Judith Ascenzi

Picu Up!: Impact of a Quality Improvement Intervention to Promote Early Mobilization in Critically Ill Children*

Objective: To determine the safety and feasibility of an early mobilization program in a PICU. Design: Observational, pre-post design. Setting: PICU in a tertiary academic hospital in the United States. Patients: Critically ill pediatric patients admitted to the PICU. Intervention: This quality improvement project involved a usual-care baseline phase, followed by a quality improvement phase that implemented a multicomponent, interdisciplinary, and tiered activity plan to promote early mobilization of critically ill children. Measurements and Main Results: Data were collected and analyzed from July to August 2014 (preimplementation phase) and July to August 2015 (postimplementation). The study sample included 200 children 1 day through 17 years old who were admitted to the PICU and had a length of stay of at least 3 days. PICU Up! implementation led to an increase in occupational therapy consultations (44% vs 59%; p = 0.034) and physical therapy consultations (54% vs 66%; p = 0.08) by PICU day 3. The median number of mobilizations per patient by PICU day 3 increased from 3 to 6 (p < 0.001). More children engaged in mobilization activities after the PICU Up! intervention by PICU day 3, including active bed positioning (p < 0.001), and ambulation (p = 0.04). No adverse events occurred as a result of early mobilization activities. The most commonly reported barriers to early mobilization after PICU Up! implementation was availability of appropriate equipment. The program was positively received by PICU staff. Conclusions: Implementation of a structured and stratified early mobilization program in the PICU was feasible and resulted in no adverse events. PICU Up! increased physical therapy and occupational therapy involvement in the children’s care and increased early mobilization activities, including ambulation. A bundled intervention to create a healing environment in the PICU with structured activity may have benefits for short- and long-term outcomes of critically ill children.

Scrub the Hub! Catheter Needleless Port Decontamination

T HE central venous catheter (CVC) is an essential tool in the care of critically ill and high-risk intraoperative patients. Catheterrelated bloodstream infection (CR-BSI) related to CVC insertion technique has been greatly reduced by the use of preventive protocols. However, late CR-BSI remains a significant threat to patient safety and healthcare cost containment. Appropriate CVC maintenance may be the most important factor in the prevention of late CR-BSI. Even transient improper CVC maintenance (e.g., with perioperative drug administration) may cause life-threatening CR-BSI. We examined the effect of scrub duration on macroscopic contamination of needleless CVC connector hubs to illustrate the importance of hub cleaning. We applied commercially available fluoresceine-impregnated powder (Brevis Corporation, Salt Lake City, UT) to CVC hubs and subsequently scrubbed the hubs with 70% isopropyl alcohol pads for 0 (control), 5, 10, and 15 s. Using ultraviolet light, we exposed residual fluorescent powder on the CVC hub. We found a direct relationship between scrub duration and powder contamination, particularly in areas with complex 3-dimensional topography. The correlation between this finding and the incidence of bacterial contamination is unclear, although Menhay has previously questioned the efficacy of a 3–5 s alcohol scrub for heavily contaminated CVC hubs. Anesthesiologists are encouraged to follow best-practice guidelines for CVC maintenance, including attention to disinfection of CVC hubs with isopropyl alcohol pads before syringe or infusion tubing connection. Future studies are needed to determine whether increasing scrub duration will also reduce bacterial colonization and CR-BSI outcomes.

Diagnostic Errors in a PICU: Insights from the Morbidity and Mortality Conference

Objectives: To describe diagnostic errors identified among patients discussed at a PICU morbidity and mortality conference in terms of Goldman classification, medical category, severity, preventability, contributing factors, and occurrence in the diagnostic process. Design: Retrospective record review of morbidity and mortality conference agendas, patient charts, and autopsy reports. Setting: Single tertiary referral PICU in Baltimore, MD. Patients: Ninety-six patients discussed at the PICU morbidity and mortality conference from November 2011 to December 2012. Interventions: None. Measurements and Main Results: Eighty-nine of 96 patients (93%) discussed at the PICU morbidity and mortality conference had at least one identified safety event. A total of 377 safety events were identified. Twenty patients (21%) had identified misdiagnoses, comprising 5.3% of all safety events. Out of 20 total diagnostic errors identified, 35% were discovered at autopsy while 55% were reported primarily through the morbidity and mortality conference. Almost all diagnostic errors (95%) could have had an impact on patient survival or safety. Forty percent of errors did not cause actual patient harm, but 25% were severe enough to have potentially contributed to death (40% no harm vs 35% some harm vs 25% possibly contributed to death). Half of the diagnostic errors (50%) were rated as preventable. There were slightly more system-related factors (40%) solely contributing to diagnostic errors compared with cognitive factors (20%); however, 35% had both system and cognitive factors playing a role. Most errors involved vascular (35%) followed by neurologic (30%) events. Conclusions: Diagnostic errors in the PICU are not uncommon and potentially cause patient harm. Most appear to be preventable by targeting both cognitive- and system-related contributing factors. Prospective studies are needed to further determine how and why diagnostic errors occur in the PICU and what interventions would likely be effective for prevention.

