Effectiveness of implementing a standardized perioperative pain management protocol in children undergoing tonsillectomy: A quality improvement project.

BACKGROUND AND PURPOSE: Tonsillectomy procedures are commonly performed worldwide. At our academic tertiary care facility, we perform approximately 1000 tonsillectomy procedures annually. We have found inconsistent pain management strategies in pediatric tonsillectomy patients have contributed to variability in postoperative complications and the number and types of postoperative pain medications required in the Post Anesthesia Care Unit (PACU). This project aimed to assess the impact of implementing a standardized perioperative pain management protocol on reducing postoperative complications in pediatric patients who underwent a tonsillectomy procedure. METHODS: A pre-post-intervention design was utilized, comparing characteristics and outcomes of pediatric patients for whom a standardized perioperative pain management protocol was implemented over a 12-week period compared to those who did not. The standardized perioperative pain management protocol was utilized intraoperatively by the anesthesiologists, nurse anesthetists, and residents. A Qualtrics survey was used by the Post Anesthesia Care Unit (PACU) nurses to gather data as they cared for patients who underwent tonsillectomy. Four outcomes were measured: (1) postoperative pain medication administration, (2) rate of postoperative respiratory complications, (3) rate of adherence, and (4) usability of a standardized pain management protocol. Data were compared between pre and post-implementation groups. RESULTS: During the quality improvement project, 180 children underwent tonsillectomy, with 81 in the control group and 99 in the intervention group. The median age did not differ between groups. The control group had higher postoperative opioid medication usage (93.8% vs. 54.5%) and a higher number of opioids administered in the recovery room. Postoperative IV fentanyl was reduced in the intervention group (49.4% vs. 28.3% in the intervention, p = .004). Respiratory interventions were more frequent in the control group (24.7% vs. 7.1%), with increased respiratory team activation. Respiratory team activation in the Post Anesthesia Care Unit (PACU) includes a 511 page for anesthesia provider assistance. Respiratory interventions included bag-mask ventilation, lidocaine, propofol or succinylcholine administration, and reintubation. The intervention group had 100% adherence to the pain management protocol, and providers found it easy to use. CONCLUSION: The quality improvement project highlighted notable improvements in the intervention group for whom a standardized perioperative pain management protocol was used, including reduced opioid medication administration, lower incidence of respiratory interventions, and high adherence to the pain management protocol. These findings underscore the effectiveness and feasibility of standardized protocols in enhancing patient outcomes.

A machine-learning approach for decision support and risk stratification of pediatric perioperative patients based on the APRICOT dataset.

BACKGROUND: Pediatric anesthesia has evolved to a high level of patient safety, yet a small chance remains for serious perioperative complications, even in those traditionally considered at low risk. In practice, prediction of at-risk patients currently relies on the American Society of Anesthesiologists Physical Status (ASA-PS) score, despite reported inconsistencies with this method. AIMS: The goal of this study was to develop predictive models that can classify children as low risk for anesthesia at the time of surgical booking and after anesthetic assessment on the procedure day. METHODS: Our dataset was derived from APRICOT, a prospective observational cohort study conducted by 261 European institutions in 2014 and 2015. We included only the first procedure, ASA-PS classification I to III, and perioperative adverse events not classified as drug errors, reducing the total number of records to 30 325 with an adverse event rate of 4.43%. From this dataset, a stratified train:test split of 70:30 was used to develop predictive machine learning algorithms that could identify children in ASA-PS class I to III at low risk for severe perioperative critical events that included respiratory, cardiac, allergic, and neurological complications. RESULTS: Our selected models achieved accuracies of >0.9, areas under the receiver operating curve of 0.6-0.7, and negative predictive values >95%. Gradient boosting models were the best performing for both the booking phase and the day-of-surgery phase. CONCLUSIONS: This work demonstrates that prediction of patients at low risk of critical PAEs can be made on an individual, rather than population-based, level by using machine learning. Our approach yielded two models that accommodate wide clinical variability and, with further development, are potentially generalizable to many surgical centers.

Adaptive Care for Perioperative Patients With Developmental Disabilities: An Exploration of Interventions and Family Experience.

