The Voice of Travel Nurses: Facilitating Effective Staffing During Pandemic and Expansion-Related Demands in a Children's Hospital.

OBJECTIVE: The aim of this study was to explore the experience and perceived value of travel nurses in a children's hospital. BACKGROUND: Children's hospitals face unique challenges related to highly specialized care requirements and workforce expansion limitations. Travel nurses can augment nurse staffing capacity during times of intense demand and may offer insights as organizations seek to strengthen work environments. METHODS: Pediatric travel nurses currently contracted at the hospital were invited to participate in a focus group or interview. Content analysis was used to summarize information and identify themes. RESULTS: From the 56 participants, 5 themes emerged. The themes were financial, flexibility, searching for healthy work environments, nursing care, and solutions. CONCLUSIONS: Hearing the voices of travel nurses may offer valuable feedback to strengthen future professional practice environments.

Perceptions of Interprofessional Practitioners Regarding Pediatric Palliative Transports.

BACKGROUND: Pediatric palliative transport (PPT) is the practice of offering critically and terminally ill children requiring life-sustaining measures the opportunity to be discharged from the hospital to home or a hospice facility for end-of-life care. Although studies have shown PPT to favorably affect both children and their families, limited research exists on the perspectives of health care practitioners. OBJECTIVES: To understand the experience of interprofessional practitioners who have cared for a critically or terminally ill child during a PPT and their perception of PPT as a care option. METHODS: This study is a qualitative descriptive inquiry conducted using 8 focus groups. Participants included interprofessional staff from 4 specialty intensive care units, the pediatric advanced care team, and the critical care transport team at a quaternary, freestanding children's hospital. Content analysis was used to summarize themes and recommendations. RESULTS: Five overarching themes were identified: PPT as a care pathway, education, communication, support, and closure. Use of PPT was perceived as aligned with the hospital's mission of family-centered care and as providing a way for the health care team to support a family's choice. Participants recommended further development of information to guide communication and processes of care that would enhance the experience for families and staff and support PPT as a care pathway. CONCLUSIONS: Pediatric palliative transport is considered a feasible, valuable, and critical end-of-life intervention. The value that PPT has brought to participating families warrants continued investment in the intervention's standardization and enhancement.

Measuring Acuity and Pediatric Critical Care Nursing Workload by Using ICU CAMEO III.

BACKGROUND: The Intensive Care Unit Complexity Assessment and Monitoring to Ensure Optimal Outcomes (ICU CAMEO III) acuity tool measures patient acuity in terms of the complexity of nursing cognitive workload. OBJECTIVE: To validate the ICU CAMEO III acuity tool in US children's hospitals. METHODS: Using a convenience sample, 9 sites enrolled children admitted to pediatric intensive care units (ICUs). Descriptive statistics were used to summarize patient, nursing, and unit characteristics. Concurrent validity was evaluated by correlating the ICU CAMEO III with the Therapeutic Intervention Scoring System-Children (TISS-C) and the Pediatric Risk of Mortality III (PRISM III). RESULTS: Patients (N = 840) were enrolled from 15 units (7 cardiac and 8 mixed pediatric ICUs). The mean number of ICU beds was 23 (range, 12-34). Among the patients, 512 (61%) were diagnosed with cardiac and 328 (39%) with noncardiac conditions; 463 patients (55.1%) were admitted for medical reasons, and 377 patients (44.9%) were surgical. The ICU CAMEO III median score was 99 (range, 59-163). The ICU CAMEO complexity classification was determined for all 840 patients: 60 (7.1%) with level I complexity; 183 (21.8%) with level II; 201 (23.9%), level III; 267 (31.8%), level IV; and 129 (15.4%), level V. Strong correlation was found between ICU CAMEO III and both TISS-C (ρ = .822, P < .001) and PRISM III (ρ = .607, P < .001) scores, and between the CAMEO complexity classifications and the PRISM III categories (ρ = .575, P = .001). CONCLUSION: The ICU CAMEO III acuity tool and CAMEO complexity classifications are valid measures of patient acuity and nursing cognitive workload compared with PRISM III and TISS-C in academic children's hospitals.

