Multidisciplinary Review of Code Events in a Heart Center.

OBJECTIVE: To identify a cause for clinical deterioration, examine resuscitation efforts, and identify and correct system issues (thus improving outcomes) via a multidisciplinary code-review process soon after cardiopulmonary arrest. METHODS: Retrospective analysis of code events in a tertiary pediatric heart center from September 2010 to December 2013 and review of surgical-cardiac data from January 2010 to December 2013. RESULTS: A multidisciplinary team reviewed 47 code events, 16 of which (34%) were deemed potentially preventable. At least 2 issues were identified during 66% (31/47) of cardiopulmonary arrests reviewed. Key issues identified were related to communication (62%), environment/culture/policy (47%), patient care (including resuscitation, 41%), and equipment (38%). About 60% of reviewed arrests resulted in educational initiatives (eg, mock code, in-service education) and 47% resulted in a new policy or modification of existing policy. Less common were changes in equipment (32%) or modification of staffing needs (11%). Changes most frequently occurred in the unit specific to the event (68%) but some changes occurred throughout the Heart Center (32%) or across the hospital system (13%). Survival to discharge after cardiopulmonary arrest has improved over time (P = .03) to 81% for cardiac surgical patients in our center. CONCLUSION: A multidisciplinary code-review committee can identify deficiencies and lead to educational initiatives and improvements in care. When coupled with a hospital-wide "code blue" review process, these changes may benefit the institution as a whole.

Improving Surveillance and Prevention of Surgical Site Infection in Pediatric Cardiac Surgery.

BACKGROUND: Postoperative cardiovascular surgical site infections are preventable events that may lead to increased morbidity, mortality, and health care costs. OBJECTIVE: To improve surgical wound surveillance and reduce the incidence of surgical site infections. METHODS: An institutional review of surgical site infections led to implementation of 8 surveillance and process measures: appropriate preparation the night before surgery and the day of surgery, use of appropriate preparation solution in the operating room, appropriate timing of preoperative antibiotic administration, placement of a photograph of the surgical site in the patient's chart at discharge, sending a photograph of the surgical site to the patient's primary care physician, 30-day follow-up of the surgical site by an advanced nurse practitioner, and placing a photograph of the surgical site obtained on postoperative day 30 in the patient's chart. RESULTS: Mean overall compliance with the 8 measures from March 2013 through February 2014 was 88%. Infections occurred in 10 of 417 total operative cases (2%) in 2012, in 8 of 437 total operative cases (2%) in 2013, and in 7 of 452 total operative cases (1.5%) in 2014. CONCLUSIONS: Institution of the surveillance process has resulted in improved identification of suspected surgical site infections via direct rather than indirect measures, accurate identification of all surgical site infections based on definitions of the National Healthcare Safety Network, collaboration with all persons involved, and enhanced communication with patients' family members and referring physicians.

Increasing parental participation during rounds in a pediatric cardiac intensive care unit.

BACKGROUND: Inviting parents of sick children to participate during the rounding process may reduce parents' anxiety and improve communication between the parents and the health care team. OBJECTIVES: To increase the percentage of available parents invited to participate in morning rounds in a pediatric cardiothoracic intensive care unit (CTICU). METHODS: Invitations to parents to participate in morning CTICU rounds were randomly audited from June 2012 to April 2014 (mean, 15 audits per month). From June 2012 to February 2013 (before intervention), 73% of parents available during morning rounds received an invitation to participate. From April 2013 to May 2013, the following interventions (family participation bundle) were implemented: (1) staff education, (2)"Invitation to Rounds" handout added to the parent welcome packet with verbal explanation, (3) bedside tool provided for parents to communicate desire to participate in rounds with the team, (4) reminder to invite parents added to nursing rounding sheet. Following interventions, family feedback was obtained by 1-on-1 (physician-parent) open-ended conversation. RESULTS: From April 2013 to April 2014, 94% of parents available during morning rounds received an invitation to participate. Reasons for not participating: chose not to participate (63%), sleeping-staff reluctant to wake (25%), not English speaking (7%), breastfeeding (5%). CONCLUSION: Implementation of a family participation bundle was successful in increasing invitations to parents to participate during morning rounds in the CTICU. Engagement of staff and addressing specific staff concerns was instrumental in the project's success.

Reduction of medication errors in a pediatric cardiothoracic intensive care unit.

Medication errors resulting in patient harm were reduced from 33 in 2010 to 3 in 2011, 6 in 2012, and 4 in 2013 by initiating the following quality improvement interventions: multidisciplinary cardiothoracic intensive care unit quality committee, nursing education, shift change medication double check, medication error huddles, safety systems checklist, distraction-free zone to enter orders, and medication bar coding.

Reducing variation in the use of inhaled nitric oxide.

BACKGROUND AND OBJECTIVE: Decreasing practice variation and following clinical guidelines improve patient outcomes and reduce costs. Inhaled nitric oxide (iNO) is an effective but expensive treatment of pulmonary hypertension and right heart failure in patients with congenital or acquired heart disease. Our objective was to implement standardized initiation and weaning guidelines for iNO usage in the cardiothoracic ICU (CTICU) to reduce variation in use while maintaining quality patient care. METHODS: All CTICU patients who received iNO from January 2011 to December 2012 were retrospectively reviewed. Standardized iNO initiation and weaning guidelines were implemented in January 2012. Variables before and after guideline implementation were compared. RESULTS: From January to December 2011, there were 36 separate iNO events (6% of CTICU admissions; n = 547). Mean ± SD iNO usage per event was 159 ± 177 hours (median: 63 hours; range: 27-661 hours). From January to December 2012, there were 47 separate iNO events (8% of CTICU admissions; n = 554). Mean iNO usage per event was 125 ± 134 hours (median: 72 hours; range: 2-557 hours). Initiation guideline compliance improved from 83% to 86% (P = .9); weaning guideline compliance improved from 17% to 79% (P < .001). Although mean iNO usage per event decreased, there was no significant reduction in utilization of iNO (P = .09). CONCLUSIONS: Implementation of standardized iNO initiation and weaning guidelines in the CTICU was successful in reducing practice variation supported by increasing guideline compliance. However, decreasing practice variation did not significantly reduce iNO utilization and does not necessarily reduce cost.

Quality improvement methodologies increase autologous blood product administration.

Whole blood from the heart-lung (bypass) machine may be processed through a cell salvaging device (i.e., cell saver [CS]) and subsequently administered to the patient during cardiac surgery. It was determined at our institution that CS volume was being discarded. A multidisciplinary team consisting of anesthesiologists, perfusionists, intensive care physicians, quality improvement (QI) professionals, and bedside nurses met to determine the challenges surrounding autologous blood delivery in its entirety. A review of cardiac surgery patients' charts (n = 21) was conducted for analysis of CS waste. After identification of practices that were leading to CS waste, interventions were designed and implemented. Fishbone diagram, key driver diagram, Plan-Do-Study-Act (PDSA) cycles, and data collection forms were used throughout this QI process to track and guide progress regarding CS waste. Of patients under 6 kg (n = 5), 80% had wasted CS blood before interventions, whereas those patients larger than 36 kg (n = 8) had 25% wasted CS before interventions. Seventy-five percent of patients under 6 kg who had wasted CS blood received packed red blood cell transfusions in the cardiothoracic intensive care unit within 24 hours of their operation. After data collection and didactic education sessions (PDSA Cycle I), CS blood volume waste was reduced to 5% in all patients. Identification and analysis of the root cause followed by implementation of education, training, and management of change (PDSA Cycle II) resulted in successful use of 100% of all CS blood volume.