Association of a Clinical Practice Guideline With Blood Culture Use in Critically Ill Children

Importance Sepsis and septic shock are common and, at times, fatal in pediatrics. Blood cultures are often obtained when clinicians suspect sepsis, yet are low-yield with a false-positive rate up to 50%. Objectives To determine whether a novel, 2-part, clinical practice guideline could decrease the rates of total blood cultures and cultures collected from central venous catheters in critically ill children and to examine the effect of the guideline on patient outcomes. Design, Setting, and Participants A retrospective cohort study was performed to determine the effect of a new clinical practice guideline on blood culture practices in a 36-bed, combined medical/surgical pediatric intensive care unit of an urban, academic, tertiary care center from April 1, 2013, to March 31, 2015. All patients admitted to the pediatric intensive care unit with length of stay of 4 hours or more were evaluated (4560 patient visits: 2204 preintervention, 2356 postintervention visits). Interventions Two documents were developed: (1) fever/sepsis screening checklist and (2) blood culture decision algorithm. Clinicians consulted these documents when considering ordering blood cultures and for guidance about the culture source. Main Outcomes and Measures Primary outcome was the total number of blood cultures collected per 100 patient-days. Results Of the 2204 children evaluated before the intervention, 1215 were male (55.1%); median (interquartile range) age was 5 (1-13) years. Postintervention analysis included 2356 children; 1262 were male (53.6%) and median (interquartile range) age was 6 (1-13) years. A total of 1807 blood cultures were drawn before the intervention during 11 196 patient-days; 984 cultures were drawn after the intervention during 11 204 patient-days (incidence rate, 16.1 vs 8.8 cultures per 100 patient-days). There was a 46.0% reduction after the intervention in the blood culture collection rate (incidence rate ratio, 0.54; 95% CI, 0.50-0.59). After the intervention, there was an immediate 25.0% reduction in the rate of cultures per 100 patient-days (95% CI, 4.2%-39.7%; P = .02) and a sustained 6.6% (95% CI, 4.7%-8.4%; P < .001) monthly decrease in the rate of cultures per 100 patient-days. Significantly fewer cultures were collected from central venous catheters after vs before the intervention (389 [39.5%] vs 1321 [73.1%]; P < .001). Rates of episodes defined as suspected infection and suspected septic shock decreased significantly after the intervention, but patients meeting these criteria underwent cultures at unchanged frequencies before vs after the intervention (52.1% vs 47.0%, P = .09, compared with 56.7% vs 55.0%, P = .75). In-hospital mortality (45 [2.0] vs 37 [1.6]; P = .23) and hospital readmissions (107 [4.9] vs 103 [4.4]; P = .42) were unchanged after the intervention. Conclusions and Relevance A systematic approach to blood cultures decreased the total number of cultures and central venous catheter cultures, without an increase in rates of mortality, readmission, or episodes of suspected infection and suspected septic shock.

The morbidity and mortality conference as an adverse event surveillance tool in a paediatric intensive care unit

Objective To determine if standardised chart review applied to records of patients discussed at a paediatric intensive care unit (PICU) morbidity and mortality conference (MMC) yields additional or different information regarding safety event occurrence and characteristics. Design Retrospective record review. Setting Single tertiary referral PICU in Baltimore, Maryland, USA. Participants 96 patients discussed at the PICU MMC over 14 months (November 2011–December 2012). Main outcome measures Safety events and their characteristics (medical error category, severity and preventability). Results A total of 275 safety events were identified through the MMC and/or chart review. The MMC identified 131 (48%) events, 53 (19%) of which were identified through the MMC alone. After chart review was performed, an additional 144 (52%) events were identified. 78 (28%) events were identified through both. High severity adverse events potentially contributing to permanent harm or death were more likely to be identified through both the MMC and chart review (47%) compared with either alone. The MMC alone identified more near-misses (21%) and preventable events (96%) compared with chart review alone or both MMC and chart review. Although chart review alone helped to identify many healthcare-associated infections, medication errors and sedation/pain control issues not elicited through the MMC, the MMC alone identified more communication errors and workflow problems. The MMC alone also identified 40% of all diagnostic errors, which would not have been discovered otherwise despite chart review by itself identifying 50% of such misdiagnoses. Conclusions Standardised chart review applied to records of patients discussed at a PICU MMC identified significantly more safety events not initially discovered through the MMC. However, the MMC was superior to chart review in identifying broader problems such as communication errors, workflow issues and certain diagnostic errors not captured by chart review, which can potentially affect many aspects of care.

