependent dosing and need for appropriate equipment and training. Of note, the majority of children who are ill and injured are brought to community hospital emergency departments. It is, therefore, imperative that all emergency departments practice patient safety principles, support a culture of safety, and adopt best practices to improve safety for all children seeking emergency care. This technical report outlined the challenges and resources necessary to minimize pediatric medical errors and to provide safe medical care for children of all ages in emergency care settings.

Optimizing Pediatric Patient Safety in the Emergency Care Setting

This is a revision of the previous American Academy of Pediatrics policy statement titled "Patient Safety in the Emergency Care Setting," and is the first joint policy statement by the American Academy of Pediatrics, the American College of Emergency Physicians, and the Emergency Nurses Association to address pediatric patient safety in the emergency care setting. Caring for children in the emergency setting can be prone to medical errors because of a number of environmental and human factors. The emergency department (ED) has frequent workflow interruptions, multiple care transitions, and barriers to effective communication. In addition, the high volume of patients, high-decision density under time pressure, diagnostic uncertainty, and limited knowledge of patients' history and preexisting conditions make the safe care of critically ill and injured patients even more challenging. It is critical that all EDs, including general EDs who care for the majority of ill and injured children, understand the unique safety issues related to children. Furthermore, it is imperative that all EDs practice patient safety principles, support a culture of safety, and adopt best practices to improve safety for all children seeking emergency care. This policy statement outlines the recommendations necessary for EDs to minimize pediatric medical errors and to provide safe care for children of all ages.

Situation awareness in intensive care unit nurses: A qualitative directed content analysis

Background

Situation awareness (SA) is an essential cognitive construct to create positive patient safety outcomes. SA of the nurses in the intensive care unit (ICU), where conditions may change rapidly, is particularly important. The present study aimed to explain the perception and experience of SA in ICU nurses based on Endsley's SA model.

Materials and methods

This qualitative directed content analysis was conducted on nurses in six hospitals in Tehran, Iran, from December 2020 to July 2021. Twenty-seven ICU nurses were selected using purposive sampling. Data were collected by semi-structured interviews and field observations. The data were analyzed based on the Elo and Kyngas method modified by Assarroudi et al. COREQ checklist was used to report the research.

Results

The concept of SA in ICU nurses, based on Endsley's model, includes perception of patients' clinical cues, perception of the human environment, perception of the physical environment, and perception of the organizational environment as generic categories of the perception of the elements in the environment. SA in ICU nurses also includes the main categories of comprehension the current situation through a sense of salience and interpretation of cues and projection the future situation through the prediction of patient status into the near future and environmental foresight.

Conclusion

Findings have further developed the concept of SA in ICU nurses based on Endsley's SA model. The insights and knowledge gained from this study can be useful for future practice, education, and research on SA among ICU nurses.

Preventing Cardiac Arrest in the Pediatric Cardiac Intensive Care Unit Through Multicenter Collaboration

Importance

Preventing in-hospital cardiac arrest (IHCA) likely represents an effective strategy to improve outcomes for critically ill patients, but feasibility of IHCA prevention remains unclear.

Objective

To determine whether a low-technology cardiac arrest prevention (CAP) practice bundle decreases IHCA rate.

Design, Setting, and Participants

Pediatric cardiac intensive care unit (CICU) teams from the Pediatric Cardiac Critical Care Consortium (PC4) formed a collaborative learning network to implement the CAP bundle consistent with the Institute for Healthcare Improvement framework; 15 hospitals implemented the bundle voluntarily. Risk-adjusted IHCA incidence rates were analyzed across 2 time periods, 12 months (baseline) and 18 months after CAP implementation (intervention) using difference-in-differences (DID) regression to compare 15 CAP and 16 control PC4 hospitals that chose not to participate in CAP but had IHCA rates tracked in the PC4 registry. Patients deemed at high risk for IHCA, based on a priori evidence-based criteria and empirical hospital-specific criteria, were selected to receive the CAP bundle. Data were collected from July 2018 to December 2019, and data were analyzed from March to August 2020.

Interventions

CAP bundle included 5 elements developed to promote increased situational awareness and communication among bedside clinicians to recognize and mitigate deterioration in high-risk patients.

Main Outcomes and Measures

Risk-adjusted IHCA incidence rate across all CICU admissions (IHCA events divided by all admissions).

