Enhanced Safety and Efficiency of Ambulatory Cardiology Admissions: A Quality Improvement Initiative.

Background: Pediatric cardiac patients have experienced evolving illnesses progressing to instability while awaiting inpatient admission from ambulatory settings. Admission delays and communication breakdowns increase the risk for tenuous patients. This quality improvement initiative aimed to improve safety and efficiency for patients admitted from an ambulatory Clinic to the Acute Cardiac Care Unit (ACCU) using standardized communication and admission processes within one year. Methods: An admission process map, in-clinic nurse monitoring, and communication pathways were developed and implemented. A standardized team handoff occurred via virtual huddle using illness severity, patient summary, action list, situational awareness, and synthesis. Escalation of care events and timeliness were compared pre- and postimplementation. Results: There was a reduction of transfers to the intensive care unit within 24 hours of ACCU admission from 9.2% to 3.8% (P = 0.26), intensive care unit evaluations (without transfer) from 5.6% to 0% (P = 0.06), and arrests from 3.7% to 0% (P = 0.16). After the pilot, clinic nurses monitored 100% of at-risk patients. Overall mean time from admission decision to virtual huddle decreased from 81 to 61 minutes and mean time to admission from 144 to 115 minutes, with 41% (n = 33) arriving ≤ 60 minutes (goal). The COVID-19 pandemic negatively affected admission timeliness while safety metrics remained optimized. Conclusions: Implementing a standardized admission process between the Clinic and ACCU enhanced safety by reducing admission wait time and escalation of care post-admission. Sustainable, reliable handoff processes, in-clinic monitoring, and standardized admission processes were established. The pandemic hindered admission efficiency without compromising safety.

Validation of the withdrawal assessment tool-1 (WAT-1) in pediatric cardiovascular patients on an inpatient unit.

PURPOSE: Sedation and analgesia are administered to critically ill patients, which may result in physical dependence and subsequent iatrogenic withdrawal. The Withdrawal Assessment Tool-1 (WAT-1) was developed and validated as an objective measurement of pediatric iatrogenic withdrawal in intensive care units (ICUs), with a WAT-1 score ≥ 3 indicative of withdrawal. This study's objectives were to test interrater reliability and validity of the WAT-1 in pediatric cardiovascular patients in a non-ICU setting. DESIGN AND METHODS: This prospective observational cohort study was conducted on a pediatric cardiac inpatient unit. WAT-1 assessments were performed by the patient's nurse and a blinded expert nurse rater. Intra-class correlation coefficients were calculated, and Kappa statistics were estimated. A two-sample, one-sided test of proportions of weaning (n = 30) and nonweaning (n = 30) patients with a WAT-1 ≥3 were compared. RESULTS: Interrater reliability was low (K = 0.132). The WAT-1 area under the receiver operating curve was 0.764 (95% confidence interval; ± 0.123). There was a significantly higher proportion (50%, p = 0.009) of weaning patients with WAT-1 scores ≥3 compared to the nonweaning patients (10%). The WAT-1 elements of moderate/severe uncoordinated/repetitive movement and loose, watery stools were significantly higher in the weaning population. PRACTICE IMPLICATIONS: Methods to improve interrater reliability warrant further examination. The WAT-1 had good discrimination at identifying withdrawal in cardiovascular patients on an acute cardiac care unit. Frequent nurse re-education may increase accurate tool use. The WAT-1 tool may be used in the management of iatrogenic withdrawal in pediatric cardiovascular patients in a non-ICU setting.

Early extubation strategy after congenital heart surgery: 1-year single-centre experience.

