High reliability pediatric heart centers: Always working toward getting better.

PURPOSE OF REVIEW: The purpose of this review is to examine high reliability through the lens of a contemporary pediatric heart center, noting that continuous improvement, rather than perfection, should be embraced. Aiming to elevate topics with lesser attention, this review elaborates on key concepts and proposed considerations for maintaining a high reliability heart center. RECENT FINDINGS: As provision of care reaches a new complexity, programs are called upon to evaluate how they can bring their teams into the future of pediatric cardiac care. Although much has been written about high reliability in healthcare, it has not been explored within pediatric heart centers. Practical application of high reliability enables a shared mental model and aligns teams toward eliminating patient harm. Suggested facilitators of high reliability within heart center teams include interprofessional collaboration, recognition of nursing expertise, psychological safety, and structural empowerment void of hierarchy. SUMMARY: As the pediatric cardiac population evolves, care becomes more complex with a narrow margin of error. High reliability can guide continuous improvement. Acknowledging culture as the underpinning of all structure and processes allows teams to rebound from failure and supports the mission of rising to exceptional patient challenges.

HeartWatch: Implementing a Pediatric Heart Center Program to Prevent Cardiac Arrests Outside the ICU.

Pediatric patients with cardiovascular disease are at increased risk of cardiopulmonary arrest. Despite utilization of Cardiac Pediatric Early Warning Scores to identify patients at risk of decompensation, our institution had a twofold increase in cardiac arrests (CAs) in the acute care cardiology unit (ACCU) over 2 years. Through a quality improvement initiative, we developed a watcher program, HeartWatch, to reduce the CA arrest rate in the ACCU by 50% over the first year of implementation. Methods: HeartWatch aims to identify patients not adequately captured by Cardiac Pediatric Early Warning Scores who are at high risk for sudden decompensation. Inclusion criteria were developed and evaluated during pilot and implemented phases (April 2020-April 2021) and then monitored in a sustained phase through June 2022. Our primary outcome was the reduction in the out-of-ICU CA rate. Results: During the 13 months, we enrolled 169 patients, and the CA rate decreased from 0.7 to 0.33 per 1,000 patient days, a 53% reduction. The CA rate further decreased to 0.28 events per 1,000 patient days, a 60% reduction, by June 2022. The most common indications for HeartWatch inclusion were high-risk single-ventricle patients (31%) and patients with diminished ventricular function (20%). Conclusions: Implementation of HeartWatch was associated with a meaningful reduction in CA in the ACCU. Creating shared mental models for high-risk patients is essential for patient safety. Future work will optimize local processes that focus on the sustainability of our gains. We will also evaluate opportunities to adapt and implement a similar framework in other institutions to assess reproducibility.