Hi, my name is Nora Coleman. I am a pediatric intensivist at Children's Healthcare of Atlanta with a passion for quality improvement and simulation. I'm excited to be here today to talk about quality, safety, and education in pediatric critical care medicine. The role of quality improvement has been long recognized as a strategy to drive change and impact patient outcomes. Quality improvement requires a collaborative and combined effort of healthcare professionals, especially frontline workers, as well as patients, their families, researchers, leaders, and educators. In the past decade, there's been a large increase in PICU quality improvement work. These interventions cover a wide range of approaches with a variety of targets. STEEP describes six characteristics of quality. These improvements should be safe, timely, effective, efficient, equitable, and patient-centered. As described in a recent paper by Inada et al., the most common clinical targets of QI interventions were healthcare-associated infections, handoffs, rounds, sedation and pain delirium, and medication safety, as well as unplanned excavations. Many studies were related to the safety effectiveness of these interventions. PICU addressed timeliness and patient-centeredness, and almost none published in PEDCCM addressed equity. The PICU environment is a highly complex environment and is challenged by constantly changing workflows and the complex interactions between people and elements of their work system. Ability to maintain high safety and quality of care requires a level of adaptive expertise to meet the demands of a high-stress environment where there are rapid changes in patient care needs and many competing priorities. In such a complex clinical environment, there are many challenges and barriers to implementing and sustaining improved quality of care. These barriers include team members that resist new and innovative quality improvement initiatives. There also is a requirement to change professional practice. It is important to understand how interprofessional staff perspectives impact the ability to sustain quality improvement initiatives, understanding things like staff buy-in, family engagement, the limitations in practical implementation and ability to safely and effectively integrate into workflow, how to bundle initiatives with other care elements, ability to understand resource constraints and utilizations, and ability to establish consistency across provider care delivery. Work as imagined does not always equate to work as done, and understanding these limitations and nuances in unit-specific culture and the micro-work system is essential to optimally implement and effectively integrate QI initiatives. Elucidating barriers early on are essential to the facilitation of solutions that address barriers in implementation and promote sustainability and success. There are also many challenges in reporting of QI research. The publication of quality improvement research studies has increased in pediatric critical care medicine over the past 10 years. However, the quality and reporting of QI-focused research is variable, highlighting an opportunity for the community to improve upon our approach to reporting quality and work. Limitations to extrapolate learning, improve patient outcomes, and demonstrate return on investment are impacted by failure to apply rigorous methodology, address the local problem in context, failure to describe problem drivers and PDSA cycles, and incorporate statistical analysis. In a study also done by Inada et al. in 2021 PEDCCM, there was the conduction of extensive review of published QI work. In 2400 published manuscripts, 6.5% of PEDCCM papers qualified as legitimate QI based on the quality improvement minimum quality criteria set, and only 6% of those papers referenced SQUIRE guidelines. This study by Bartman et al., published in PEDCCM in 2021, discusses that we must improve quality-focused research by raising the quality of QI project execution, manuscript writing, and peer review. With a focus on what should be and how we get there, our patients everywhere will benefit. Below are some of the requirements for QI research described in this paper. First, we'll talk about problem description. QI projects must include the rationale and discuss where we are and where we are going. Next, it's important in the context to consider and report individual specifics at the institution where the QI initiative was being implemented. It is important to apply the model for understanding success in quality, ensuring that the context is high-quality research. It is also important to discuss how we measure quality improvement data. There should be a precise description of what is and what is not accounted for. This requires at least one process and one outcome measure to link intervention with outcome. In the analysis portion of manuscript writing, we must analyze and report QI data using things like interrupted time series or process control charts to display normal variation in system performance over time. And finally, in the interpretation of data, we must discuss why the intervention did or did not work, why the change magnitude was larger or smaller than observed, what was the degree of improvement, what the degree of improvement reveals about the interplay between interventions and system. In order to raise the bar on the quality of published QI data, there's three components, QI execution, writing, and peer review. Many institutions are now offering training options for practicing faculty. Institutions without such programs should consider developing internal courses or send PICU staff to external courses. All QI publications