Elizabeth Mack

High-reliability emergency response teams in the hospital: improving quality and safety using in situ simulation training

Introduction In situ simulation training is a team-based training technique conducted on actual patient care units using equipment and resources from that unit, and involving actual members of the healthcare team. We describe our experience with in situ simulation training in a major childrens medical centre. Materials and methods In situ simulations were conducted using standardised scenarios approximately twice per month on inpatient hospital units on a rotating basis. Simulations were scheduled so that each unit participated in at least two in situ simulations per year. Simulations were conducted on a revolving schedule alternating on the day and night shifts and were unannounced. Scenarios were preselected to maximise the educational experience, and frequently involved clinical deterioration to cardiopulmonary arrest. Results We performed 64 of the scheduled 112 (57%) in situ simulations on all shifts and all units over 21 months. We identified 134 latent safety threats and knowledge gaps during these in situ simulations, which we categorised as medication, equipment, and/or resource/system threats. Identification of these errors resulted in modification of systems to reduce the risk of error. In situ simulations also provided a method to reinforce teamwork behaviours, such as the use of assertive statements, role clarity, performance of frequent updating, development of a shared mental model, performance of independent double checks of high-risk medicines, and overcoming authority gradients between team members. Participants stated that the training programme was effective and did not disrupt patient care. Conclusions In situ simulations can identify latent safety threats, identify knowledge gaps, and reinforce teamwork behaviours when used as part of an organisation-wide safety programme.

Clinical decision support systems in the pediatric intensive care unit

Objective: To review the use of clinical decision support systems (CDSS) available in the pediatric intensive care unit (PICU). Data Sources: Relevant English language publications indexed in Medline, as well as CDSS-related white papers and texts. Study Selection and Data Extraction: Studies related to CDSS were considered. Data Synthesis: CDSS are operationally defined as computer software programs that aid healthcare providers in their clinical decision making. Once used solely for diagnostic support, many CDSS now have the ability to transform clinical practice through interactive assistance with therapeutic best practices. The recent emphasis on improving quality and patient safety through the incorporation of electronic health records as supported by Leapfrog and other agencies has encouraged advancements in the use of CDSS tools that leverage the capabilities of stand-alone electronic health records. CDSS are of particular interest in the PICU where rapid decision-making benefits from tools that can improve patient safety. CDSS have been described in the PICU with varying effects on healthcare outcomes. A growing consensus indicates that the success of such interventions depends as much or more on how they are implemented and used in such complex environments as on their programming. In the current review, the types and features of various CDSS tools and the supporting evidence are discussed. Factors such as liability, human factors engineering, alert fatigue, and audit trails are also covered. Conclusion: CDSS have the potential to improve clinical practice in PICU settings. Care should be taken when selecting and implementing such systems to achieve the goal of improved clinical practice while avoiding potential adverse impacts sometimes associated with the implementation of new technologies in complex healthcare settings.

Endovascular treatment of near-fatal neonatal superior vena cava syndrome.

Objective: We describe the endovascular management of an 8-wk-old previously healthy female who developed superior vena cava syndrome secondary to Pseudomonas septic shock and disseminated intravascular coagulation. Doppler ultrasound confirmed near-total thrombotic occlusion of the superior vena cava and right internal jugular vein. She was taken emergently for cardiac catheterization, which confirmed the large superior vena cava thrombus extending into the right internal jugular vein and innominate vein with almost complete occlusion of the innominate vein. The superior vena cava to right atrium gradient was 14 mm Hg with very little antegrade flow into the right atrium, right femoral artery occlusion, and branch pulmonary artery emboli. Intervention involved serial balloon dilation inflations across the superior vena cava and innominate vein with improvement in the superior vena cava to right atrium gradient to 5 mm Hg and significant improvement in left ventricular function. Anticoagulation included heparin infusion for 48 hrs followed by enoxaparin for 1 month, alteplase for 48 hrs, eptifibatide (glycoprotein IIb/IIIa inhibitor) for 9 days followed by aspirin. Data Sources: Chart review. Case reports are exempt from approval of our Institutional Review Board. Study Selection: None. Data Extraction: None. Data Synthesis: None. Conclusions: Daily head ultrasounds were performed without evidence of intracranial hemorrhage. All thromboses resolved within 3 wks. Her organ function recovered and she was discharged to home. The etiology of her colitis is still unknown. At 9-month follow-up, she was doing well with no residual organ dysfunction.