INTRODUCTION: Our aim was to present the initial experience with a protocol-driven early extubation strategy and to identify risk factors associated with failed spontaneous breathing trials within 12 hours after surgery. METHODS: A single institutional retrospective study of children up to 18 years of age was conducted in post-operative cardiac surgical patients over a 1-year period. A daily spontaneous breathing trial protocol was used to assess patients' readiness for extubation. The study population (n = 129) was stratified into two age groups: infants (n = 84) and children (n = 45), and further stratified according to ventilation time: early extubation (ventilation time less than 12 h, n = 86) and deferred extubation (ventilation time more than 12 h, n = 43). Mann-Whitney U-test and binomial logistic regression were used for statistical analysis. RESULTS: Early extubated infants had shorter ICU (4 versus 6 days, p = 0.003) and hospital length of stays (16 versus 19 days, p = 0.006), lower re-intubation rates (1 versus 7 patients, p = 0.003), and lower mortality (0 versus. 4 patients, p = 0.01) than deferred extubated infants. There was no significant difference in the studied outcomes in the children group. Malnourished infants and longer cardiopulmonary bypass times were independently associated with failed spontaneous breathing trials within 12 hours after cardiac surgery. CONCLUSIONS: Early extubated infants after cardiac surgery had shorter ICU and hospital length of stay, without an increase in morbidity and mortality, compared to infants who deferred extubation. Nutritional status and longer cardiopulmonary bypass times were risk factors for failed spontaneous breathing trial.

Development and Implementation of an Inpatient CAMEO© Staffing Algorithm to Inform Nurse- Patient Assignments in a Pediatric Cardiac Inpatient Unit.

BACKGROUND: Nursing workload measurement systems are vital to determine nurse staffing for safe care. The Inpatient Complexity and Assessment and Monitoring to Ensure Optimal Outcomes (CAMEO©) acuity tool provides a standardized language to communicate the acuity and complexity of nursing care in the pediatric inpatient setting. DESIGN AND METHODS: A process improvement project was implemented on a pediatric cardiac inpatient unit to utilize the Inpatient CAMEO© tool to inform nurse-patient assignments. Development of the Inpatient CAMEO© Staffing Algorithm utilized a modified Delphi methodology. Six Delphi rounds were performed for algorithm development, addressing potential implementation barriers, educating nursing staff, piloting feasibility, and final full implementation. RESULTS: The cardiac inpatient unit's charge nurses' algorithm utilization was 86% (n = 12) during the feasibility pilot. The algorithm impacted and changed 28% (n = 4) of the shifts' assignments. One-year post algorithm implementation, CAMEO© documentation rates increased from 25 to 30% to >60%. A retrospective, two-week point-prevalence analysis one-year post-implementation described adherence to the Inpatient CAMEO© Staffing Algorithm for 87% (n = 375) of the nurses' patient assignments. CONCLUSIONS: The Inpatient CAMEO© Staffing Algorithm was developed based upon the Inpatient CAMEO© tool and the Inpatient CAMEO© Complexity Classification System to inform nurse-patient assignments and allocate nursing resources. The Inpatient CAMEO© Staffing Algorithm was feasible and sustainable for over one year following implementation at a single center's pediatric cardiac inpatient unit.

Clinical descriptors of pneumothorax following chest tube removal in paediatric cardiac surgery.

BACKGROUND: There is limited data describing the characteristics of paediatric post-operative cardiac surgery patients who develop pneumothoraces after chest tube removal. Patient management after chest tube removal is not standardised across paediatric cardiac surgery programmes. The purposes of this study were to describe the frequency of pneumothorax after chest tube removal in paediatric post-operative cardiac surgical patients and to describe the patient and clinical characteristics of those patients who developed a clinically significant pneumothorax requiring intervention. METHODS: A single-institution retrospective descriptive study (1 January, 2010-31 December, 2018) was utilised to review 11,651 paediatric post-operative cardiac surgical patients from newborn to 18 years old. RESULTS: Twenty-five patients were diagnosed with a pneumothorax by chest radiograph following chest tube removal (0.2%). Of these 25 patients, 15 (1.6%) had a clinically significant pneumothorax and 8 (53%) did not demonstrate a change in baseline clinical status or require an increase in supplemental oxygen, 14 (93%) required an intervention, 9 (60%) were <1 year of age, 4 (27%) had single-ventricle physiology, and 5 (33%) had other non-cardiac anomalies/genetic syndromes. CONCLUSIONS: In our cohort of patients, we confirmed the incidence of pneumothorax after chest tube removal is low in paediatric post-operative cardiac surgery patients. This population does not always exhibit changes in clinical status despite having clinically significant pneumothoraces. We suggest the development of criteria, based on clinical characteristics, for patients who are at increased risk of developing a pneumothorax and would require a routine chest radiograph following chest tube removal.