should adhere to the SQUIRE guidelines and incorporate the majority of the components. Peer reviewers are also instrumental in driving improvement in manuscript quality. Reviewers should critique papers and look for significant work that can be generalizable, work that is novel even when placed in the context of previous work, a well-designed project that incorporates QI science tools and methods, and the SQUIRE guide lighting formatting. To review the quality and simulation studies published in PEDCCM in 2021, I will be focusing on the three papers below and quickly provide a short review of each paper. This study, eSimpler, a dynamic electronic health record integrated checklist for clinical decision support during PICU daily rounds, was this quality improvement study that occurred in a quaternary PICU in an academic freestanding children's hospital. The goal of this study was to design, implement, and evaluate a rounding checklist that was embedded into the electronic health record. This new dynamic checklist was compared to a former static checklist that was used in 2011. Dynamic checklists, as opposed to static ones, not only display data appropriate to a patient's clinical context, such as is the endotracheal tube position relevant for intubated patients, but also provides electronic health record data relevant to the checklist item. These dynamic checklists enhance situational awareness by allowing the comparison of patient's intended care plan with actual care ordered and documented. The eSimpler tool was a clinical decision support tool with prompts that displayed relevant data automatically pulled from the electronic health record. eSimpler was implemented for 49,000 patient days over six months. Several checklist-driven processes were measured and studied. These included increased prescription of mechanical or pharmacologic VTE prophylaxis, recognition of renal dysfunction, and central catheter utilization. In conclusion, eSimpler was a dynamic electronic health record informed checklist that required less time to complete and improved certain care process compared with the prior static checklist with limited electronic health record data. In this study, early mobilization in a PICU, a qualitative sustainability analysis of PICU-UP, presented a semi-structured phone interviews to characterize interprofessional staff perspectives of the PICU-UP program. Using data saturation, thematic analysis was performed on interview transcripts. The purpose of this study was to identify staff-reported factors and perceptions that influenced implementation and sustainability of an early mobilization program in the PICU. Fifty-two staff members across multiple disciplines were interviewed. Three themes emerged. Those were factors influencing the implementation process, staff perceptions of PICU-UP, and improvements in program integration. In conclusion, three years after implementation, the PICU-UP remained well-received by staff, although there were several barriers that remain relevant, and those were consistent with execution of early mobility, challenges with resource management, sedation decisions, and patient heterogeneity. This study highlights the importance of understanding staff perception in order to identify barriers and develop solutions that can grow and strengthen PICU mobility initiatives. The COVID-19 pandemic influenced medical education and simulation training worldwide. This study, Readiness for and Response to Coronavirus Disease 2019 Among Pediatric Health Care Providers, the Role of Simulation for Pandemics and Other Disasters, was an international survey study aimed to characterize self-reported efforts by the pediatric simulation community. The survey was sent to 555 individual members of three large international pediatric simulation societies. The study highlighted differences between the intercontinental geographic regions in terms of COVID-19-based simulations and continuation of non-COVID-19 education-based sims. Although most participants in the American region and India initiated educational activities for the care of COVID-19 patients, this was only true for 47% of European respondents. Frequent modifications to existing simulation programs included the use of telesimulation and virtual reality training. Forty-nine percent of institutions discontinued non-coronavirus 2019-related simulation training. In-situ simulation was the most prevalent training mode for COVID-19 simulations. This focused on airway management and cardiopulmonary resuscitation. The differences in the use of telesimulation were striking as many resource-rich regions did not adopt their approach as frequently as expected. In conclusion, the swift incorporation of disease-specific sessions and the transition of standard education to virtual or hybrid simulation training modes occurred frequently. This approach depended heavily on local requirements, limitations, and circumstances. In particular, the use of telesimulation allowed education to continue while maintaining social distancing requirements. In summary, quality improvement plays a major role in the outcomes of our pediatric patients. Implementations of quality initiatives depends on understanding local barriers in staff perception and unit-based culture and addressing those limitations to ensure success and sustainability of QI initiatives. As the pediatric critical care community continues to engage in QI-based research, there is an opportunity to raise the bar, aiming for higher quality, project execution, rigorous data analysis reporting, and critical peer review.

quality improvement

safety

education

pediatric critical care medicine

collaboration