All right. I also wanted to thank SCCM for the opportunity to present and Mark Hall for the lovely introduction. My name is Erin Paquette. I'm a pediatric intensivist in Chicago at Lurie Children's and Northwestern University, and I'm going to present a year in review for quality improvement studies. I have funding for work that is unrelated to my talk today and no other disclosures to report. So the learning objectives of this talk were to identify different approaches to quality improvement work in the PICU, to appreciate the relationship between education and QI work, as well as for you to be able to leave here remembering at least one QI initiative implemented in a PICU in the past year. So with that, I'll get started. The first study is by Dewan et al. This is the assessment of a situation awareness QI intervention to reduce cardiac arrests in the PICU. This study, the primary aim of the study was to decrease CPR events by 25% over a two-year period using CPR events per 1,000 patient days as their metric. This was studied in a population of patients admitted to the PICU from February 2017 to December of 2020. You can see from this slide, I'm not going to go through each of these individually, but there were a number of key drivers that were set out as the driving measures for this study. These were each mapped, and I think the importance of this slide is that each motivation or driver for the study was mapped to a number of interventions that were implemented in the PICU during this time. The first was the building and implementation of a warning tool that was universally applied. Then there were immediate and temporary warning signs placed at the bedside that then turned into a permanent bedside sign that outlined the risk factors and a mitigation plan for each patient. The PICUs had a combination of huddles and what they called puddles. So there were twice daily senior leadership huddles that required attendance from all levels of caregivers in the PICU, and then puddles, which were pod-based huddles that focused on a subset of patients to discuss patients who were watchers and provide safety updates for patients that had high risk of progression to cardiac arrest. There was a structured event review after every arrest event with shared learnings, continuing ongoing education and process review, and then there was an automated database to capture all events. They hypothesized that if they could improve accurate prediction of clinical deterioration events, they would then generate shared situational awareness that this would lead to decreased cardiac arrest and ultimately decreased mortality within the PICU. They had two process metrics that include their percent prediction of events that were predicted using their protocol versus all clinical deterioration events, and then accurate high risk status identification based on their measures implemented for this study and their mitigation plan versus all those of high risk status. And then their outcome metrics included arrest events and mortality. Their two primary balancing metrics were number needed to evaluate, which was 16, meaning that for every 16 patients labeled as high risk, they identified one deterioration event that would occur without this process in place. And then their huddle time, which was on average less than half a minute per huddle event, so not a high time-consuming intervention. They were able to demonstrate over the period of the study on the top graph showing CPR events per 1,000 patient days. The first half shows pre to the second half of the graph post-intervention, and these are the interventions that were employed along the x-axis here. They showed a 52% reduction in CPR events per 1,000 patient days over their time period, as well as a 45% reduction in their mortality rate. So I think that the main outcome or the main impact of that study was showing that shared situational awareness really could have a significant impact on both CPR events and mortality events within the PICU. The second study focuses on a type of QI work called human factor analysis and the use of identification of latent safety threats in a PICU. This was by Trovavich et al. So the background for this study is knowledge that adverse events can, when they reach the patient, lead to untoward clinical outcomes for our patients, that these often reflect a mismatch between people and their work environment, organization, tasks, or tools and technology that we have at our availability. That latent safety threats reflect the pre-contributory factors that result in adverse outcomes. These can be system-based threats that materialize at any time and shape the performance of individuals and teams within any clinical setting. And the understanding latent safety threats can help to broaden the scope and effectiveness of interventions designed to prevent adverse events. So what is human factors approach? This is a discipline that applies knowledge of human strengths and limitations to the design of work systems in order to ensure the optimization of those systems and to address real-world challenges through the use of frameworks and models. The framework that was employed for this study was the Systems Engineering Initiative for Patient Safety Framework, and this framework examines five interacting work system factors that can influence performance. These are the environment, organization, person, task, and tools and technologies that are available. The model that they used was one of migration and transgression of practices, and this model looks at mechanisms by which workers can potentially lead to patient harm, either through compliance with or transgression of policies and procedures. And compliance with policies and procedures, they termed legal behaviors in this study where deviance from them reflected illegal behaviors. And the hypothesis is generally that what we want to do is to avoid illegal behaviors, promote compliance with policies and procedures in order to reduce latent safety threats. So that was one of the primary objectives of this study was to look to see whether that was the case. This was a prospective observational study in a medical, surgical, and cardiac unit in a quaternary care facility over a five-month period. Individuals were directly observed among various roles in the critical care team, and they were human factor specialists that did this observation. They identified latent safety threats through inductive and deductive coding and consensus between two coders who looked at clinical activities, work system factors, and behaviors of these individuals. A total of 32 healthcare providers were observed for a period of 188 hours total of observation. They identified more than 225 unique latent safety threats. These involved 13 clinical activities, the most common of which involved transport, consulting, the time of handover or rounds, so critical communication, touch points during the day, and charting and documentation. They identified transgressions or issues along all five systems factors, and most importantly, I think this study demonstrated that they identified that these transgressions occurred nearly 25 percent of the time in what were termed legal behaviors. And so I think the major impact of this study is that promoting only compliance of policies and procedures will not address a good proportion, a quarter of latent safety threats that are occurring, potentially occurring in our