Racial and Ethnic Disparities in Parental Refusal of Consent in a Large, Multisite Pediatric Critical Care Clinical Trial

Objective To evaluate whether race or ethnicity was independently associated with parental refusal of consent for their childs participation in a multisite pediatric critical care clinical trial. Study design We performed a secondary analyses of data from Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE), a 31‐center cluster randomized trial of sedation management in critically ill children with acute respiratory failure supported on mechanical ventilation. Multivariable logistic regression modeling estimated associations between patient race and ethnicity and parental refusal of study consent. Result Among the 3438 children meeting enrollment criteria and approached for consent, 2954 had documented race/ethnicity of non‐Hispanic White (White), non‐Hispanic Black (Black), or Hispanic of any race. Inability to approach for consent was more common for parents of Black (19.5%) compared with White (11.7%) or Hispanic children (13.2%). Among those offered consent, parents of Black (29.5%) and Hispanic children (25.9%) more frequently refused consent than parents of White children (18.2%, P < .0167 for each). Compared with parents of White children, parents of Black (OR 2.15, 95% CI 1.56‐2.95, P < .001) and Hispanic (OR 1.44, 95% CI 1.10‐1.88, P = .01) children were more likely to refuse consent. Parents of children offered participation in the intervention arm were more likely to refuse consent than parents in the control arm (OR 2.15, 95% CI 1.37‐3.36, P < .001). Conclusions Parents of Black and Hispanic children were less likely to be approached for, and more frequently declined consent for, their childs participation in a multisite critical care clinical trial. Ameliorating this racial disparity may improve the validity and generalizability of study findings. Trial registration ClinicalTrials.gov: NCT00814099.

Multistate Outbreak of an Emerging Burkholderia cepacia Complex Strain Associated With Contaminated Oral Liquid Docusate Sodium

