Improved Code Team Performance and Outcomes After Implementation of Moderate Fidelity In Situ Simulation in a Pediatric Cardiac Acute Care Unit.

Children with cardiac disease suffer higher rates of in-hospital cardiac arrest. Cardiac arrest outside of the intensive care unit (ICU) is an infrequent event, which is a threat for suboptimal code team performance. Shorter time to the first epinephrine dose during cardiac arrest has been associated with improved survival and neurologic outcomes. Moderate fidelity in situ simulation training was implemented in the pediatric cardiac acute care unit (PCACU) to improve code team performance in August 2015. A small interprofessional team of simulation facilitators was developed that included nurses, physicians, and advanced practice providers. The primary outcome was time to first epinephrine dose in pulseless electrical activity (PEA) scenarios. Time to epinephrine of all simulation exercises, and actual cardiac arrests, that occurred in the PCACU were reviewed through May 2022. A total of 72 simulations were performed and 42 (58%) were PEA scenarios. A center line shift was observed for time to epinephrine for simulated PEA cardiac arrests (from 5 to 3 min). After implementation of simulation exercises, a center line shift was observed for time to epinephrine for actual cardiac arrests in the PCACU (from 8 to 2 min). Survival to hospital discharge after cardiac arrest improved after implementation of the training (0% vs. 64%, p = 0.02). Code team performance, as measured by time to epinephrine, can be improved following implementation of in situ simulation exercises in a pediatric cardiac acute care unit. Optimizing code team performance may contribute to improved patient outcomes.

Management of routine postoperative pain for children undergoing cardiac surgery: a Paediatric Acute Care Cardiology Collaborative Clinical Practice Guideline.

BACKGROUND: Pain following surgery for cardiac disease is ubiquitous, and optimal management is important. Despite this, there is large practice variation. To address this, the Paediatric Acute Care Cardiology Collaborative undertook the effort to create this clinical practice guideline. METHODS: A panel of experts consisting of paediatric cardiologists, advanced practice practitioners, pharmacists, a paediatric cardiothoracic surgeon, and a paediatric cardiac anaesthesiologist was convened. The literature was searched for relevant articles and Collaborative sites submitted centre-specific protocols for postoperative pain management. Using the modified Delphi technique, recommendations were generated and put through iterative Delphi rounds to achieve consensus. RESULTS: 60 recommendations achieved consensus and are included in this guideline. They address guideline use, pain assessment, general considerations, preoperative considerations, intraoperative considerations, regional anaesthesia, opioids, opioid-sparing, non-opioid medications, non-pharmaceutical pain management, and discharge considerations. CONCLUSIONS: Postoperative pain among children following cardiac surgery is currently an area of significant practice variability despite a large body of literature and the presence of centre-specific protocols. Central to the recommendations included in this guideline is the concept that ideal pain management begins with preoperative counselling and continues through to patient discharge. Overall, the quality of evidence supporting recommendations is low. There is ongoing need for research in this area, particularly in paediatric populations.

Improved outcomes after implementation of a specialized pediatric cardiac rapid response team.

INTRODUCTION: The efficacy of a specialized pediatric cardiac rapid response team is unknown. We hypothesized that a specialized cardiac rapid response team would facilitate team-wide communication between the cardiac stepdown unit and cardiac intensive care unit (ICU) teams and improve patient care. MATERIALS AND METHODS: A specialized pediatric cardiac rapid response team was implemented in June 2015. All pediatric cardiac rapid response team activations and outcomes from implementation through December 2018 were reviewed. Cardiac arrests and unplanned transfers to the cardiac ICU were indexed to 1000 patient-days to account for inpatient volume trends and evaluated over time. RESULTS: There were 202 cardiac rapid response team activations in 108 unique patients during the study period. After implementation of the pediatric cardiac rapid response team, unplanned transfers from the cardiac stepdown unit to the cardiac ICU decreased from 16.8 to 7.1 transfers per 1000 patient days (p = 0.012). The stepdown unit cardiac arrest rate decreased from 1.2 to 0.0 arrests per 1000 patient-days (p = 0.015). There was one death on the cardiac stepdown unit in the 5 years since the implementation of the cardiac rapid response team, compared to four deaths in the previous 5 years. CONCLUSIONS: A reduction in unplanned cardiac ICU transfers, cardiac arrests, and mortality on the cardiac stepdown unit has been observed since the implementation of a specialized pediatric cardiac rapid response team. A specialized cardiac rapid response team may improve communication and empower the interdisciplinary care team to escalate care for patients experiencing clinical decline.