#Healthcare: Patient and Family Uses and Perceptions of Health Care Social Media.

BACKGROUND/INTRODUCTION: Although social media is becoming a primary resource for information and support in all aspects of life, including health care, limited information is available describing social media use in parents whose child undergoes surgical care. OBJECTIVES/AIMS: The aims of this study were to describe how patients/families use social media to address health care needs and understand their perceptions of social media privacy and reliability. METHODS: A descriptive survey of 39 questions, both fixed choice and open ended, was distributed to a convenience sample of parents during their child's preoperative visit. Descriptive statistics were used to summarize fixed-choice responses. Content analysis was used to assess open-ended responses and comments. RESULTS: A total of 205 completed surveys were available for review. Overall, 195 (95.6%) reported using social media, with 70 (35%) using social media up to 5 times a day and another 61 (30.5%) using it 6 to 40 times a day. Respondents used social media for medical information (122/60.1%), to make health care decisions (53/26.5%), after a diagnosis (104/52%), after a medical visit (88/44%), and to update friends and family (129/65.5%). Most respondents were undecided (111/58.1%) when asked how reliable medical information was on social media sites, with 33 (17.3%) believing medical information to be "reliable to very reliable" on social media sites. Among the 61 comments received, 4 themes emerged: Spectrum of Social Media Use, Social Media and Health Care Interaction, Social Media as a Source of Support and Peer Experience, and Reliability of Social Media. DISCUSSION: Most respondents utilized social media for health care information while reporting feeling undecided on the reliability of the information. Understanding the multiple ways patients and families utilize social media provides health care members opportunities to discuss medical information, inform health care decision making, and support patient and family needs.

Iatrogenic withdrawal syndrome in specialty pediatric critical care.

AIM: To describe the occurrence of opioid and benzodiazepine withdrawal symptoms in a cohort of pediatric intensive care unit (PICU) patients, the characteristics of this group, and patterns of withdrawal scoring observed during medication weaning. BACKGROUND: Patients in the PICU are a complex and vulnerable population. Opioids and benzodiazepines are routinely administered in this setting. Providers must be equipped to recognize and assess symptoms of narcotic and benzodiazepine withdrawal. METHODS: A retrospective chart review was conducted to describe all patients admitted to the medical intensive care unit who received continuous infusions of morphine and midazolam during a one-year period. Patient demographics, diagnosis, and presence of co-morbidities were abstracted. The number of days on continuous infusions was measured, along with Withdrawal Assessment Tool-1 (WAT-1) scores and documented symptoms that could be associated with withdrawal. WAT-1 scoring ranges from 0 to 12, a WAT-1 score of 3 or higher is considered to indicate clinically significant withdrawal symptoms. Descriptive statistics were utilized to summarize demographic and clinical variables. RESULTS: Among 60 cases, patient ages ranged 5 weeks to 29 years (median 3.5 years). Eighty percent of patients had a primary respiratory diagnosis and 88.3% had one or more co-morbidities. Forty-four patients (73.3%) had symptoms consistent with withdrawal. Thirty-one percent of patients had a maximum WAT-1 score between 3 and 8. The majority of patients (55%) had a history of opioid and/or benzodiazepine exposure. CONCLUSIONS: The information learned highlights the need for ongoing conversation and continued study of how best to assess and manage withdrawal syndrome in pediatric critical care environments.

Macronutrient Analysis of Modified-Fat Breast Milk Produced by 3 Methods of Fat Removal.