Cardiac Children's Hospital Early Warning Score: Italian Validation.

BACKGROUND/PURPOSE: The Cardiac Children's Hospital Early Warning Score (C-CHEWS) is an early warning scale used to identify paediatric patients experiencing clinical deterioration which may warrant a transfer to an ICU. However, no studies have tested the C-CHEWS in an Italian paediatric cardiac population. The aims of this study were to translate/back-translate and validate the Italian version of the C-CHEWS and its algorithm. DESIGN AND METHOD: Retrospective study. Sensitivity, specificity, accuracy, positive predictive value, negative predictive value were used to evaluate the performance of C-CHEWS. In additions the Cohen's kappa statistic was calculated to evaluate the agreement between patient's status described by C-CHEWS score (≥5) and actual ICU transfer. RESULTS: High discrimination was observed for sensitivity (81.5%), specificity (99.6%), accuracy (99.7%), positive predictive value (86.7%), and negative predictive value (99.8%). The Cohen's kappa score was observed to be equal to 0.837 (p-value <0.001) indicating there was excellent significant agreement between a C-CHEWS score ≥ 5 and effective evaluation for patients transfer to an ICU. CONCLUSION: The Italian version of the C-CHEWS proved to be a sensitive, specific and reliable tool in the early detection of a physical deterioration of hospitalized paediatric cardiac surgical patients. PRACTICE IMPLICATIONS: This tool may help doctors, nurses and all healthcare professionals to promptly recognize and treat clinical deterioration and facilitate urgent transfers to the PICU.

Quality Improvement Basics: A Crash Course for Pediatric Cardiac Care.

BACKGROUND: Lack of knowledge of quality improvement (QI) methodology and change management principles can explain many of the difficulties encountered when trying to develop effective QI initiatives in health care. METHODS: An interactive QI workshop at the 14th Annual Meeting of the Pediatric Cardiac Intensive Care Society provided an overview of the role of QI in health care, basic QI frameworks and tools, and leadership and organizational culture pitfalls. The top five QI projects submitted to the meeting were later presented to an expert QI panel in a separate session to illustrate examples of QI principles. RESULTS: Workshop presenters introduced two major QI methodologies used to design QI projects. Important first steps include identifying a problem, forming a multidisciplinary team, and developing an aim statement. Key driver diagrams were highlighted as an important tool to develop a project's framework. Several diagnostic tools used to understand the problem were discussed, including the "5 Why's," cause-and-effect charts, and process flowcharts. The importance of outcome, process, and balancing measures was emphasized. Identification of interventions, the value of plan-do-study-act cycles to fuel continuous QI, and use of statistical process control, including run charts or control charts, were reviewed. The importance of stakeholder engagement, transparency, and sustainability was discussed. Later, the top five QI projects presented highlighted multiple "QI done well" practices discussed during the preconference QI workshop. CONCLUSIONS: Understanding QI methodology and appropriately applying basic QI tools are pivotal steps to realizing meaningful and sustained improvement.

Collective quality improvement in the paediatric cardiology acute care unit: establishment of the Pediatric Acute Care Cardiology Collaborative (PAC3).

Collaborative quality improvement and learning networks have amended healthcare quality and value across specialities. Motivated by these successes, the Pediatric Acute Care Cardiology Collaborative (PAC3) was founded in late 2014 with an emphasis on improving outcomes of paediatric cardiology patients within cardiac acute care units; acute care encompasses all hospital-based inpatient non-intensive care. PAC3 aims to deliver higher quality and greater value care by facilitating the sharing of ideas and building alignment among its member institutions. These aims are intentionally aligned with the work of other national clinical collaborations, registries, and parent advocacy organisations. The mission and early work of PAC3 is exemplified by the formal partnership with the Pediatric Cardiac Critical Care Consortium (PC4), as well as the creation of a clinical registry, which links with the PC4 registry to track practices and outcomes across the entire inpatient encounter from admission to discharge. Capturing the full inpatient experience allows detection of outcome differences related to variation in care delivered outside the cardiac ICU and development of benchmarks for cardiac acute care. We aspire to improve patient outcomes such as morbidity, hospital length of stay, and re-admission rates, while working to advance patient and family satisfaction. We will use quality improvement methodologies consistent with the Model for Improvement to achieve these aims. Membership currently includes 36 centres across North America, out of which 26 are also members of PC4. In this report, we describe the development of PAC3, including the philosophical, organisational, and infrastructural elements that will enable a paediatric acute care cardiology learning network.

