Beth Wathen

A Multicenter Collaborative Approach to Reducing Pediatric Codes Outside the ICU

OBJECTIVES: The Child Health Corporation of America formed a multicenter collaborative to decrease the rate of pediatric codes outside the ICU by 50%, double the days between these events, and improve the patient safety culture scores by 5 percentage points. METHODS: A multidisciplinary pediatric advisory panel developed a comprehensive change package of process improvement strategies and measures for tracking progress. Learning sessions, conference calls, and data submission facilitated collaborative group learning and implementation. Twenty Child Health Corporation of America hospitals participated in this 12-month improvement project. Each hospital identified at least 1 noncritical care target unit in which to implement selected elements of the change package. Strategies to improve prevention, detection, and correction of the deteriorating patient ranged from relatively simple, foundational changes to more complex, advanced changes. Each hospital selected a broad range of change package elements for implementation using rapid-cycle methodologies. The primary outcome measure was reduction in codes per 1000 patient days. Secondary outcomes were days between codes and change in patient safety culture scores. RESULTS: Code rate for the collaborative did not decrease significantly (3% decrease). Twelve hospitals reported additional data after the collaborative and saw significant improvement in code rates (24% decrease). Patient safety culture scores improved by 4.5% to 8.5%. CONCLUSIONS: A complex process, such as patient deterioration, requires sufficient time and effort to achieve improved outcomes and create a deeply embedded culture of patient safety. The collaborative model can accelerate improvements achieved by individual institutions.

An Interdisciplinary Initiative to Reduce Unplanned Extubations in Pediatric Critical Care Units

OBJECTIVE: Unplanned extubations in pediatric critical care units can result in increased mortality, morbidity, and length of stay. We sought to reduce the incidence of these events by reliably measuring occurrences and instituting a series of coordinated interdisciplinary interventions. METHODS: This was an internal review board–approved quality improvement project. Data were prospectively collected from the electronic medical record, and analyzed over 24 months (January 1, 2009–December 2010), and divided into 3 periods: baseline (9 months), intervention with multiple rapid improvement cycles (8 months), and postintervention (7 months). Interventions included standardization of endotracheal tube taping practices upon admission, improved patient handoffs, systematic review of unplanned events, reexamination of sedation practices, and promotion of transparency of performance measures. RESULTS: The PICU experienced 21 events in the 9 months before the initiative, 13 events over the 8-month intervention period, and 5 events in the 7-month postintervention period. The cardiac intensive care unit (CICU) experienced 11, 4, and 0 events, respectively. Mean event rates per 100 patient days for each interval were 0.80, 0.50, and 0.29 for the PICU and 0.74, 0.44, and 0 for the CICU. Monthly event rates for the CICU were significantly different by using the Kruskal-Wallis test (P < .05) but not for the PICU (P = .36) CONCLUSIONS: Through accurate tracking, multiple practice changes, and promoting transparency of efforts and data, an interdisciplinary team reduced the number of unplanned extubations in both ICUs. This reduction has been sustained throughout the postintervention monitoring period.

Thrombosis risk factor assessment and implications for prevention in critically ill children.

Objectives: To describe nursing compliance with a computer-based pediatric thrombosis risk assessment tool; to generate an estimate of risk factors present in our population; and to explore relationships between risk factors and confirmed thrombotic events. Design: Institutional review board-approved prospective, observational cohort study. Setting: Pediatric intensive care unit within a tertiary care children’s hospital. Patients: All infants and children admitted to the pediatric intensive care unit during a 6-month study period (January 1, 2010–June 30, 2010). Measurements and Main Results: Eight hundred admissions were enrolled, representing 742 patients. Thrombosis risk assessment scores were recorded for 707 admissions (88% of total). Mean age = 6.95 ± 6 yrs, mean weight = 28 ± 23 kg, 45% female. A total of 32 thrombi (14 prehospital and 18 in-hospital) were present in the study group. This translated to an overall occurrence rate of 4.3% (1.9% for prehospital and 2.4% for in-hospital). Logistic regression identified that for every 1-point increase in total thrombosis score, the risk of developing a symptomatic thrombus increased by 1.57-fold (95% confidence interval 0.192–5.5) to 2.12-fold (95% confidence interval 0.175–18.34), for prehospital and in-hospital thrombi, respectively (p < .05). The most important risk factors identified for development of any thrombus were thrombophilia (acquired or inherited) (p < .001), presence of a central catheter (p = .01), and age <1 or >14 yrs (p = .052). Conclusions: Incorporation of a scoring system into the bedside nursing assessment flow sheet was successful and identified children at risk for in-hospital thrombosis. The overall score appears to be most indicative of thrombus risk. These data may serve as a platform for future development of routine screening and possible interventional trials in critically ill children.

Rapid Response Team Activations in Pediatric Surgical Patients.

Introduction The rapid response team (RRT) is a multidisciplinary team who evaluates hospitalized patients for concerns of nonemergent clinical deterioration. RRT evaluations are mandatory for children whose Pediatric Early Warning System (PEWS) score (assessment of childs behavior, cardiovascular and respiratory status) is ≥4. We aimed to determine if there were differences in characteristics of RRT calls between children who were admitted primarily to either medical or surgical services. We hypothesized that RRT activations would be called for less severely ill children with lower PEWS score on surgical services compared with children admitted to a medical service. Materials and Methods We performed a retrospective review of all children with RRT activations between January 2008 and April 2015 at a tertiary care pediatric hospital. We evaluated the characteristics of RRT calls and made comparisons between RRT calls made for children admitted primarily to medical or surgical services. Results A total of 2,991 RRT activations were called, and 324 (11%) involved surgical patients. Surgical patients were older than medical patients (median: 7 vs. 4 years; p < 0.001). RRT evaluations were called for lower PEWS score in surgical patients compared with medical (median: 3 vs. 4, p < 0.001). Surgical patients were more likely to remain on the inpatient ward following the RRT (51 vs. 39%, p < 0.001) and were less likely to require an advanced airway than medical patients (0.9 vs. 2.1%; p = 0.412). RRT evaluations did not differ between day and night shifts (52% day vs. 48% night; p = 0.17). All surgical patients and all but one medical patient survived the event; surgical patients were more likely to survive to hospital discharge (97 vs. 91%, p < 0.001) Conclusions RRT activations are rare events among pediatric surgical patients. When compared with medical patients, RRT evaluation is requested for surgical patients with a lower PEWS score and these children are less likely to require transfer to a higher level of care, suggesting that pediatric surgery team, families, and nursing staff may not be as comfortable with clinical deterioration.

1151: IMPLEMENTING A VENOUS THROMBOEMBOLISM PREVENTION PROGRAM IN THE PEDIATRIC INTENSIVE CARE UNIT.

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) calculated: (1) for a 30% collection rate: (-)

647: Unplanned extubations in critically ill children

23,590 and (-)

Low-Dose Epinephrine Boluses for Acute Hypotension in the PICU

27,691, (2) for a 20% collection rate: (-)

Improved sensitivity and specificity of pediatric hospital-acquired venous thromboembolism case identification by addition of radiographic and pharmacologic elements.

111,460 and (-)

873: TRANSPYLORIC TUBE PLACEMENT IN THE PICU

100,446, and (3) for a 50% collection rate: (+)

363: DWINDLE-DOSE EPINEPHRINE IN THE PEDIATRIC INTENSIVE CARE UNIT.

302,151 and (+)