BACKGROUND: Infants with chylothorax after congenital heart disease surgery are commonly treated using modified-fat breast milk. The effect of fat removal on breast milk macronutrients remains unclear. We compared macronutrient content of breast milk with breast milk skimmed using 3 methods, including a novel device, a cream separator. METHODS: Thawed frozen breast milk samples from 30 women were defatted using refrigerated centrifuge, cream separator, and manual separation after refrigeration. We used standard assays to measure energy, protein, and fat content of breast milk samples. RESULTS: All fat removal methods yielded skimmed breast milk with substantially lower fat and energy content. Mean energy content in breast milk skimmed by centrifuge (36.7 [SD 3.6] kcal/100 mL) was similar to that from cream separator (38.8 [3.5] kcal/100 mL). Both centrifuge and cream separator methods removed almost all fat and substantially more fat than the manual fat removal method. For unprocessed milk, energy and fat content estimated by creamatocrit was similar to reference method measurements; in skimmed milk, the creamatocrit significantly overestimated fat content. Mean protein content of skimmed breast milk was similar to unprocessed breast milk (mean 1.25 [0.31] g/100 mL). CONCLUSION: Breast milk fat removal did not significantly alter protein levels. In skimmed breast milk, the overestimation of fat content using creamatocrit method suggests a need for more accurate bedside methods to assess macronutrient content. The similar macronutrient composition of breast milk skimmed by cream separator and centrifuge suggests the potential for cream separator use as a new, portable defatting method for hospitals and families.

Interprofessional Use and Validation of the AACN Healthy Work Environment Assessment Tool.

BACKGROUND: Health care work environments affect patient outcomes, staff satisfaction and retention, and organizational financial viability. The American Association of Critical-Care Nurses (AACN) Healthy Work Environment Assessment Tool (HWEAT) is a resource for patient care units and organizations to assess the work environment and track progress on their journey to excellence. OBJECTIVE: To validate interprofessional use of the AACN HWEAT across a large free-standing children's hospital. METHODS: The AACN HWEAT was administered to staff members across professional categories. Responses were averaged to achieve an overall score and a score for each standard included in the instrument. Nurses' and physicians' scores were further stratified. Test-retest reliability and internal consistency were assessed. Construct validity was measured by correlating the AACN HWEAT and the Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety Culture (H-SOPS). RESULTS: Of 2621 AACN HWEAT surveys, 1030 (39.3%) were returned for review. The organization-wide HWEAT mean overall score was 3.58 (3.87 for physicians vs 3.54 for nurses, P= .02). Test-retest reliability was indicated by Spearman correlation coefficients of 0.50 to 0.68. Internal consistency was shown by a Cronbach α of 0.77 overall (range for standards, 0.77-0.81). Convergent validity between AACN HWEAT standards and AHRQ H-SOPS items was shown by correlation coefficients of 0.30 to 0.52. CONCLUSION: The AACN HWEAT was both reliable and valid, supporting its interprofessional use as an organizational measure. Active evaluation of health care environments is critical to achieving optimal patient outcomes.

Informing Leadership Models: Nursing and Organizational Characteristics of Neonatal Intensive Care Units in Freestanding Children's Hospitals.

BACKGROUND: Neonatal intensive care units (NICUs) located in freestanding children's hospitals may exhibit significant variation in nursing and organizational characteristics, which can serve as opportunities for collaboration to understand optimal staffing models and linkages to patient outcomes. OBJECTIVES: Adopting methods used by Hickey et al in pediatric cardiovascular critical care, the purpose of this study was to provide a foundational description of the nursing and organizational characteristics for NICUs located in freestanding children's hospitals in the United States. METHODS: Clinical nurse leaders in NICUs located in freestanding children's hospitals were invited to participate in an electronic cross-sectional survey. Descriptive analyses were used to summarize nursing and organizational characteristics. RESULTS: The response rate was 30% (13/43), with 69.2% of NICUs classified as level III/IV and 30.8% classified as level II/III. Licensed bed capacity varied significantly (range, 24-167), as did the proportion of full-time equivalent nurses (range, 71.78-252.3). Approximately three-quarters of staff nurses held baccalaureate degrees or higher. A quarter of nurses had 16 or more years (26.3%) of experience, and 36.9% of nurses had 11 or more years of nursing experience. Nearly one-third (29.2%) had 5 or less years of total nursing experience. Few nurses (10.6%) held neonatal specialty certification. All units had nurse educators, national and unit-based quality metrics, and procedural checklists. CONCLUSION: This study identified (1) variation in staffing models signaling an opportunity for collaboration, (2) the need to establish ongoing processes for sites to participate in future collaborative efforts, and (3) survey modifications necessary to ensure a more comprehensive understanding of nursing and organizational characteristics in freestanding children's hospital NICUs.