Results

The bundle was activated in 2664 of 10 510 CAP hospital admissions (25.3%); admission characteristics were similar across study periods. There was a 30% relative reduction in risk-adjusted IHCA incidence rate at CAP hospitals (intervention period: 2.6%; 95% CI, 2.2-2.9; baseline: 3.7%; 95% CI, 3.1-4.0), but no change at control hospitals (intervention period: 2.7%; 95% CI, 2.3-2.9; baseline: 2.7%; 95% CI, 2.2-3.0). DID analysis confirmed significantly reduced odds of IHCA among all admissions at CAP hospitals compared with control hospitals during the intervention period vs baseline (odds ratio, 0.72; 95% CI, 0.56-0.91; P = .01). DID odds ratios were 0.72 (95% CI, 0.53-0.98) for the surgical subgroup, 0.74 (95% CI, 0.48-1.14) for the medical subgroup, and 0.72 (95% CI, 0.50-1.03) for the high-risk admission subgroup at CAP hospitals after intervention. All-cause risk-adjusted mortality rate did not change after intervention.

Conclusions and Relevance

Implementation of this CAP bundle led to significant IHCA reduction across multiple pediatric CICUs. Future studies may determine if this bundle can be effective in other critically ill populations.

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.

Effect of post-ICU follow-up by a rapid response team after congenital heart surgery

Patients with congenital heart disease who have a variety of cardiac/extracardiac problems are at high risk for deterioration. This study aimed to determine the effectiveness of post-intensive care unit (ICU) follow-up by a rapid response team (RRT) after congenital heart surgery. This before-and-after study was conducted at an urban regional tertiary hospital. We enrolled 572 consecutive patients who underwent congenital heart surgery and were transferred alive from the paediatric ICU (PICU) between April 2015 and March 2020. Post-ICU follow-up for 48 h was started in April 2018. The primary and secondary endpoints were unplanned ICU readmission and clinical outcomes at ICU readmission, respectively. Overall, 346 and 226 patients were analysed pre- and post-intervention, respectively. Patient demographics were similar between groups, but in the post-intervention group, patients tended to have had more complicated surgery. Unplanned ICU readmission rates within 30 days were similar between groups. Regarding the demographics and outcomes at ICU readmission, patients in the post-intervention group had lower predicted mortality rates (1.7% vs 5.3%, P = 0.001), required less ventilator days (median, 0.5 days [interquartile range (IQR) 0–1] vs median, 3 days [IQR 0.5–4], P = 0.02), and had a shorter ICU stay (median, 3 days [IQR 2–4] vs median, 6 days [IQR 3–9], P = 0.03), but there was no significant between-group difference in ICU mortality. Post-ICU follow-up by a RRT after congenital heart surgery did not decrease unplanned ICU readmission but improved several outcomes at ICU readmission.

Patient Deterioration on General Care Units: A Concept Analysis

Patient deterioration is a phenomenon that occurs from the inability to recognize it or respond to a change in condition. Despite the published reports on recognizing a deteriorating patient on general care floors, a gap remains in the ability of nurses to describe the concept, affecting patient outcomes. Walker and Avant's approach was applied to analyze patient deterioration. The aim of this article was to explore and clarify the meaning of patient deterioration and identify attributes, antecedents, and consequences. The defining attributes were compared to early warning scores. An operational definition was developed and its value to nurses established.

Modification of a children's hospital pediatric early warning score (EWS): An evaluation of inter-rater reliability, nurses' critical thinking and perceptions of the tool

Pediatric early warning scores (EWS) have been utilized to assist the identification of children at risk for clinically decompensating, experiencing a cardiac or respiratory arrest, or requiring a transfer to a higher level of care. Although their use is widespread, little consistency exists between tools and research evaluating the effectiveness of these tools is lacking. This quasi-experimental project evaluated twenty-five medical-surgical staff nurses' use and perceptions as well as the inter-rater reliability of a newly modified pediatric EWS tool at a free standing, academic Midwestern pediatric hospital. The tool was modified utilizing existing literature and an interdisciplinary team's expertise. Five fictionalized patients, presented in case studies, were developed and nurses were asked to score these patients using the newly modified tool with rationale. Inter-rater reliability was assessed utilizing Fleiss' Kappa and qualitative questionnaire data was analyzed for emerging themes. Overall, Fleiss' Kappa showed that there was moderate agreement between the nurses' judgments and scoring, with scores primarily differing due to the difficulty level of each case study. Nurses' responses to a questionnaire indicated differing levels of comfort identifying and managing children that present with mid-range total scores as opposed to those who scored in the lower or higher ranges. This project's findings highlight nurses' concerns that an objective tool may not accurately describe a subjective assessment. The results of this project indicated that use of this tool, with some modifications to address nursing concerns, may help to identify clinically decompensating pediatric patients being treated on medical-surgical units.

