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.

Measuring Critical Care Unit Performance Using a Postoperative Mechanical Ventilation Quality Metric.

BACKGROUND: Safely minimizing postoperative mechanical ventilation duration after congenital heart surgery could be a cardiac intensive care unit (CICU) quality measure. We aimed to measure CICU performance using duration of postoperative mechanical ventilation and identify organizational factors associated with this metric. METHODS: Observational analysis of 16,848 surgical hospitalizations of patients invasively ventilated on admission from the operating room from 26 Pediatric Cardiac Critical Care Consortium CICUs. We fitted a multivariable model to predict duration of postoperative mechanical ventilation adjusting for pre- and postoperative factors to measure CICU performance accounting for postoperative illness severity. We used our model to calculate observed-to-expected (adjusted) ventilation duration ratios for each CICU, describe variation across CICUs, and characterize outliers based on bias-corrected bootstrap 95% CIs. We explored associations between organizational characteristics and patient-level adjusted ventilation duration by adding these as independent variables to the model. RESULTS: We observed wide variation across CICUs in adjusted ventilation duration ratios, ranging from 0.7 to 1.7. Nine of 26 CICUs had statistically better than expected ventilation duration, while 10 were significantly worse than expected. Organizational characteristics associated with shorter adjusted ventilation duration included mixed (60%-90%) staffing by critical care or anesthesia-trained attendings, lower average attending-to-patient ratio, average CICU daily occupancy 80% to 90%, and greater nurse staffing ratios and experience. CONCLUSIONS: CICU performance in postoperative duration of mechanical ventilation varies widely across Pediatric Cardiac Critical Care Consortium centers. Several potentially modifiable organizational factors are associated with this metric. Taken together, these findings could spur efforts to improve ventilation duration at outlier hospitals.

Inadequate Oxygen Delivery Dose and Major Adverse Events in Critically Ill Children With Sepsis.

BACKGROUND: The inadequate oxygen delivery (IDo2) index is used to estimate the probability that a patient is experiencing inadequate systemic delivery of oxygen. Its utility in the care of critically ill children with sepsis is unknown. OBJECTIVE: To evaluate the relationship between IDo2 dose and major adverse events, illness severity metrics, and outcomes among critically ill children with sepsis. METHODS: Clinical and IDo2 data were retrospectively collected from the records of 102 critically ill children with sepsis, weighing >2 kg, without preexisting cardiac dysfunction. Descriptive, nonparametric, odds ratio, and correlational statistics were used for data analysis. RESULTS: Inadequate oxygen delivery doses were significantly higher in patients who experienced major adverse events (n = 13) than in those who did not (n = 89) during the time intervals of 0 to 12 hours (P < .001), 12 to 24 hours (P = .01), 0 to 24 hours (P < .001), 0 to 36 hours (P < .001), and 0 to 48 hours (P < .001). Patients with an IDo2 dose at 0 to 12 hours at or above the 80th percentile had the highest odds of a major adverse event (odds ratio, 23.6; 95% CI, 5.6-99.4). Significant correlations were observed between IDo2 dose at 0 to 12 hours and day 2 maximum vasoactive inotropic score (ρ = 0.27, P = .006), day 1 Pediatric Logistic Organ Dysfunction (PELOD-2) score (ρ = 0.41, P < .001), day 2 PELOD-2 score (ρ = 0.44, P < .001), intensive care unit length of stay (ρ = 0.35, P < .001), days receiving invasive ventilation (ρ = 0.42, P < .001), and age (ρ = -0.47, P < .001). CONCLUSIONS: Routine IDo2 monitoring may identify critically ill children with sepsis who are at the highest risk of adverse events and poor outcomes.

Parent Perception of Their Role in the Pediatric Cardiac Intensive Care Unit.

BACKGROUND/INTRODUCTION: One way the goal of establishing a partnership with families is accomplished, specific to the pediatric intensive care units, is 24-hour visitation and presence/participation during medical rounds and procedures. Despite the breadth of literature on the positive effect of parent presence, as well as the nearly nationwide adoption of 24-hour pediatric intensive care unit visitation, there is little to no research about how these changes have affected parents' perception of their role in the pediatric cardiac intensive care unit (PCICU). OBJECTIVES/AIMS: The purpose of this study was to explore and better understand the experience of parents in the PCICU within a patient/family-centered care model. METHODS: Using a qualitative descriptive approach, interviews were conducted with parents of children currently admitted as inpatients in the PCICU. Participants were asked broad, open-ended questions and probes to attain qualitative descriptions of their experiences and perceptions of their parental role in the PCICU. The research design for this study was based on naturalistic inquiry and was used to describe rather than interpret parental experiences in their own words. RESULTS: Eleven parents from 7 families were interviewed; parents described their role in terms of 2 main categories, as one who is an advocate and decision maker and one who provides emotional and physical support. Parents valued the expertise of the PCICU team but also shared the significance of the team recognizing their role as parents. Incorporating parents as an integral member of the health care team is a fundamental component to PCICU care. DISCUSSION/CONCLUSION: The role of parents is irreplaceable, particularly in the PCICU. The medical complexity of the intensive care can be a barrier to act as parents resulting in a disruption of family-centered care. Nursing staff avert this disruption through modeling parenting to their child's present circumstances and involvement in normal parenting tasks.