Validation of the Children's Hospital Early Warning System for Critical Deterioration Recognition.

OBJECTIVE: Early warning scores, such as the Children's Hospital Early Warning Score (CHEWS), are used by hospitals to identify patients at risk for critical deterioration and trigger clinicians to intervene and prevent further deterioration. This study's objectives were to validate the CHEWS and to compare the CHEWS to the previously validated Brighton Pediatric Early Warning Score (PEWS) for early detection of critical deterioration in hospitalized, non-cardiac patients at a pediatric hospital. DESIGN AND METHODS: A retrospective cohort study reviewed medical and surgical patients at a quaternary academic pediatric hospital. CHEWS scores and abstracted PEWS scores were obtained on cases (n=360) and a randomly selected comparison sample (n=776). Specificity, sensitivity, area under the receiver-operating characteristic curves (AUROC) and early warning times were calculated for both scoring tools. RESULTS: The AUROC for CHEWS was 0.902 compared to 0.798 for PEWS (p<0.001). Sensitivity for scores ≥3 was 91.4% for CHEWS and 73.6% for PEWS with specificity of 67.8% for CHEWS and 88.5% for PEWS. Sensitivity for scores ≥5 was 75.6% for CHEWS and 38.9% for PEWS with specificity of 88.5% for CHEWS and 93.9% for PEWS. The early warning time from critical score (≥5) to critical deterioration was 3.8h for CHEWS versus 0.6h for PEWS (p<0.001). CONCLUSION: The CHEWS system demonstrated higher discrimination, higher sensitivity and longer early warning time than the PEWS for identifying children at risk for critical deterioration.

Creating Opportunities for Optimal Nutritional Experiences for Infants With Complex Congenital Heart Disease.

INTRODUCTION: To our knowledge, successful breastfeeding in the population with single ventricle congenital heart disease has not been reported in the literature, particularly during the interstage period. METHOD: A retrospective case study including inpatient nutrition and a complete history of daily logs with the home surveillance monitoring program was performed. RESULTS: Successful full breastfeeding (exceeding prescribed weight growth goals) after Stage I surgery was achieved during the interstage period. The infant was discharged at 3.41 kg, not consistently breastfeeding, and progressed to 7.05 kg at 5 months of age, fully breastfeeding. CONCLUSION: Supporting breastfeeding for infants who have undergone repairs for single ventricle anatomy can be challenging but can be accomplished. It requires a concerted team effort, clear communication, and collaboration among caregivers, the mother, and her supporters.

Implementing a Distraction-Free Practice With the Red Zone Medication Safety Initiative.

BACKGROUND: The incidence of medication errors remains a continued concern across the spectrum of health care. Approaches to averting medication errors and implementing a culture of safety are key areas of focus for most institutions. We describe our experience of implementing a distraction-free medication safety practice across a large free-standing children's hospital. METHODS: A nurse-led interprofessional group was convened to develop a program-wide quality improvement process for the practice of medication safety. A key driver diagram was developed to guide the Red Zone Medication Safety initiative. Change acceleration process was used to evaluate the implementation and impact of the initiative. RESULTS: Since implementation in 2010, there has been a significant reduction in medication events of 79.2% (P = .00184) and 65.3% (P = .035) (in the cardiac intensive care unit and acute care cardiac unit, respectively), including months with unprecedented zero reportable medication events. There also has been a sustained decrease in the number of events reaching the patient (33.3% in the cardiac intensive care unit and 57.1% in the acute care cardiac unit). CONCLUSIONS: The implementation of a distraction-free practice was found to be feasible and effective, demonstrating a sustained decrease in the overall number of medication events, event rate, and number of events reaching patients. This interprofessional approach was successful in a large inpatient cardiovascular program and then effectively transferred across all hospital inpatient units. Additional sites of implementation include other high-risk patient care areas such as procedure/operative units.