INTRODUCTION: Patients with developmental disabilities commonly experience psychological distress during health care visits. There is limited research describing which individualized interventions are being implemented to promote optimal care in the perioperative area. METHOD: In this prospective observational study of 60 patients with developmental diagnoses, aged 3-21 years, we recorded adaptive care plan (ACP) interventions and assessed family experience. RESULTS: Patients receiving ACPs had diverse diagnoses, including autism spectrum and 10 other unique syndromes. Most patients received previsit planning (90%), adaptations to standard protocols (60%), child life specialist preparation (67%), procedural support (90%), and were given fast-acting anxiolytics before anesthesia induction (68%). Families reported that ACPs were important for managing a child's stress (94%) and promoting safety (92%). DISCUSSION: ACPs promote safe, productive health care encounters for patients with various diagnoses, ages, and coping abilities. Families find ACPs important for stress management and promoting safety.

How the Wake Up Safe pediatric anesthesia collaborative increased quality improvement capability and collaboration.

Wake Up Safe is a patient safety organization consisting of 40 institutions with a mission to improve the processes of care and outcomes for newborns, infants, and children having anesthesia for surgery and medical procedures. It was recognized that the level of quality improvement (QI), knowledge, and experience varied greatly between member institutions. In Fiscal Year 2015, the group's leadership created a subcommittee on QI and education in efforts to provide member institutions with the skills and resources to use QI methodology to improve care at their own institution. This subcommittee developed a program to improve members' knowledge in safety analytics and QI science and to help members implement change in their own institutions. This review describes the development and implementation of this initiative. As a result of this initiative, significant progress was made improving the QI capability of the collaborative over a two-year period. This educational and support program included workshops, an online discussion forum, site visits, and project presentations.

Timely completion of spinal fusion: A multidisciplinary quality improvement initiative to improve operating room efficiency.

BACKGROUND: Failure to complete surgery within the scheduled timeframe impairs operating room efficiency leading to patient dissatisfaction and unplanned labor costs. We sought to improve timely completion (within 30 min of scheduled time) of first-case spine fusion surgery (for idiopathic scoliosis) from a baseline of 25%-80% over 12 months. We also targeted timely completion of perioperative stages within predetermined target completion times. METHODS: The project was conducted in three overlapping phases over 16 months. A simplified process map outlining five sequential perioperative stages, preintervention baselines (N = 24) and time targets were defined. A multidisciplinary team conducted a series of tests of change addressing the aims. The key drivers included effective scheduling, team communications, family engagement, data collection veracity, standardized pathways, and situational awareness. Data collected by an independent data collector and from electronic medical records were analyzed using control charts and statistical process control methods. RESULTS: Post-intervention, timely case completion increased from 25% to 68% (N = 49) (95% CI 15.1-62.7), (p = 0.003) and was sustained (N = 14). Implementation of prediction model for case-scheduling decreased difference between scheduled and actual case end-time (33 vs. 53 min [baseline]) and variance [lower/upper control limits ([-26, 51] vs. [-109, 216] min [baseline]). Average start time delay decreased from 6 to 2 min and on-time surgical starts improved from 50% to 70% (95% CI 3.2-41.6%). Timely completion increased for anesthesia induction (60% to 85%), surgical procedure (26% to 48%) and emergence from anesthesia (44% to 80%) but not for intraoperative patient preparation (30% to 25%) perioperative stages. Families reported satisfaction with preoperative processes (N = 14), and no untoward intraoperative safety events occurred. CONCLUSIONS: Application of QI methodology reduced time variation of several tasks and improved timely completion of spine surgery. Beyond the study period, sustained team behavior, adaptive changes, and vigilant monitoring are imperative for continued success.

Optimizing Pediatric Induction Experiences Using Human-centered Design.