Effect of Daily Multidisciplinary Team Reflection in Ambulatory Care: A Qualitative Analysis

Purpose

Participants and Methods

Results

Conclusion

Endo-anesthesia: a primer

Gastrointestinal (GI) endoscopy has witnessed a Cambrian explosion of techniques, indications, and expanding target populations. GI endoscopy encompasses traditional domains that include preventive measures, palliation, as alternative therapies in patients with prohibitive risks of more invasive procedures, and indicated primary treatments. But, it has expanded to include therapeutic and diagnostic interventional endosonography, luminal endoscopic resection, third space endotherapy, endohepatology, and endobariatrics. The lines between surgery and endoscopy are blurred on many occasions within this paradigm. Moreover, patients with high degrees of co-morbidity and complex physiology require more nuanced peri-endoscopic management. The rising demand for endoscopy services has resulted in the development of endoscopy referral centers that offer these invasive procedures as directly booked referrals for regional and rural patients. This further necessitates specialized programs to ensure appropriate evaluation, risk stratification, and optimization for safe sedation and general anesthesia if needed. This landscape is conducive to the organic evolution of endo-anesthesia to meet the needs of these focused and evolving practices. In this primer, we delineate important aspects of endo-anesthesia care and provide relevant clinical and logistical considerations pertaining to the breadth of procedures.

Low Inadequate Oxygen Delivery Index is Associated with Decreased Cardiac Arrest Risk in High-Risk Pediatric ICU Patients

Supplemental Digital Content is available in the text.

To evaluate the Inadequate Oxygen Delivery Index (IDO₂) in the PICU to identify patients labeled as high risk by clinician concern who will not experience a cardiac arrest.

Characteristics of Disease-Specific and Generic Diagnostic Pitfalls: A Qualitative Study

IMPORTANCE

Progress in understanding and preventing diagnostic errors has been modest. New approaches are needed to help clinicians anticipate and prevent such errors. Delineating recurring diagnostic pitfalls holds potential for conceptual and practical ways for improvement.

OBJECTIVES

To develop the construct and collect examples of "diagnostic pitfalls," defined as clinical situations and scenarios vulnerable to errors that may lead to missed, delayed, or wrong diagnoses.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study used data from January 1, 2004, to December 31, 2016, from retrospective analysis of diagnosis-related patient safety incident reports, closed malpractice claims, and ambulatory morbidity and mortality conferences, as well as specialty focus groups. Data analyses were conducted between January 1, 2017, and December 31, 2019.

MAIN OUTCOMES AND MEASURES

From each data source, potential diagnostic error cases were identified, and the following information was extracted: erroneous and correct diagnoses, presenting signs and symptoms, and areas of breakdowns in the diagnostic process (using Diagnosis Error Evaluation and Research and Reliable Diagnosis Challenges taxonomies). From this compilation, examples were collected of disease-specific pitfalls; this list was used to conduct a qualitative analysis of emerging themes to derive a generic taxonomy of diagnostic pitfalls.

RESULTS

A total of 836 relevant cases were identified among 4325 patient safety incident reports, 403 closed malpractice claims, 24 ambulatory morbidity and mortality conferences, and 355 focus groups responses. From these, 661 disease-specific diagnostic pitfalls were identified. A qualitative review of these disease-specific pitfalls identified 21 generic diagnostic pitfalls categories, which included mistaking one disease for another disease (eg, aortic dissection is misdiagnosed as acute myocardial infarction), failure to appreciate test result limitations, and atypical disease presentations.

CONCLUSIONS AND RELEVANCE

Recurring types of pitfalls were identified and collected from diagnostic error cases. Clinicians could benefit from knowledge of both disease-specific and generic cross-cutting pitfalls. Study findings can potentially inform educational and quality improvement efforts to anticipate and prevent future errors.

Improving Shared Situation Awareness for High-risk Therapies in Hospitalized Children

BACKGROUND

High-risk therapies (HRTs), including medications and medical devices, are an important driver of preventable harm in children's hospitals. To facilitate shared situation awareness (SA) and thus targeted harm prevention, we aimed to increase the percentage of electronic health record (EHR) alerts with the correct descriptor of an HRT from 11% to 100% on a high-acuity hospital unit over a 6-month period.

