Sustained Performance of Cardiac Arrest Prevention in Pediatric Cardiac Intensive Care Units.

Importance: The Pediatric Cardiac Critical Care Consortium (PC4) cardiac arrest prevention (CAP) quality improvement (QI) project facilitated a decreased in-hospital cardiac arrest (IHCA) incidence rate across multiple hospitals. The sustainability of this outcome has not been determined. Objective: To examine the IHCA incidence rate at participating hospitals after the QI project ended and discern which factors best aligned with sustained improvement. Design, Setting, and Participants: This observational cohort study compared IHCA data from the CAP era (July 1, 2018, to December 31, 2019) with data from the 2-year follow-up era (March 1, 2020, to February 28, 2022). Data were obtained from pediatric cardiac intensive care units (CICUs) from 17 PC4 CAP-participating hospitals. Intervention: The CAP practice bundle was designed to facilitate local practice integration, with the intention to implement, adapt, and continue CAP processes beyond the CAP era. A web-based survey was administered 2 years after the end of the project to estimate CAP-specific QI work. Main Outcomes and Measures: Risk-adjusted IHCA incidence rates across all admissions were compared between study eras. The survey generated a novel hospital-specific QI sustainability score, which is generally reflective of the sum of local CAP work performed. Results: There were no clinically important differences in demographic and admission characteristics between the 13 082 CAP era admissions and 16 284 follow-up admissions (total mean [SD] age, 5.1 [8.4] years; 56.1% male). Risk-adjusted IHCA incidences were not different between the CAP vs follow-up eras (2.8% vs 2.8%; odds ratio, 1.03; 95% CI, 0.89-1.19), suggesting sustained prevention improvement. There was also no difference between eras in risk-adjusted IHCA incidence within medical, surgical, or high-risk subgroups. A lower hospital QI sustainability score was correlated with higher odds for IHCA in the follow-up vs CAP era (correlation coefficient, -0.58; P = .02). Five hospitals had increases of 1% or greater in risk-adjusted IHCA rates in the follow-up era; these hospitals had significantly lower QI sustainability scores and were less likely to have adopted sustainability elements during the CAP era or report persistent engagement for CAP-related QI processes during follow-up. Conclusions and Relevance: In this cohort study of all CICU admissions across 17 hospitals, IHCA prevention was feasible and sustainable; the established reduction in risk-adjusted IHCA rate was maintained for at least 2 years after the end of the CAP project. Both implementation strategies and continued engagement in CAP processes during the follow-up era were associated with sustained improvement.

Using participatory research to identify actionable facilitators and barriers to effective inpatient interdisciplinary communication.

BACKGROUND: Communication failures occur often in the inpatient setting. Efforts to understand and improve communication often exclude patients or are siloed by discipline. OBJECTIVE: We aimed to identify barriers and facilitators to effective communication within interdisciplinary inpatient internal medicine (IM) teams using a participatory research approach. DESIGN: We conducted a single-center participatory mixed methods study using group-level assessment (GLA) and concept mapping to iteratively engage stakeholders. Stakeholder groups included patients/families, IM faculty, IM residents, nurses and ancillary staff, and care managers. Stakeholder-specific GLA sessions were conducted. Participants responded to prompts addressing interdisciplinary communication then worked in small groups to synthesize the qualitative data into unique ideas. A subset of each stakeholder group then sorted ideas through a concept mapping exercise. Multidimensional scaling and hierarchical cluster analysis were used to generate a concept map of the data. RESULTS: Participants generated 97 unique ideas that were then sorted. The research team chose an eight-cluster concept map representing patient inclusion and engagement, processes and resources, team morale and inclusive dynamics, attitudes and behaviors, effective communication, barriers to communication, the culture of healthcare, and clear expectations. Three larger domains of patient inclusion and engagement, organizational conditions and role clarity, and team dynamics and behaviors were noted. CONCLUSION: Use of a participatory research approach made it feasible to engage diverse stakeholders including patients. Our results highlight the need to identify context-specific facilitators and barriers of interdisciplinary communication. The importance of clear expectations was identified as a prioritized area to target communication improvement efforts.

Parent Participation in Morbidity and Mortality Review: Parent and Physician Perspectives.

This study examined Morbidity and Mortality (M&M) review practices and perspectives of physicians and parents regarding parent participation in M&M review. Surveys were distributed to parents of children with a prior hospitalization for congenital heart disease (CHD) and physicians caring for pediatric CHD patients. Response distributions and Fisher's exact tests were performed to compare parent and physician responses. Qualitative survey data were thematically analyzed. Ninety-two parent and 36 physician surveys were analyzed. Physicians reported parent input or participation was rarely sought in M&M review. Parents with direct experience of adverse events or death of their child reported providers discussed events with them in a timely manner and answered their questions; however, nearly half wished their healthcare team had done something differently during the disclosure. There was no statistical difference between groups regarding transparency (P = .37, .79); however, there was a significant difference in perspectives regarding parental involvement in the M&M review (P < .001). Common themes important to parents which emerged from the qualitative analysis were being adequately informed, feeling their perspectives were acknowledged and respected, having attentive and empathetic providers, and receiving consistent messaging. Although rarely included in current practice, parent participation in M&M could offer unique insight and increase accountability to proposed change elucidated by M&M review.

Preventing Cardiac Arrest in the Pediatric Cardiac Intensive Care Unit Through Multicenter Collaboration.