PURPOSE: Anesthesia inhalation induction (falling asleep for a surgery using a medical mask) is often stressful for children. When children become anxious about induction, they may resist wearing the anesthesia mask. High anxiety during induction is associated with poorer outcomes after surgery, such as increased emergence delirium, increased pain and negative behavioral changes after discharge. The purpose of this project was to design an optimal anesthesia induction experience for children, with a focus on decreasing patient anxiety during inhalation induction. DESIGN: Designing for the perioperative environment requires in-depth knowledge of existing processes, needs of key stakeholders, strengths/shortcomings of existing approaches, and iterative testing of design concepts. We used a human centered design model (design research) to approach this challenge. METHODS: Hospital staff partnered with a design team at the Live Well Collaborative. Families and staff were consulted during all phases of the design process. The iterative design research process (research, ideation, refinement) was used to develop product and process concepts for optimizing the induction experience. Requirements for an optimal induction experience were defined during the research phase through reviewing the scientific literature, process mapping and benchmarking with other products. Product and process concepts were developed during the ideation phase. Concepts were tested and refined during the refinement phase. FINDINGS: The research phase provided insights about the current anesthesia induction process and what interventions help engage children in medical care. Key insights included normalizing the anesthesia mask through medical play, providing patients with an increased sense of control preoperatively and during induction, and engaging multiple senses during the process. The ideation phase led to the development of several design concepts, including an app that is activated by breathing into the anesthesia mask. During the refinement phase, concepts were shared and refined with input from families and clinical staff. This phase led to the development of a novel zoo-themed gaming app. CONCLUSIONS: The design research process facilitated the creation of a new anxiety reduction tool for the perioperative environment. The breath-controlled induction app simultaneously employs multiple evidence-based anxiety reduction techniques and is designed to seamlessly integrate into the fast-paced perioperative workflow during key stress points. Testing in the clinical setting is needed to determine the effectiveness of the app for preoperative anxiety reduction.

How do we measure organisational wellness? Development of a comprehensive patient-centred and employee-centred visual analytical solution.

BACKGROUND: Dashboards are visual information systems frequently employed by healthcare organisations to track key quality improvement and patient safety performance metrics. The typical healthcare dashboard focuses on specific metrics, disease processes or units within a larger healthcare organisation. Here, we describe the development of a visual analytical solution (keystone dashboard) for monitoring an entire healthcare organisation. METHODS: The improvement team reviewed and assessed various data sources across the organisation and selected a group of patient and employee related metrics that afforded a broad overview of the organisation's well-being. Metrics spanned the organisation and included data from patient safety, quality improvement, human resources, risk management and medical staff affairs. Each metric was assigned a numeric weight that correlated with its impact. A visual model incorporating the various data fields was then constructed. RESULTS: The keystone dashboard incorporates a data heatmap and density visualisation to emphasis areas of higher density and/or weighted values. The heatmap is used to indicate the weight/magnitude of each metric within a data range in two dimensions: location and time. The visualisation 'heats up' depending on the combination of counts events and their assigned impact for the reporting month. Most data sources update in near real time. SUMMARY: The keystone dashboard serves as a comprehensive and collaborative integration of data from patient safety, quality improvement, human resources, risk management and medical staff affairs. This visual analytical solution incorporates and analyses metrics into a single view with the intent of providing valuable insight into the health of an entire organisation. This dashboard is unique as it provides a broad overview of a healthcare organisation by incorporating key metrics that span the organisation.

Factors Associated With Postadenotonsillectomy Unexpected Admissions in Children.

BACKGROUND: Postadenotonsillectomy unexpected admission remains an important challenge. Unexpected admissions can be quite frightening, increase health care burden, and cause unnecessary suffering in children and families. Identifying factors associated with postadenotonsillectomy unexpected admissions using a pragmatic approach could lead to a shift in the assessment and management of children presenting for adenotonsillectomy. METHODS: Institutional review board (IRB) approval, consent, and assent were obtained for this single-center, prospective, observational study done in children aged 0-17 years undergoing tonsillectomy. Data were collected from direct observation, electronic medical record, and phone calls using Research Electronic Data Capture (REDCap) database. Incidence, causes, and factors associated with 3-week and 3-day postadenotonsillectomy unexpected admissions were analyzed. RESULTS: The study included 2375 children. Clinical intraoperative adverse events were reported in 6.2%. Three-week and 3-day unexpected admissions occurred in 7.9% and 5.9%, respectively, with bleeding being the commonest reason for both. On multivariable analysis, for 3-week unexpected admissions, the odds ratio was 2.3 (95% confidence interval, 1.44-3.76) with using preoperative medications, 1.4 (1.02-1.97) with home medications for comorbidities, 0.56 (0.34-0.90) with using intraoperative acetaminophen, and 0.60 (0.36-0.94) with otolaryngologic preoperative comorbidity versus otherwise. For 3-day unexpected admissions, the odds ratio was 1.10 (1.05-1.16) with 1 U increase in total comorbidities, 1.70 (1.03-2.81) with the presence of recent upper respiratory infection, and 1.83 (1.16-2.90) with intravenous versus inhalational anesthesia induction. CONCLUSIONS: Overall, our study shows the factors that contribute to unexpected admissions postadenotonsillectomy. Identification of both modifiable and nonmodifiable factors associated with unexpected admissions after adenotonsillectomy will enable appropriate risk mitigation.