Factors Associated With Increased Laboratory Use in the Pediatric Cardiac Intensive Care Unit.

BACKGROUND: Laboratory testing is frequently used to guide postoperative management and contributes to hospital resource utilization; however, there is little evidence identifying patient or clinical factors to inform the appropriate frequency of laboratory testing in the pediatric cardiac intensive care unit. OBJECTIVES: To examine the factors associated with increased laboratory utilization following pediatric congenital heart surgery. METHODS: For each patient, the total number of tests and types of laboratory tests were recorded. Patients whose number of tests was greater than the 90th percentile were categorized as increased laboratory use. RESULTS: A sample of 250 unique patients and 909 nursing shifts were obtained for patient- and shift-level analyses. The top 10% of patients identified as the high laboratory utilization group (>128 laboratory tests). High-use group reported significantly younger patients and longer bypass time (P < .001). Patients in the highest Risk Adjustment for Congenital Heart Surgery 1 risk category were 34.7 times more likely to be in high laboratory utilization group (P = .006), independent of age at time of surgery and time on bypass (receiver operating characteristic curve = 0.855). At the shift level, time on bypass (P = .002), age younger than 30 days at surgery (P < .001), 3 to 5 years' registered nurse experience (P < .001), staff precepting (P = .03), and weekday shift status (P = .03) were all independently associated with high laboratory utilization. CONCLUSIONS: There are multiple factors associated with increased laboratory utilization. Recognition of specific patient and nursing factors can be used to impact patient management.

Simulation training improves team dynamics and performance in a low-resource cardiac intensive care unit.

INTRODUCTION: Although simulation training has been utilized quite extensively in highincome medical environments, its feasibility and effect on team performance in lowresource pediatric Cardiac Intensive Care Unit (CICU) environments has not been demonstrated. We hypothesized that lowfidelity simulationbased crisis resource management training would lead to improvements in team performance in such settings. METHODS: In this prospective observational study, the effect of simulation on team dynamics and performance was assessed in 23 healthcare providers in a pediatric CICU in Southeast Asia. A 5day training program was utilized consisting of various didactic sessions and simulation training exercises. Improvements in team dynamics were assessed using participant questionnaires, expert evaluations, and video analysis of time to intervention and frequency of closedloop communication. RESULTS: In subjective questionnaires, participants noted significant (P < 0.05) improvement in team dynamics and performance over the training period. Video analysis revealed a decrease in time to intervention and significant (P < 0.05) increase in frequency of closedloop communication because of simulation training. CONCLUSIONS: This study demonstrates the feasibility and effectiveness of simulationbased training in improving team dynamics and performance in lowresource pediatric CICU environments, indicating its potential role in eliminating communication barriers in these settings.

The Effects of Endotracheal Suctioning in the Pediatric Population: An Integrative Review.

BACKGROUND: Critically ill pediatric patients with endotracheal tubes routinely receive endotracheal tube suctioning to clear secretions and ensure tube patency. This common practice can result in adverse effects. OBJECTIVES: The aim of this study was to evaluate the research literature on the stressors of endotracheal suctioning and consequent effect on the pediatric patient. METHODS: An integrative review was conducted using the Whittemore and Knafl modified framework for integrative reviews, and article selection was guided by the Preferred Reporting Items for Systematic Reviews and Meta-analyses flow diagram. A literature search was conducted via PubMed, the Cumulative Index to Nursing and Allied Health Literature, and Scopus. Selected articles were evaluated to present the current evidence on the stressors of endotracheal suctioning in the pediatric population. RESULTS: This review includes 14 articles, with a total of 849 patients, ranging in age from premature neonates to 17 years of age. The available literature aligned into 3 categories: neurovascular effects, respiratory systems effects, and pain related to endotracheal tube suctioning. Pain was the most prevalent category, with half of the studies using endotracheal suctioning as a painful procedure to validate pain assessment tools rather than examining the effect of suctioning. A majority of the studies (67%) were conducted in the premature neonate population. Children with congenital cardiac or pulmonary defects, genetic syndromes, or neurological injuries were frequently excluded. CONCLUSIONS: Literature regarding the effects of endotracheal suctioning in children is limited. There are many extrapersonal, interpersonal, and intrapersonal stressors associated with endotracheal suctioning that merit future research.

Continuing to challenge practice to be evidence based.

Practice habits continue in clinical practice despite the availability of research and other forms of evidence that should be used to guide critical care practice interventions. This article is based on a presentation at the 2014 National Teaching Institute of the American Association of Critical-Care Nurses. The article is part of a series of articles that challenge critical care nurses to examine the evidence guiding nursing practice interventions. Four common practice interventions are reviewed: (1) weight-based medication administration, (2) chest tube patency maintenance, (3) daily interruption of sedation, and (4) use of chest physiotherapy in children. For weight-based administration of medication, the patient's actual weight should be measured, rather than using an estimate. The therapeutic effectiveness and dosages of medications used in obese patients must be critically evaluated. Maintaining patency of chest tubes does not require stripping and milking, which probably do more harm than good. Daily interruption of sedation and judicious use of sedatives are appropriate in most patients receiving mechanical ventilation. Traditional chest physiotherapy does not help children with pneumonia, bronchiolitis, or asthma and does not prevent atelectasis after extubation. Critical care nurses are challenged to evaluate their individual practice and to adopt current evidence-based practice interventions into their daily practice.