Establishing excellence: Implementation of an onboarding and continuing education curriculum for pediatric intensive care unit nurse practitioners and physician associates.

ABSTRACT: This study describes a novel curriculum for onboarding and clinical education for nurse practitioners and physician associates (NPs and PAs) in the pediatric intensive care unit setting. The objective was to provide details on the initial orientation and continuing education program to ensure the attainment of knowledge and skills needed to care for critically ill patients safely and effectively. A needs assessment was completed, and a knowledge gap identified in five themes: (1) in-depth knowledge on common critical care diagnoses; (2) understanding of pathophysiology; (3) disease management processes; (4) critical thinking; and (5) procedure competency. Using Kern 6-step curriculum and the Kirkpatrick evaluation model, we designed a program for orientation and continuing education for critical care NPs and PAs. Transformative learning theory provided the framework for the program because the cyclical steps of disorienting dilemma, critical reflection, discourse, and action were used repeatedly to transform a new graduate to a competent critical care provider and then into an expert who is able to, in turn, teach others. A total of 31 NPs and 5 PAs completed the 12-week orientation phase. Participants reported that the orientation phase was valuable to their educational advancement and increased critical care knowledge. All participants showed improvement in knowledge, skills, and ability to provide competent patient care.

Rapid response events with multiple triggers are associated with poor outcomes in children.

Objective: We describe the characteristics and outcomes of pediatric rapid response team (RRT) events within a single institution, categorized by reason for RRT activation (RRT triggers). We hypothesized that events with multiple triggers are associated with worse outcomes. Patients and Methods: Retrospective 3-year study at a high-volume tertiary academic pediatric hospital. We included all patients with index RRT events during the study period. Results: Association of patient and RRT event characteristics with outcomes including transfers to ICU, need for advanced cardiopulmonary support, ICU and hospital length of stay (LOS), and mortality were studied. We reviewed 2,267 RRT events from 2,088 patients. Most (59%) were males with a median age of 2 years and 57% had complex chronic conditions. RRT triggers were: respiratory (36%) and multiple (35%). Transfer to the ICU occurred after 1,468 events (70%). Median hospital and ICU LOS were 11 and 1 days. Need for advanced cardiopulmonary support was noted in 291 events (14%). Overall mortality was 85 (4.1%), with 61 (2.9%) of patients having cardiopulmonary arrest (CPA). Multiple RRT trigger events were associated with transfer to the ICU (559 events; OR 1.48; p < 0.001), need for advanced cardiopulmonary support (134 events; OR 1.68; p < 0.001), CPA (34 events; OR 2.36; p = 0.001), and longer ICU LOS (2 vs. 1 days; p < 0.001). All categories of triggers have lower odds of need for advanced cardiopulmonary support than multiple triggers (OR 1.73; p < 0.001). Conclusions: RRT events with multiple triggers were associated with cardiopulmonary arrest, transfer to ICU, need for cardiopulmonary support, and longer ICU LOS. Knowledge of these associations can guide clinical decisions, care planning, and resource allocation.

Evaluation of a Theory-Informed Pediatric Rapid Response Training Program Using the Logic Model.

BACKGROUND AND OBJECTIVES: The activators of rapid-response (RR) events tasked with recognition of clinical decompensation, initial management, and response activation seldom receive RR training. RR activators often experience negative emotions of "failure to rescue" that can compromise team performance during RRs. We used the logic model framework for development and evaluation of an educational program grounded in self-determination theory for pediatric RR activators. METHODS: The program unfolded in a large quaternary pediatric hospital to impart knowledge and skills; foster autonomy, competence, and relatedness; and improve participants' satisfaction with performance in RRs. Logic model-guided inputs-activities-outputs-outcomes-context for program evaluation. Preintervention-postintervention follow-up surveys and interviews generated data to determine outcomes and impact of the program. The evaluation instruments were tested for validity and internal consistency. RESULTS: Over 4 years, 207 multidisciplinary RR activators were trained. Iterative modifications yielded a workshop that incorporated multiple learning modalities, a standardized learner-centered case bank, formalized evaluation tools, and a database to track participation. Significant improvements in RR-related knowledge, self-efficacy, and self- determination were noted. Workshop evaluation yielded a mean score of 4.85 (0.27) on a 5-point scale. At 6-months follow-up survey and interviews, participants reported application of the knowledge and increased confidence with participation in real-life RR events. The workshop gained traction across the hospital, was associated with improved RR clinical outcomes, and contributed to professional advancement of the educators. CONCLUSIONS: We successfully implemented a self-determination theory-informed RR training program for pediatric RR activators, and the logic model framework was used to facilitate comprehensive evaluation.