Validation of a Simple Tool for Electronic Documentation of Behavioral Responses to Anesthesia Induction.

BACKGROUND: Anxiety and distress behaviors during anesthesia induction are associated with negative postoperative outcomes for pediatric patients. Documenting behavioral responses to induction is useful to evaluate induction quality at hospitals and to optimize future anesthetics for returning patients, but we lack a simple tool for clinical documentation. The Induction Compliance Checklist is a tool for grading induction behaviors that is well validated for research purposes, but it is not practical for routine documentation in busy clinical practice settings. The Child Induction Behavioral Assessment tool was developed to provide a simple and easy to use electronic tool for clinical documentation of induction behaviors. The aim of this study was to test the Child Induction Behavioral Assessment tool's concurrent validity with the Induction Compliance Checklist and the interrater reliability. METHODS: This prospective, observational study included 384 pediatric patients undergoing anesthesia inhalation induction. Concurrent validity with the Induction Compliance Checklist and interrater reliability of the Child Induction Behavioral Assessment were evaluated. Two researchers alternated scoring the Induction Compliance Checklist. The 2 researchers independently scored the Child Induction Behavioral Assessment. The anesthesia clinician caring for the patient also independently scored the Child Induction Behavioral Assessment by completing their routine documentation in the patient's medical record. Two age groups were evaluated (ages 1-3 and 4-12 years old). RESULTS: Clinicians' and researchers' Child Induction Behavioral Assessment scores demonstrated a strong correlation with the Induction Compliance Checklist (P < .0001). There was an excellent agreement between the 2 researchers' Child Induction Behavioral Assessment scores for the younger and older age groups, respectively (Kappa [95% CI] = 0.97 (0.94-0.99); K = 0.94 (0.89-0.99)]. The agreement between the researchers and the 117 clinicians who documented Child Induction Behavioral Assessment assessments in the medical record was good overall (intraclass correlation coefficient = 0.70), with fair agreement with the 1- to 3-year-old patients (intraclass correlation coefficient = 0.56) and good agreement for the 4- to 12-year-old patients (intraclass correlation coefficient = 0.74). CONCLUSIONS: The Child Induction Behavioral Assessment scale is a simple and practical electronic tool used to document pediatric behavioral responses to anesthesia inductions. This study provides evidence of the tool's validity and reliability for inhalation inductions. Future research is needed at other hospitals to confirm validity.

Quality Initiative Using Theory of Change and Visual Analytics to Improve Controlled Substance Documentation Discrepancies in the Operating Room.

BACKGROUND: Discrepancies in controlled substance documentation are common and can lead to legal and regulatory repercussions. We introduced a visual analytics dashboard to assist in a quality improvement project to reduce the discrepancies in controlled substance documentation in the operating room (OR) of our free-standing pediatric hospital. METHODS: Visual analytics were applied to collected documentation discrepancy audit data and were used to track progress of the project, to motivate the OR team, and in analyzing where further improvements could be made. This was part of a seven-step improvement plan based on the Theory of Change with a logic model framework approach. RESULTS: The introduction of the visual analytics dashboard contributed a 24% improvement in controlled substance documentation discrepancy. The project overall reduced documentation errors by 71% over the studied period. CONCLUSION: We used visual analytics to simultaneously analyze, monitor, and interpret vast amounts of data and present them in an appealing format. In conjunction with quality-improvement principles, this led to a significant improvement in controlled substance documentation discrepancies.