To the Editor—We read with interest the article by Marquez et al in which the authors report an epidemiologic investigation into a Burkholderia cepacia complex outbreak among pediatric patients. This prompted a national recall of oral liquid docusate in 2016. Here, we describe a similar outbreak in our pediatric intensive care unit (PICU) from May 19, 2017 to July 30, 2017, that prompted another national product recall. In May 2017, we were notified by our clinical microbiology laboratory of 3 patients in the PICU, all infants with multiple chronic medical conditions who had cultures (1 from blood and 2 from tracheal aspirates) positive for B. cepacia within the same week. A thorough review of the patients’ history, exposures and medications was conducted. Given the commonality of mechanical ventilation, we focused on possible respiratory sources of infection or exposure to previously recalled oral liquid docusate products. We did not identify common respiratory medications or equipment exposures among cases and all environmental cultures were negative for B. cepacia. As part of the outbreak investigation, bacterial isolates from cases were analyzed by the Maryland Department of Health (MDH) using pulsed-field gel electrophoresis and by the Burkholderia cepaciaResearch Laboratory andRepository (BCRLR) at the University of Michigan using repetitive extragenic palindromic polymerase chain reaction (rep-PCR). The isolates from the 3 cases were closely related, suggesting a common exposure. The BCRLRdesignated this strain “1072,”whichwas different from the B. cepacia strain associated with the 2016 docusate outbreak. Additionally, external communications revealed that 2 critically ill infants at another hospital were infected with a similar strain of B. cepacia, raising concern for a multistate outbreak. Five weeks after the initial cases, another critically ill infant with a prolonged PICU admission had a respiratory culture that grew B. cepacia strain 1072. Investigators fromMDH visited our facility to review infection control practices and helped coordinate investigations among our hospital, the Centers for Disease Control and Prevention (CDC), and other hospitals with suspect Burkholderia cases. Lists of medications dispensed to all cases were compared among the affected hospitals. Two months after the initial cases, a fifth case was identified in a ventilated PICU patient whose urine culture grew B. cepacia strain 1072. Due to concerns for ongoing local transmission, universal contact precautions for all PICU patients was initiated. Our institution debuted real-time video surveillance of healthcare workers behavior with instant verbal feedback on hand hygiene compliance and adherence to standard and contact precautions. We also conducted targeted surveillance cultures. No additional respiratory cultures were positive; however, 2 stool cultures were positive for B. cepacia strain 1072. The investigation timeline is depicted in Figure 1. A CDC epidemiologist noted that the National Drug Code (NDC) for oral liquid docusate from the manufacturer associated with the 2016 docusate outbreak (NDC 0536-0590-85) appeared in medication administration data for case patients at another hospital, and an infection preventionist at our hospital determined that docusate with this NDC had also been administered to case patients at our hospital. Based on this finding, we provided opened and unopened bottles of docusate to the CDC and US Food and Drug Administration for culture. In late July, we were informed that an open bottle of liquid docusate grew B. cepacia, after which all docusate products from the implicated manufacturer were removed from our patient care areas and pharmacies. Burkholderia cepacia isolated from the opened docusate bottle was confirmed as strain 1072, implicating the contaminated oral liquid docusate as the likely common source of infections at the hospitals with affected patients. In early August, there was a voluntary recall of liquid docusate due to contamination concerns and later that week, a broader recall of additional liquid medications took place. Respiratory and bloodstream infections after exposure to an enteral medication are somewhat unexpected. We speculate that B. cepacia might have colonized and infected infants via aspiration of enteral fluids, translocation across the enteric mucosa or migration into the genitourinary tract from the gastrointestinal tract, putting the most critically ill patients at highest risk. We learned several unique lessons from this experience: (1) Identification of respiratory sites of infection should not limit investigation to only respiratory-related sources. (2) Despite early identification of a bacterial strain different from that implicated in previously recalled products, outbreak investigators should maintain a high level of suspicion and use NDC codes to identify common products or manufacturers. (3) Rapid reporting to and involvement of federal, state and local agencies in outbreak investigations can help identify a common exposure and support identification of pathogenic bacteria in medications and other products. In addition, access to a national reference laboratory for molecular typing was invaluable in this investigation and outbreak confirmation. (4) While there are no national guidelines on disclosure to patients and families in outbreak investigations, clinicians should provide clear and effective communication. Throughout this

Becoming Parent and Nurse: High-Fidelity Simulation in Teaching Ambulatory Central Line Infection Prevention to Parents of Children with Cancer

BACKGROUND Ambulatory central-line infections in children with cancer are life-threatening. Infections are two to three times more frequent in outpatients than inpatients, for whom evidence-based bundles have decreased morbidity. Most cancer care now takes place at home, where parents perform many of the same tasks as nurses. However, parents often feel stressed and unprepared. To address this, high-fidelity simulation, which has been effective for teaching novice nurses, was evaluated for parent central-line education. METHODS In a feasibility study using a pretest/posttest design, after completion of usual central-line education, parents participated in a high-fidelity simulation practice session. Parents were assessed in three domains: (1) knowledge of infection prevention; (2) psychomotor skill competence; and (3) ability to recognize health care provider nonadherence to best practices. Parents also completed a 5-point Likert simulation experience survey. RESULTS A convenience sample of 17 parents participated between December 2015 and March 2016. Knowledge median scores increased from pre- to posttest from 10 to 15 of 16 points possible (p ≤ 0.001; Wilcoxon signed rank test). Median skills scores increased from pre- to posttest from 8 to 12 points of 12 possible (p ≤ 0.001). Following simulation, median recognition scores increased from 3 to 6 with 6 points possible (p ≤ 0.001). For the parent experience survey, 100% of participants strongly agreed or agreed that simulation was meaningful for learning central-line care. CONCLUSIONS As an adjunct to usual care central-line education, translation of high-fidelity simulation to parent education is a novel approach that shows promise for improving central-line care at home in children with cancer.

929: EVALUATING THE IMPACT OF COMMUNICATION TECHNOLOGY ON PICU INTERDISCIPLINARY ROUNDS

Crit Care Med 2015 • Volume 43 • Number 12 (Suppl.) Foley care events by 30 min and reduce maximum hr between Foley Care events from 16.5 hr to 13 hr from April to July of 2015. Since the implementation of the Safety Cross, May 2015, there has not been a CAUTI recorded on the MICU. Conclusions: Volunteers are an integral part to implementing a successful CQI program within a medical ICU, without requiring large additional system resources. Utilizing volunteers to complete Foley care chart abstraction, communicate with nursing staff, and create data visuals has led to a reduction in average time between Foley care.