Buprenorphine ingestion in a 23-month-old boy.

Case: A previously healthy 23-month-old 12.6-kg boy presented to an outside community emergency department with vomiting and respiratory depression after a single episode of red-orange emesis that looked and smelled like his mother’s buprenorphine/naloxone tablets (8 mg/2 mg formulation). She reported slowed respirations, small pupils, and somnolence, but she denied witnessing any ingestion; therefore, the amount ingested and the time of ingestion remained unknown. At presentation to the emergency department, the patient’s respiratory rate was 14 per minute, with an oxygen saturation of 93% on room air; pupils were miotic, and the patient was described as lethargic. He was treated with 0.4 mg (0.03 mg/kg) of intravenous naloxone initially, without documented improvement in arousal or respiratory status. A second dose of naloxone 0.4 mg was administered intravenously immediately after the first dose. This second dose of naloxone resulted in arousal with crying and a respiratory rate of 18 per minute. At this time he was given 1 g/kg activated charcoal with sorbitol orally. A third dose of naloxone 0.4 mg was administered 20 minutes after the second dose, and at that time a naloxone infusion was initiated at 0.06 mg/hr. Approximately 15 minutes after initiation of the infusion he experienced recurrence of somnolence and bradypnea, and the naloxone infusion was increased to 0.2 mg/hr (0.015 mg/kg) with improvement. The patient was then transferred to the PICU. Question: Why can it be more concerning to find buprenorphine pill fragments in the mouth than to have a known ingestion in which pills are swallowed? Discussion: Buprenorphine is a semisynthetic opioid available in commercial form in the United States as a single tablet, a combination pill with naloxone, an injectable solution, a sublingual film with naloxone, and a topical patch. Suboxone (buprenorphine/naloxone) is a lemon-lime flavored, orange-colored tablet. Buprenorphine is a partial μ …

1217: BOLUSING MEDICATIONS OFF INFUSION PUMP IN PICU IMPACTS LINE ENTRIES, NURSE TIME, NURSE SATISFACTION

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) intensive care environment, metabolic derangements, and several medications can cause delirium. Diagnosing delirium in children is challenging. The Cornell Assessment for Pediatric Delirium (CAPD) screening tool has been validated in critically ill patients 0 to 21 years of age. Notably, this tool accounts for developmental milestones and allows nurses to evaluate the patient over the course of a 12 hour shift. This work evaluated the effect CAPD had on detecting and managing delirium in our pediatric intensive care unit (PICU). Methods: This was a quality improvement project. Baseline data consisted of patients prescribed antipsychotics in the PICU for signs and symptoms consistent with delirium. The CAPD screening tool was implemented in November 2015 and was performed for all patients in the PICU. After which, the number of patients diagnosed with delirium was collected. Additional data collected includes time to pharmaceutical management, described as minimizing benzodiazepines and other offending medications and/or adding antipsychotics, starting dose of antipsychotics, and duration of antipsychotic therapy. Results: The incidence of delirium increased from 1% prior to implementation of the CAPD to 17% after implementation. Of the 29 patients diagnosed with delirium by CAPD after implementation, 11 (37.9%) were developmentally delayed. Time to pharmaceutical management was similar between the two groups. The time to antipsychotic was slightly shorter after implementation with a median of 1 day compared to 2 days, but only 7 of 29 patients were treated with an antipsychotic. Following implementation, the duration of antipsychotic therapy decreased from 12 days to 7 days. Conclusions: The CAPD increased the diagnosis of delirium. As described in a previous study, the CAPD appears to over predict delirium in patients with developmental delay. Based on these results, adjustments to education of the multidisciplinary team and how the CAPD is utilized will be made.