Increasing compliance of safe medication administration in pediatric anesthesia by use of a standardized checklist.

BACKGROUND: Medication errors pose a significant risk perioperatively. In the perioperative environment, common medication administration processes are not typically performed. Given the common administration of potentially harmful medications and the potential for medication errors, patient risk is substantial. Specifically, intravenous acetaminophen has been used more frequently in the perioperative period which yielded an increase in medication administration errors reported. AIMS: This project was initiated by Cincinnati Children's Hospital after an increase in perioperative acetaminophen dosing errors was reported. After mapping the administration process of perioperative acetaminophen, we sought to reduce medication errors by the use of a safety checklist. Acetaminophen was used as a surrogate for other perioperative medications in this quality improvement project. METHODS: Use of a failure mode effects analysis assisted the team in understanding the failures of the process of safe medication administration. Subsequently, key drivers of this process were designed to include accurate understanding and documentation of medication history, consistent communication between perioperative caregivers, and an efficient checklist process. A multidisciplinary team conducted a series of tests to modify key drivers. Data were collected by utilizing data from a paper checklist, prior to the electronic medical record change that was prompted by this study. A total of 633 checklists and electronic medical records were analyzed during a 6-month period; data were analyzed using control charts and statistical process control methods. RESULTS/ANALYSIS: The percentage of compliance with the safe administration checklist for acetaminophen in the preoperative period increased to 97%. Use of the paper checklist likely prompted the appropriate increase in compliance with safe administration. Additionally, provider-specific feedback produced a significant increase in compliance with the use of the checklist. CONCLUSION: Application of quality improvement methods, specifically a safety checklist, were utilized to improve the safe administration of acetaminophen during the perioperative period. Increasing reliability of accurate delivery and administration of medication to patients are crucial in optimizing patient safety. Use of a medication safety checklist may be beneficial in reducing potential administration errors, specifically for high-risk medications.

A quality improvement project to reduce postoperative adverse respiratory events and increase safety in the postanesthesia care unit of a pediatric institution.

BACKGROUND: Quality improvement methods can identify solutions and make dramatic improvements in patient safety during daily clinical care. The science of quality improvement in healthcare is still a very new concept in developing countries like China. AIMS: We initiated a quality improvement project to minimize adverse respiratory events in our postanesthesia care unit with the guidance of an experienced quality improvement expert from Cincinnati Children's Hospital Medical Center. METHODS: We set up a quality improvement team that included anesthesia safety team members at Shanghai Children's Medical Center, and a quality improvement expert in pediatric anesthesia from Cincinnati Children's Hospital Medical Center. Data from the previous year were reviewed. After using Failure Mode and Effect Analysis to access risks associated with the current process, a Key Driver Diagram and a Smart Aim were developed. Key drivers included establishing a safety culture, resource allocation to meet needs, education and training, standardization of care, improved communication and handoff, and enhanced detection, recognition, and response to adverse events. Using Plan-Do-Study-Act cycles of the improvement model, interventions were conducted to improve the process. The primary outcome was the percentage of postoperative respiratory adverse events in the postanesthesia care unit, and we calculated the average recovery time as a balancing measure. Data were collected and analyzed using a run chart and control chart. RESULTS: The median percentage of respiratory adverse events in postanesthesia care unit decreased from 2.8% to 1.4%. Respiratory adverse events were reduced by over 30% compared to the previous period with no significant change in mean recovery time. CONCLUSION: Using quality improvement methods, we successfully reduced the percentage of respiratory adverse events in the postanesthesia care unit. This helped to establish a safety culture among the anesthesia staff. Quality and safety improvement can be successfully implemented in developing countries like China with collaboration with quality improvement experts from more experienced institutions.

The Child Induction Behavioral Assessment Tool: A Tool to Facilitate the Electronic Documentation of Behavioral Responses to Anesthesia Inductions.