Importance: Preventing in-hospital cardiac arrest (IHCA) likely represents an effective strategy to improve outcomes for critically ill patients, but feasibility of IHCA prevention remains unclear. Objective: To determine whether a low-technology cardiac arrest prevention (CAP) practice bundle decreases IHCA rate. Design, Setting, and Participants: Pediatric cardiac intensive care unit (CICU) teams from the Pediatric Cardiac Critical Care Consortium (PC4) formed a collaborative learning network to implement the CAP bundle consistent with the Institute for Healthcare Improvement framework; 15 hospitals implemented the bundle voluntarily. Risk-adjusted IHCA incidence rates were analyzed across 2 time periods, 12 months (baseline) and 18 months after CAP implementation (intervention) using difference-in-differences (DID) regression to compare 15 CAP and 16 control PC4 hospitals that chose not to participate in CAP but had IHCA rates tracked in the PC4 registry. Patients deemed at high risk for IHCA, based on a priori evidence-based criteria and empirical hospital-specific criteria, were selected to receive the CAP bundle. Data were collected from July 2018 to December 2019, and data were analyzed from March to August 2020. Interventions: CAP bundle included 5 elements developed to promote increased situational awareness and communication among bedside clinicians to recognize and mitigate deterioration in high-risk patients. Main Outcomes and Measures: Risk-adjusted IHCA incidence rate across all CICU admissions (IHCA events divided by all admissions). Results: The bundle was activated in 2664 of 10 510 CAP hospital admissions (25.3%); admission characteristics were similar across study periods. There was a 30% relative reduction in risk-adjusted IHCA incidence rate at CAP hospitals (intervention period: 2.6%; 95% CI, 2.2-2.9; baseline: 3.7%; 95% CI, 3.1-4.0), but no change at control hospitals (intervention period: 2.7%; 95% CI, 2.3-2.9; baseline: 2.7%; 95% CI, 2.2-3.0). DID analysis confirmed significantly reduced odds of IHCA among all admissions at CAP hospitals compared with control hospitals during the intervention period vs baseline (odds ratio, 0.72; 95% CI, 0.56-0.91; P = .01). DID odds ratios were 0.72 (95% CI, 0.53-0.98) for the surgical subgroup, 0.74 (95% CI, 0.48-1.14) for the medical subgroup, and 0.72 (95% CI, 0.50-1.03) for the high-risk admission subgroup at CAP hospitals after intervention. All-cause risk-adjusted mortality rate did not change after intervention. Conclusions and Relevance: Implementation of this CAP bundle led to significant IHCA reduction across multiple pediatric CICUs. Future studies may determine if this bundle can be effective in other critically ill populations.

Development of a System to Measure and Improve Outcomes in Congenital Heart Disease: Heart Institute Safety, Quality, and Value Program.

Achieving excellent outcomes for patients with congenital heart disease requires coordinated effort and resources, and a need has developed for a structure that facilitates improvement and measures cardiac centers' progress toward optimal patient care. METHODS: The Heart Institute (HI) at Cincinnati Children's Hospital developed a Safety, Quality and Value (SQV) program to formalize the use of quality improvement (QI) methods with the goal of optimizing patient outcomes, experience, and value. The SQV program adopted a conceptual framework that considers aspects of structure, process, outcome, and value in defining quality metrics, and the program used the Model for Improvement to guide design and implementation of QI interventions. RESULTS: In the first four years since its inception, the SQV program facilitated important improvements in clinical outcomes, cost reductions, and safety. In addition to achieving measurable improvements, the creation of a formal SQV program fostered a culture of transparency and accountability, providing a new structure for how the HI shares clinical data among clinicians, hospital leadership, and the public. CONCLUSION: The creation of an infrastructure to strategically design, implement, and support QI efforts in a clinically busy pediatric acquired and congenital heart institute was successful in meeting its initial aims and is a promising approach and model for other programs.

Usability Testing of an Interactive Dashboard for Surgical Quality Improvement in a Large Congenital Heart Center.

BACKGROUND: Interactive data visualization and dashboards can be an effective way to explore meaningful patterns in large clinical data sets and to inform quality improvement initiatives. However, these interactive dashboards may have usability issues that undermine their effectiveness. These usability issues can be attributed to mismatched mental models between the designers and the users. Unfortunately, very few evaluation studies in visual analytics have specifically examined such mismatches between these two groups. OBJECTIVES: We aimed to evaluate the usability of an interactive surgical dashboard and to seek opportunities for improvement. We also aimed to provide empirical evidence to demonstrate the mismatched mental models between the designers and the users of the dashboard. METHODS: An interactive dashboard was developed in a large congenital heart center. This dashboard provides real-time, interactive access to clinical outcomes data for the surgical program. A mixed-method, two-phase study was conducted to collect user feedback. A group of designers (N = 3) and a purposeful sample of users (N = 12) were recruited. The qualitative data were analyzed thematically. The dashboards were compared using the System Usability Scale (SUS) and qualitative data. RESULTS: The participating users gave an average SUS score of 82.9 on the new dashboard and 63.5 on the existing dashboard (p = 0.006). The participants achieved high task accuracy when using the new dashboard. The qualitative analysis revealed three opportunities for improvement. The data analysis and triangulation provided empirical evidence to the mismatched mental models. CONCLUSION: We conducted a mixed-method usability study on an interactive surgical dashboard and identified areas of improvements. Our study design can be an effective and efficient way to evaluate visual analytics systems in health care. We encourage researchers and practitioners to conduct user-centered evaluation and implement education plans to mitigate potential usability challenges and increase user satisfaction and adoption.