Validation of the Children's Hospital Early Warning System for Critical Deterioration Recognition.

OBJECTIVE: Early warning scores, such as the Children's Hospital Early Warning Score (CHEWS), are used by hospitals to identify patients at risk for critical deterioration and trigger clinicians to intervene and prevent further deterioration. This study's objectives were to validate the CHEWS and to compare the CHEWS to the previously validated Brighton Pediatric Early Warning Score (PEWS) for early detection of critical deterioration in hospitalized, non-cardiac patients at a pediatric hospital. DESIGN AND METHODS: A retrospective cohort study reviewed medical and surgical patients at a quaternary academic pediatric hospital. CHEWS scores and abstracted PEWS scores were obtained on cases (n=360) and a randomly selected comparison sample (n=776). Specificity, sensitivity, area under the receiver-operating characteristic curves (AUROC) and early warning times were calculated for both scoring tools. RESULTS: The AUROC for CHEWS was 0.902 compared to 0.798 for PEWS (p<0.001). Sensitivity for scores ≥3 was 91.4% for CHEWS and 73.6% for PEWS with specificity of 67.8% for CHEWS and 88.5% for PEWS. Sensitivity for scores ≥5 was 75.6% for CHEWS and 38.9% for PEWS with specificity of 88.5% for CHEWS and 93.9% for PEWS. The early warning time from critical score (≥5) to critical deterioration was 3.8h for CHEWS versus 0.6h for PEWS (p<0.001). CONCLUSION: The CHEWS system demonstrated higher discrimination, higher sensitivity and longer early warning time than the PEWS for identifying children at risk for critical deterioration.

Validation of the Cardiac Children's Hospital Early Warning Score: an early warning scoring tool to prevent cardiopulmonary arrests in children with heart disease.

OBJECTIVE: Most inpatient pediatric arrests are preventable by early recognition/treatment of deterioration. Children with cardiac disease have the highest arrest rates; however, early warning scoring systems have not been validated in this population. The objective of this study was to validate the Cardiac Children's Hospital Early Warning Score (C-CHEWS) tool in inpatient pediatric cardiac patients. The associated escalation of care algorithm directs: routine care (score 0-2), increased assessment/intervention (3-4), or cardiac intensive care unit (CICU) consult/transfer (≥5). DESIGN: Sensitivity and specificity were estimated based on retrospective review of patients that experienced unplanned CICU transfer/arrest (n = 64) and a comparison sample (n = 248) of admissions. The previously validated Pediatric Early Warning Score (PEWS) tool was used for comparison. Patients' highest C-CHEWS scores were compared with calculated PEWS scores. Area under the receiver operating characteristic (AUROC) curve was calculated for PEWS and C-CHEWS to measure discrimination. RESULTS: The AUROC curve for C-CHEWS was 0.917 compared with PEWS 0.785 (P < .001). The algorithm AUROC curve was 0.902 vs. PEWS of 0.782. C-CHEWS algorithm sensitivity was 96.9 (score ≥ 2), 79.7 (≥4), and 67.2 (≥5) vs. PEWS of 81.1(≥2), 37.5 (≥4), and 23.4 (≥5). C-CHEWS specificity was 58.1 (≥2), 85.5 (≥4), and 93.6 (≥5) vs. PEWS of 81.1 (≥2), 94.8 (≥4) and 97.6 (≥5). Lead time of elevated C-CHEWS scores (≥2) was a median of 9.25 hours prior to event vs. PEWS, which was 2.25 hours and lead time for critical C-CHEWS scores (≥5) was 2 hours vs. 0 hours for PEWS (P < .001). CONCLUSIONS: C-CHEWS has excellent discrimination to identify deterioration in children with cardiac disease and performed significantly better than PEWS both as an ordinal variable and when choosing cut points to maximize AUROC. C-CHEWS has a higher sensitivity than PEWS at all cut points.