Measurement of Quality of Nursing Practice in Congenital Cardiac Care.

BACKGROUND: The impact of nursing care on patients' outcomes has been demonstrated in adult and pediatric settings. However, limited attention has been given to standardized measurement of pediatric nursing care. A collaborative group, the Consortium for Congenital Cardiac Care Measurement of Nursing Practice, was formed to address this gap. The purpose of this study was to assess the current state of measurement of the quality of pediatric cardiovascular nursing in freestanding children's hospitals across the United States. METHODS: A qualitative descriptive design was used to assess the state of measurement of nursing care from the perspective of experts in pediatric cardiovascular nursing. Nurse leaders from 20 sites participated in audiotaped phone interviews. The data were analyzed by using conventional content analysis. RESULTS: Each level of data coding was increasingly comprehensive. Guided by Donabedian's quality framework of structure, process, and outcome, 2 encompassing patterns emerged: (1) structure and process of health care delivery and (2) structure and process of evaluation of care. Similarities in the structure of health care delivery included program expansion and subsequent hiring of nurses with a bachelor of science in nursing and experienced nurses to provide safety and optimal outcomes for patients. Programs varied in how they evaluated care in terms of structure, measurement, collection and dissemination of data. CONCLUSION: External factors and response to internal processes of health care delivery were similar in different programs; evaluation was more varied. Seven opportunities for measurement that address both structure and process of nursing care were identified to be developed as benchmarks.

Complexity Assessment and Monitoring to Ensure Optimal Outcomes Tool for Measuring Pediatric Critical Care Nursing.

BACKGROUND: Historically, nursing productivity has been measured in adult settings and based on time, intensity, and resource allocation. OBJECTIVE: To develop a comprehensive measure of pediatric critical care nursing workload. METHODS: An expert panel of pediatric critical care nurses used a modified Delphi method to identify 14 domains of nursing care with a number of corresponding care items in each domain. By consensus, they assigned each care item a cognitive complexity rating from 1 to 5. The panel next developed a classification system (classes I-V) to support interpretation of the patient's total score. The Complexity Assessment and Monitoring to Ensure Optimal Outcomes (CAMEO) tool was initiated with a cohort of 75 pediatric cardiac critical care patients to verify comprehensive capture of nursing care. Results of completed CAMEO tools were summarized by using descriptive statistics. RESULTS: The cognitive workload across 14 domains of care was described, and each care item in the domain was scored. The range of CAMEO total scores was 25 to 230 (median, 124). For the initial cohort of patients, the cognitive complexity of care classifications were 13% as class I or II, 80% as class III or IV, and 7% as class V. CONCLUSIONS: The CAMEO tool was comprehensive in describing and quantifying the cognitive workload of pediatric critical care nurses. The CAMEO classification process informs staffing needs that support synergy between the needs of patients and their families and nurses' knowledge and skill. Articulation of nursing care focused on informed clinical decision making is needed to justify the value of skilled nurses.

Heat retention head wrap for rewarming infants undergoing cardiopulmonary bypass surgery.