METHODS

The interdisciplinary team defined an HRT as a medication or device with a significant risk for harm that required heightened awareness. Our aim for interventions was to (1) educate staff on a new HRT algorithm; (2) develop a comprehensive table of HRTs, risks, and mitigation plans; (3) develop bedside signs for patients receiving HRTs; and (4) restructure unit huddles. Qualitative interviews with families, nurses, and medical teams were used to assess shared SA and inform the development and adaptation of interventions. The primary outcome metric was the percentage of EHR alerts for an HRT that contained a correct descriptor of the therapy for use by the care team and institutional safety leaders.

RESULTS

The percentage of EHR alerts with a correct HRT descriptor increased from an average of 11% to 96%, with special cause variation noted on a statistical process control chart. Using qualitative interview data, we identified critical awareness gaps, including establishing a shared mental model between nursing staff and the medical team as well as engagement of families at the bedside to monitor for complications.

CONCLUSIONS

Explicit, structured processes and huddles can increase HRT SA among the care team, patient, and family.

A Structural, Cognitive, and Behavioral Model for Error Analysis of Group B Streptococcus Prophylaxis in Pregnancy

The objective of this study was to develop a structural-cognitive-behavioral model for error analysis of group B streptococcus (GBS) prophylaxis failure, classify delivery cases into this model, and examine compliance with treatment guidelines. A retrospective, cohort study was conducted of women with liveborn pregnancies greater than 24 weeks in April 2018 at a single hospital. We created a structural-cognitive-behavioral model of five assessments for adherence to GBS prophylaxis guidelines and then classified these into four distinct error stages. A descriptive analysis was performed to determine if the pregnancy had a perfect process, a GBS prophylaxis failure, or a fortuitous outcome. There were 313 women who met the study criteria. The rate of GBS positive was 12.8%, negative 37.4%, and unknown 49.8%. The most common errors were cognitive perception errors related to incorrectly documenting GBS status, 57.7% ( N  = 79). Of these errors, 15.2% ( N  = 12) led to GBS prophylaxis failure. Perfect outcomes occurred in 62.7% ( N  = 196) women, GBS prophylaxis failure occurred in 13.7% ( N  = 43), and fortuitous outcomes occurred in 23.6% ( N  = 74). In our study, we were able to identify structural, cognitive, and behavioral errors that contribute to GBS prophylaxis failures. In other cases, these errors may contribute to fortuitous outcomes.

Assessment of a Situation Awareness Quality Improvement Intervention to Reduce Cardiac Arrests in the PICU

OBJECTIVES

To use improved situation awareness to decrease cardiopulmonary resuscitation events by 25% over 18 months and demonstrate process and outcome sustainability.

DESIGN

Structured quality improvement initiative.

SETTING

Single-center, 35-bed quaternary-care PICU.

PATIENTS

All patients admitted to the PICU from February 1, 2017, to December 31, 2020.

INTERVENTIONS

Interventions targeted situation awareness and included bid safety huddles, bedside mitigation signs and huddles, smaller pod-based huddles, and an automated clinical decision support tool to identify high-risk patients.

MEASUREMENTS AND MAIN RESULTS

The primary outcome metric, cardiopulmonary resuscitation event rate per 1,000 patient-days, decreased from a baseline of 3.1-1.5 cardiopulmonary resuscitation events per 1,000 patient-days or by 52%. The secondary outcome metric, mortality rate, decreased from a baseline of 6.6 deaths per 1,000 patient-days to 3.6 deaths per 1,000 patient-days. Process metrics included percent of clinical deterioration events predicted, which increased from 40% to 67%, and percent of high-risk patients with shared situation awareness, which increased from 43% to 71%. Balancing metrics included time spent in daily safety huddle, median 0.4 minutes per patient (interquartile range, 0.3-0.5), and a number needed to alert of 16 (95% CI, 14-25). Neither unit acuity as measured by Pediatric Risk of Mortality III scores nor the percent of deaths in patients with do-not-attempt resuscitation orders or electing withdrawal of life-sustaining technologies changed over time.

CONCLUSIONS

Interprofessional teams using shared situation awareness may reduce cardiopulmonary resuscitation events and, thereby, improve outcomes.

Perioperative Safety: Engage, Integrate, Empower, Sustain to Eliminate Patient Safety Events

Supplemental Digital Content is available in the text.

The perioperative environment is one of the most complex areas within a hospital with significant safety risks. Despite a long history of safety-focused work, a recent cluster of patient safety events prompted a renewed comprehensive approach to improve safety processes and transform culture.