PURPOSE: The purpose of this study was to develop and implement an electronic tool for documenting pediatric patients' behavioral responses to anesthesia induction. DESIGN: Quality improvement methodology was used in the tool development and implementation. METHODS: The Child Induction Behavioral Assessment (CIBA) tool was developed based upon existing validated tools and through discussions with content experts and key stakeholders. Staff usage of the tool was monitored and the clinical utility of the tool was assessed. FINDINGS: The CIBA tool facilitated frequent documentation of behavioral responses to inductions. The majority of clinicians reported that they found the prior CIBA ratings useful when developing induction plans for returning patients. CONCLUSIONS: Electronic documentation using the CIBA tool may provide useful information for optimizing induction plans for returning patients. Future research is needed to directly test the CIBA tool's validity.

Infusion Medication Error Reduction by Two-Person Verification: A Quality Improvement Initiative.

OBJECTIVE: Errors made in the administration of intravenous medication can lead to catastrophic harm. The frequency of hospital settings in which medication pumps are being used are increasing. We sought to improve medication safety by implementing a 2-person verification system before medication administration. METHODS: Our quality improvement initiative took place in an anesthesia radiology imaging service at a tertiary pediatric hospital. Key drivers included frequent educational meetings with clinicians, written reminders, display of visual reminders, constant feedback in the clinical areas that carried out the processes, and sharing of knowledge on displayed run charts. A multidisciplinary team conducted a series of tests of changes to address the interventions. Data were collected and entered into a database by an independent and impartial data collector. Data were analyzed via run charts and statistical process control methods. RESULTS: The team ran 24 plan-do-study-act ramps. The rate of 2-person verification of infusion pump programming increased from 0% to 90% and was sustained. Overall, 4 errors were rectified before the medication was administered to the patient. There was no delay in case starts (>90% before and during the project). This project played a key role, as part of a larger initiative within the department of anesthesia, in reducing medication errors. CONCLUSIONS: A brief 2-person verification approach can reduce medication errors due to inaccurate infusion pump programming. This improvement was achieved with the use of plan-do-study-act cycles. The impact can be significant and will promote a hospital safety culture.

Perioperative Respiratory Adverse Events in Pediatric Ambulatory Anesthesia: Development and Validation of a Risk Prediction Tool.

BACKGROUND: Perioperative respiratory adverse events (PRAEs) are the most common cause of serious adverse events in children receiving anesthesia. Our primary aim of this study was to develop and validate a risk prediction tool for the occurrence of PRAE from the onset of anesthesia induction until discharge from the postanesthesia care unit in children younger than 18 years undergoing elective ambulatory anesthesia for surgery and radiology. The incidence of PRAE was studied. METHODS: We analyzed data from 19,059 patients from our department's quality improvement database. The predictor variables were age, sex, ASA physical status, morbid obesity, preexisting pulmonary disorder, preexisting neurologic disorder, and location of ambulatory anesthesia (surgery or radiology). Composite PRAE was defined as the presence of any 1 of the following events: intraoperative bronchospasm, intraoperative laryngospasm, postoperative apnea, postoperative laryngospasm, postoperative bronchospasm, or postoperative prolonged oxygen requirement. Development and validation of the risk prediction tool for PRAE were performed using a split sampling technique to split the database into 2 independent cohorts based on the year when the patient received ambulatory anesthesia for surgery and radiology using logistic regression. A risk score was developed based on the regression coefficients from the validation tool. The performance of the risk prediction tool was assessed by using tests of discrimination and calibration. RESULTS: The overall incidence of composite PRAE was 2.8%. The derivation cohort included 8904 patients, and the validation cohort included 10,155 patients. The risk of PRAE was 3.9% in the development cohort and 1.8% in the validation cohort. Age ≤ 3 years (versus >3 years), ASA physical status II or III (versus ASA physical status I), morbid obesity, preexisting pulmonary disorder, and surgery (versus radiology) significantly predicted the occurrence of PRAE in a multivariable logistic regression model. A risk score in the range of 0 to 3 was assigned to each significant variable in the logistic regression model, and final score for all risk factors ranged from 0 to 11. A cutoff score of 4 was derived from a receiver operating characteristic curve to determine the high-risk category. The model C-statistic and the corresponding SE for the derivation and validation cohort was 0.64 ± 0.01 and 0.63 ± 0.02, respectively. Sensitivity and SE of the risk prediction tool to identify children at risk for PRAE was 77.6 ± 0.02 in the derivation cohort and 76.2 ± 0.03 in the validation cohort. CONCLUSIONS: The risk tool developed and validated from our study cohort identified 5 risk factors: age ≤ 3 years (versus >3 years), ASA physical status II and III (versus ASA physical status I), morbid obesity, preexisting pulmonary disorder, and surgery (versus radiology) for PRAE. This tool can be used to provide an individual risk score for each patient to predict the risk of PRAE in the preoperative period.