Comparison of Rapid-Response Systems Across Multisite Locations of a Pediatric Hospital System.

OBJECTIVES: Rapid response (RR) systems reduce mortality and cardiopulmonary arrests outside the ICU. Patient characteristics, RR practices, and hospital context and/or mechanism influence post-RR outcomes. We aim to describe and compare RR function and outcomes within our institution's multiple sites. METHODS: We conducted a 3-year retrospective study to compare RR use, clinical characteristics, and outcomes between our hospital's central campus (CC) and 2 satellite campuses (SCs). RR training and procedures are uniform across all campuses. RESULTS: Among the 2935 RRs reviewed, 1816 occurred during index admissions at the CC and 405 occurred at SCs. CC, when compared with SCs, had higher age at RR (3.2 years vs 1.4 years), prevalence of complex chronic conditions (62.4% vs 34.4%), surgical complications (20.2% vs 5%), severity of illness, and risk of mortality (P < .001). CC had higher daytime RR activations, longer time from admission to RR, and more activations by nurses (P < .001). Respiratory diagnoses were most prevalent uniformly, but cardiac, neurologic, and hematologic diagnoses were higher at CC (P < .001). Cardiac and/or respiratory arrests during RR and transfers to the ICU were similar. Cardiorespiratory interventions post-RR, hospital length of stay, and mortality were higher and ICU stay was shorter (P < .01) in the CC. Outcomes were mainly affected by patient characteristics and not RR factors on multivariate analysis. CONCLUSIONS: Patient illness severity, RR characteristics, and outcomes are significantly different in our multisite locations. Outcomes are predominantly affected by patient severity and not RR characteristics. Standardized RR training and procedures likely balance the effect of varying RR characteristics on eventual outcomes.

Fostering self-determination of bedside providers to promote active participation in rapid response events.

BACKGROUND: Widespread implementation of rapid response (RR) systems positively impacts outcomes of clinically unstable hospitalized patients. Collaboration between bedside providers and specialized responding teams is crucial for effective functioning of RR system. Bedside, providers often harbor negative feelings about having to 'call for help' that could impact their active participation in RR. OBJECTIVE: The objective of the study is to enhance active participation of bedside providers in RR by fostering self-determination through targeted education. DESIGN: Needs assessment affirmed that bedside providers in our tertiary academic pediatric hospital felt loss of control over patient care, lack of competence, and disconnect from the RR team. We used the principles of autonomy, competence, and relatedness posited by the self-determination theory to guide the development, implementation, and evaluation of our educational program for bedside providers. RESULTS: Forty-two bedside providers participated in our program. Participants reported significant improvement in RR-related clinical knowledge. More importantly, there was significant enhancement in individual perceptions of autonomy (pre-mean: 2.12, post-mean: 4.4) competence (pre-mean: 2.15, post-mean: 4.4), and relatedness (pre-mean: 2.65, post-mean: 4.5) with RR (p < 0.01). The evaluation results for overall educational effectiveness showed a mean score of 4.69 ± 0.79. All scores were based on a 5-point Likert scale of 1: poor to 5: excellent. Educators noted good participant engagement. The program's structure, evaluations, and data management were modified based on the feedback. CONCLUSIONS: We successfully developed and implemented targeted educational program for bedside providers based on self-determination theory. The evaluations showed improvement in bedside providers' clinical RR knowledge and perceptions of autonomy, competence, and relatedness following the training.

Family-Initiated Pediatric Rapid Response: Characteristics, Impetus, and Outcomes.

BRIEF DESCRIPTION: Family-initiated rapid response (FIRR) empowers families to express concern and seek care from specialized response teams. We studied FIRRs that occurred in a pediatric tertiary hospital over a 3-year period. The main aims were to describe the characteristics and outcomes of FIRRs and compare them with clinician-activated RRs (C-RRs). Of the 1,906 RRs events reviewed, 49 (2.6%) were FIRRs. All FIRRs had appropriate clinical triggers with the most common being uncontrolled pain. Chronic conditions and previous admissions were present in 61%. More than half of FIRRs had a vital sign change that should have qualified C-RR activation. Seventy-six percent FIRRs needed at least one or more interventions. Twenty-seven percent of FIRRs needed transfer to intensive care unit compared with 60% transfer rate for C-RRs. PURPOSE OF SUBMISSION/RELEVANCE TO HEALTHCARE QUALITY: Family-initiated rapid response events were activated for legitimate concerns and frequently needed clinical interventions. Enhanced information and awareness of FIRR can improve utilization of the system and enhance family satisfaction, patient safety, and outcomes. Disseminating the information on FIRR and the importance of family involvement will improve the care of children and empower family members.