BACKGROUND: A major postoperative problem for infants undergoing cardiopulmonary bypass surgery is hypothermia. OBJECTIVE: To determine the safety and feasibility of a newly designed Heat Retention Head Wrap on infants during the rewarming period of cardiopulmonary bypass surgery. METHODS: A sample of 10 infants was recruited into this descriptive pilot study. The health care providers completed ease-of-use questionnaires to describe the feasibility of the head wrap. Interval body temperatures were recorded to characterize temperature progression from onset of rewarming to arrival in the cardiac intensive care unit (ICU) and were compared with the temperature progression of a similar group of nonparticipants. Adverse events were recorded on the basis of perioperative body temperatures and skin assessments. RESULTS: The head wrap was easily applied to the infant's head and was removed without difficulty. A steady increase in median body temperature from (1) the onset of rewarming (28°C), to (2) removal of bypass cannulas (28.9°C), to (3) removal of the rectal temperature probe before transfer from the operating room to the cardiac ICU (34.5°C), and (4) upon arrival in the cardiac ICU (36.0°C) was observed. No skin lesions or temperature-related adverse events were observed. CONCLUSIONS: The newly designed Heat Retention Head Wrap was associated with a gradual normalization of temperature during rewarming and did not interfere with routine perioperative care of infants undergoing bypass surgery. This pilot study indicates that the head wrap is both safe and feasible for use in infants undergoing cardiopulmonary bypass surgery.

Management of peripherally inserted central catheters (PICC) in pediatric heart failure patients receiving continuous inotropic support.

The study aim was to evaluate present practice of maintaining PICC line patency in pediatric heart failure patients receiving continuous inotropes by comparing one cohort receiving low dose continuous heparin with one receiving no heparin. A case control retrospective chart review compared the two cohorts on duration of patency (measured in days) and need for thrombolytic agents. Median duration of patency for the heparin group was 24 days versus 16 days for the no heparin group (p=0.07). Use of thrombolytic agents was 28% in the heparin group compared to 50% in the no heparin group (p=0.08). Although not statistically significant, findings were clinically significant and supportive of current practice.

Coping while caring for the dying child: nurses' experiences in an acute care setting.

The aim of this study was to describe and understand behavior and coping strategies used by pediatric nurses caring for dying children on an inpatient acute care cardiology unit. Qualitative descriptive methods consisting of semistructured questions were presented to acute care nurses participating in focus groups. The nurses who participated in the focus groups had cared for an acutely ill child who died. Conventional content analysis was used to analyze data and organize results. The categories that emerged included the following: boundaries, memories, disconnecting, and labeling. Colleague support, institutional resources, and nurses' experience level were critical to the process of coping. Coping and grieving are facilitated by colleague and unit resources. Studies exploring job dissatisfaction, stress, and burnout from an inadequate grieving process are required.

Paediatric nurse practitioner managed cardiology clinics: patient satisfaction and appointment access.

AIM: This article summarizes a comparative study of patient/family satisfaction and appointment wait times in physician managed vs. paediatric nurse practitioner managed cardiology clinics. BACKGROUND: Appointment wait times exceeded 40 days in the outpatient cardiology department at a children's hospital. To address the gap in available appointments, paediatric nurse practitioner managed cardiology clinics were implemented. METHODS: A sample of 128 patients who presented concurrently in physician or paediatric nurse practitioner managed cardiology clinics from December 2009 through February 2010 was recruited for participation. The hospital's ambulatory patient satisfaction survey was utilized to measure level of patient satisfaction with care. Survey responses were evaluated using Fisher's exact test. Appointment wait times were compared pre and post implementation of paediatric nurse practitioner managed clinics. RESULTS: Sixty-five physician families and 63 paediatric nurse practitioner families completed the satisfaction survey. There was no statistically significant difference in patient satisfaction between clinic types. Appointment wait time decreased from 46 to 43 days, which was not statistically significant. Paediatric nurse practitioner clinics included a statistically higher percentage total of urgent appointments compared to that in physician clinics. CONCLUSIONS: Paediatric nurse practitioner managed cardiology clinics are a strategic solution for improving patient access and facilitating high quality patient care while earning high levels of patient satisfaction. This healthcare delivery model illustrates the potential for expanded utilization of advanced practice nurses.

The meaning of cost for families of children with congenital heart disease.