Interventions designed using quality improvement methods reduce the incidence of serious airway events and airway cardiac arrests during pediatric anesthesia.

BACKGROUND: Although serious complications during pediatric anesthesia are less common than they were 20 years ago, serious airway events continue to occur. Based on Quality Improvement (QI) data from our institution, a QI project was designed to reduce the incidence of serious airway events and airway cardiac arrests. METHODS: A quality improvement team consisting of members of the Department of Anesthesia was formed and QI data from previous years were analyzed. The QI team developed a Smart Aim, Key Driver Diagram, and specific Interventions that focused on the accessibility of emergency drugs, the use of nondepolarizing muscle relaxants for endotracheal intubation in children 2 years and younger, and the presence of anesthesia providers until emergence from anesthesia in high-risk patients. RESULTS: The percentage of cases where muscle relaxants were utilized in children 2 years and younger for endotracheal intubation and where atropine and succinylcholine were readily available increased at both our base and outpatient facilities. Over the 2.5-year study period, the incidence of serious airway events and airway cardiac arrests was reduced by 44% and 59%, respectively compared to the previous 2-year period. CONCLUSION: We utilized QI methodology to design and implement a project which led to greater standardization of clinical practice within a large pediatric anesthesia group. Based on an understanding of system issues impacting our clinical practice, we designed and tested interventions that led to a significant reduction in the incidence of serious airway events and airway cardiac arrests.

A quality improvement project to reduce the intraoperative use of single-dose fentanyl vials across multiple patients in a pediatric institution.

OBJECTIVE: The use of a single-dose vial across multiple patients presents a risk to sterility and is against CDC guidelines. We initiated a quality improvement (QI) project to reduce the intraoperative use of single-dose vials of fentanyl across multiple patients at Cincinnati Children's Hospital Medical Center (CCHMC). METHODS: The initial step of the improvement project was the development of a Key Driver Diagram. The diagram has the SMART aim of the project, key drivers inherent to the process we are trying to improve, and specific interventions targeting the key drivers. The number of patients each week receiving an IV dose of fentanyl, from a vial previously accessed for another patient was tracked in a high turnover operating room (OR). The improvement model used was based on the concept of building Plan-Do-Study-Act (PDSA) cycles. Tests of change included provider education, provision of an increased number of fentanyl vials, alternate wasting processes, and provision of single-use fentanyl syringes by the pharmacy. RESULTS: Prior to initiation of this project, it was common for a single fentanyl vial to be accessed for multiple patients. Our data showed an average percentage of failures of just over 50%. During the end of the project, after 7 months, the mean percentage failures had dropped to 5%. Preparation of 20 mcg single-use fentanyl syringes by pharmacy, combined with education of providers on appropriate use, was successful in reducing failures to below our goal of 25%. CONCLUSIONS: Appropriately sized fentanyl syringes prepared by pharmacy, education on correct use of single-dose vials, and reminders in the OR, reduced the percentage of patients receiving a dose of fentanyl from a vial previously accessed for another patient in a high-volume otolaryngology room.

Case report of transfusion-related acute lung injury in a pediatric spine surgery patient transfused leukoreduced red blood cells.

Despite leukoreduced red blood cells (LR-RBCs) reducing the risk of transfusion-related acute lung injury (TRALI), we present a case of a 16-year-old female with kyphosis who received a transfusion of one unit of LR-RBCs, which lead to life-threatening, intraoperative TRALI. The clinical presentation included pulmonary edema, severe postoperative lactic acidosis, left ventricular dysfunction, increased creatine phosphokinase, fatty infiltration of the liver, and hemodynamic instability requiring inotropic support. This presentation is not the classic description of TRALI. Our patient improved with supportive treatment and was successfully extubated on postoperative day 4. TRALI work-up revealed antibody formation to HLA A2, A68, B44, and DQA 5 for the LR-RBCs unit administered.