The Cardiac Children's Hospital Early Warning Score (C-CHEWS).

Inpatient pediatric cardiovascular patients have higher rates of cardiopulmonary arrests than other hospitalized children. Pediatric early warning scoring tools have helped to provide early identification and treatment to hospitalized children experiencing deterioration thus preventing arrests from occurring. However, the tools have rarely been used and have not been validated in the pediatric cardiac population. This paper describes the modification of a pediatric early warning scoring system for cardiovascular patients, the implementation of the tool, and its companion escalation of care algorithm on an inpatient pediatric cardiovascular unit.

Integration of complementary and alternative medicine in a major pediatric teaching hospital: an initial overview.

OBJECTIVE: To describe the establishment of a multidisciplinary team of complementary and alternative medicine (CAM) providers and educators in an urban pediatric hospital and affiliated medical school. BACKGROUND: Pediatric CAM use is increasing. Physicians are interested in CAM-related education but few programs had been developed in pediatrics. In 1998, Children's Hospital Boston established the Center for Holistic Pediatric Education and Research (CHPER), a CAM multidisciplinary team providing clinical services, education, and research. METHOD: A retrospective review describing data from patient consultation notes, CAM lectures, clinical practice guidelines, curriculum materials, team meeting minutes, and team member manuscripts and publications. RESULTS: Over 5.5 years, CHPER staff provided over 2100 consults: acupuncture, massage, holistic pediatrician, relaxation therapies, biofeedback, hypnosis, and bio-pharmaceutics. Acupuncture and massage therapies were incorporated into a Clinical Practice Guideline. Formal education was delivered through didactic sessions, workshops, self-learning modules, clinical observation, and clinical practice. CHPER faculty published 1 book and 64 articles on CAM-related topics. CONCLUSION: An interdisciplinary team of CAM clinicians and educators can be integrated into an urban pediatric teaching hospital to provide CAM medical education and clinical services.

From mothers to daughters: transgenerational food and diet communication in an underserved group.

Studies show that young girls are highly influenced by their mothers' attitudes toward food and body image. To investigate the nature of the information about food that mothers transfer to their daughters, the researchers used focus groups comprising African American women. Results suggest that when educators work with low-income African American women, they should be cognizant of overeating from the perspectives of early food scarcity, reverence for the mother's authoritative role in the family and respect for cultural differences in body size norms. In addition, nutrition educators should counsel young mothers to understand the impact of their eating habits on their daughters.

Pediatric faculty development in integrative medicine.

As more patients use complementary and alternative medical (CAM) therapies, faculty may be asked to teach trainees about topics requiring faculty development training. Our purpose in this study was to evaluate qualitatively and quantitatively a new faculty development program covering 4 key areas of CAM: herbs and dietary supplements, mind-body therapies, massage, and acupuncture. Faculty members (N = 6) volunteered for the program and were included in the study if they completed at least 3 of the 6 scheduled sessions. For each session, participants completed a pretest evaluating their knowledge and confidence about the topic, then they received background reading and focused discussion questions. Each session was a case-based, experiential seminar led by an expert in the content area. Participants completed post-session questionnaires measuring knowledge, confidence, and communication practices at the end of each session and at the end of the series of seminars. They also were asked for feedback and suggestions for the following year. All participants strongly agreed that they gained important knowledge; scores on tests about herbs increased from 62% at baseline to 84% at completion, and scores on knowledge of acupuncture increased from 60% before the session to 98% after. All participants strongly agreed that their confidence in talking with patients, colleagues, and trainees improved; on average, confidence scores improved an average of 1.8 out of a total of 5 possible points for all topics. Participants more frequently asked patients about their use of herbs (from 50% at baseline to 75% at the end) and increased the percentage of training encounters in which they discussed CAM with trainees or colleagues from 10% to 25%. We concluded that faculty development in integrative medicine is feasible and results in qualitative and quantitative improvements in knowledge, confidence, and clinical and teaching behaviors.