INTRODUCTION: The purpose of this study was to describe the cost burden of congenital heart disease (CHD) and the associated social impact as experienced by families. METHOD: Qualitative methods were used to collect and interpret data. Semi-structured interviews were conducted with parents of children with various degrees of CHD complexity and socioeconomic status currently admitted for congenital heart surgery at a large tertiary care regional center. RESULTS: The meaning of cost burden as defined by participants resulted in the emergence of two major categories, lifestyle change and uncertainty. Cost was described beyond monetary terms and as a result, data in each category were further clustered into three underlying subcategories labeled financial, emotional, and family burden. The child's disease complexity and parent's socioeconomic status seem to be linked to higher levels of stress experienced in terms of finances, emotional drain, and family member burden. Prenatal diagnosis was noted to trigger early discussion of financial uncertainty, often resulting in altered personal spending prior to birth. DISCUSSION: The cost experienced by parents of children with complex CHD was described as both life-changing and uncertain. Informing families of these types of additional stressors may allow issues of finances to be considered early in the overall preparation of caring for a child with complex CHD.

Hypoplastic left heart syndrome.

Hypoplastic left heart syndrome (HLHS) refers to the abnormal development of the left-sided cardiac structures, resulting in obstruction to blood flow from the left ventricular outflow tract. In addition, the syndrome includes underdevelopment of the left ventricle, aorta, and aortic arch, as well as mitral atresia or stenosis. HLHS has been reported to occur in approximately 0.016 to 0.036% of all live births. Newborn infants with the condition generally are born at full term and initially appear healthy. As the arterial duct closes, the systemic perfusion becomes decreased, resulting in hypoxemia, acidosis, and shock. Usually, no heart murmur, or a non-specific heart murmur, may be detected. The second heart sound is loud and single because of aortic atresia. Often the liver is enlarged secondary to congestive heart failure. The embryologic cause of the disease, as in the case of most congenital cardiac defects, is not fully known. The most useful diagnostic modality is the echocardiogram. The syndrome can be diagnosed by fetal echocardiography between 18 and 22 weeks of gestation. Differential diagnosis includes other left-sided obstructive lesions where the systemic circulation is dependent on ductal flow (critical aortic stenosis, coarctation of the aorta, interrupted aortic arch). Children with the syndrome require surgery as neonates, as they have duct-dependent systemic circulation. Currently, there are two major modalities, primary cardiac transplantation or a series of staged functionally univentricular palliations. The treatment chosen is dependent on the preference of the institution, its experience, and also preference. Although survival following initial surgical intervention has improved significantly over the last 20 years, significant mortality and morbidity are present for both surgical strategies. As a result pediatric cardiologists continue to be challenged by discussions with families regarding initial decision relative to treatment, and long-term prognosis as information on long-term survival and quality of life for those born with the syndrome is limited.

Otolaryngologists' responses to errors and adverse events.

OBJECTIVES: The objectives of this study were to describe otolaryngologists' emotional reactions to errors and adverse events, their efforts to take responsibility, and their attempts to implement improvements. STUDY DESIGN AND METHODS: A retrospective, anonymous survey of 2,500 U.S. otolaryngologists who were members of the American Academy of Otolaryngology-Head and Neck Surgery about errors in their practice was conducted. Respondents were asked whether an error had occurred in their practice in the past 6 months and, if so, to describe the error, its consequences, and any corrective actions taken. Two aspects of these reports stood out, which were beyond the scope of the original study: the respondents' emotional responses and their corrective actions. RESULTS: The response rate was 18.6%. Two hundred ten (45%) respondents reported a total of 212 analyzable error reports and 230 corrective actions. Corrective actions included disclosure to the patient (20 [9%]), ameliorating the consequences of the event to the patient (107 [50%]), personal practice changes (14 [7%]), improvements in the respondent's practice or department (60 [28%]), and hospitalwide or broader corrective actions (19 [9%]). Emotional reactions to errors and adverse events were reported by 22 (10%) otolaryngologists, including regret, embarrassment, guilt, anxiety, loss of temper, and irritation. Legal action was mentioned by five physicians (2%). CONCLUSIONS: Otolaryngologists took actions not only to treat their patients, but also to improve patient care in their practice, department, hospital, or community. Emotional reactions to errors and adverse events are common and need to be addressed in medical training and practice.