critical care settings. And so we need to look more broadly and potentially observe other human systems factors that could be in play even when people are complying with set practices and procedures. The third study I'd like to review is Enhanced Efficiency in Pediatric Interfacility Transport through a Centralized Hospital System Communication Center. This is by Kronerich et al. So we know that specialized pediatric transport teams can improve patient outcomes and may be beneficial, therefore, to patients and hospital systems. The goal of this study was to look at the implementation of a new centralized communication center to coordinate inter and intra and interfacility transports of pediatric patients within a three hospital facilities in the same hospital system. They retrospectively compared data over two 12-month time periods with a washout year in between and stopping in 2018 due to a significant bed expansion that occurred following that time. They looked at four key indicators, including transport volume, dispatch time, missed transport opportunities, and time to patient acceptance. Over the course of the implementation of this intervention, they saw a 60.5% increase in their total number of completed transports. They were able to demonstrate a 15% reduction in time to physician acceptance of a patient transport and a 40% decrease in terms of dispatch time for the transport team to receive the patient. They were also overall able to demonstrate a 60% reduction in lost transports, I think, contributing the most to their increased number of transports that occurred over their intervention period. Here we go. Okay. The fourth study that I'd like to talk about to go through is video recorded in situ simulation before moving to a new combined neonatal pediatric intensive care facility. This study, the goal of it was to look at simulation-based education in order to try to identify and address potential pitfalls in moving to this new combined unit. We know that simulation-based education can be a successful tool for training teams and adapting to new environments. This study focused on technical and logistical processes with verbal debriefing to identify areas of potential problems and video recording in order to identify problems that might not have been identified by the surveys and the teams that participated directly in the intervention. In addition to simulating the processes to identify problems, they also evaluated staff satisfaction and anxiety about the move. They looked at four different scenarios that ranged from care for a neonate to care for an adolescent with a variety of different diagnoses. The participants who took part in this study were introduced to the facilities and oriented to them on the structural and infrastructural conditions. They had 15 minutes to prepare for each scenario. They were video recorded for observation and then debriefing focused on improving overall processes of care by summarizing the scenario, anchoring it within its clinical context, facilitating latent conditions, and then exploring active failures. The video review demonstrated problems along four areas, including infrastructure such as placement of items within rooms, technical like accessibility of equipment, structural including the conditions, overall structural conditions of the facility, and administrative such as processes in patient care, how labor was divided and time was managed. They did their first study simulation and a survey at that time. They moved to the new ICU, and then to look at how this was received over time, they did a second and third survey four and eight weeks after moving to the new unit. They used a known implementation framework model to evaluate their approach, and as I mentioned, they were able to demonstrate problems over four domains. The only point for me to put up here for you to see each of these is that there were problems and improvements that were able to be identified in each domain they examined. They were able to reach eight doctors and eight nurses, and then to expand the impact through to the entire ward using these four different scenarios. Overall, there were 91 difficulties identified and 53 that were able to be solved. In eight weeks following the intervention demonstrating the ability to maintain it, 93 percent of people stated that the suggestions or these 53 suggestions or improvements were at least partially still in place at that time. And overall, the people that participated felt that the simulation increased their feeling of being well-prepared to work in the new ICU environment. The last two studies I want to quickly review are studies that didn't follow strict QI frameworks or methodologies, but I think demonstrate quality improvement practices within our units that are well for us to be mindful of. The first by McSherry et al. looked at prognostic and goals of care communication in the PICU, which was a systematic review. We know that post-intensive care symptoms contribute to a number of prognostic complexities and uncertainties in our patients. The prognostic goals of care conversations as part of shared decision-making can help to address these and shape the experiences of patients and caregivers, and that goal-concordant care can optimize palliative care and communication in this setting. So through a structured systematic review, they looked at several perspectives that – I don't know why these slides are not projecting completely, but I'll review the key materials that looked at several perspectives and processes that helped to improve making goal-concordant care. The first was within caregivers and clinicians, and this was that the strengths that you can't see or satisfaction that you can't see was that people felt satisfied when they were able to have real-time communication with patients and families where they were able to ensure the understanding of patients and caregivers of the clinical information that they were trying to impart upon them. Families were unsatisfied by mishandling of communication, diminishing of parental concern, mishandling of hope, any behavior they perceived of as unprofessional, or if they felt that people were judging their child's worth. Families also felt themselves accountable for understanding the complexities and uncertainties of medical information, where you'll see on the flip side, the clinicians shared that feeling of responsibility. So there's a little bit of a mismatch in both feeling that that's a responsibility that they need to take on and an area for improvement. Moving on to the last study, which is Screening for Social Needs in Critically Ill Patients Addressing More Than Just Health Conditions by Maholtz et al. This study is based on our background knowledge that social needs in patients requiring critical care are little studied, but there's good literature that demonstrates poverty correlated with increased utilization of critical care resources and morbidity from critical care admission. The objective here was to develop an effective process to screen for social needs in patients admitted to a PICU. This included patients residing in a single high-risk community hospitalized from September 2020 to June 2021. They demonstrated that they were able to achieve high participation of eligible families at 60 percent. Eighty-nine percent of those families were comfortable with screening, which is a large area that's raised in the outpatient as well as inpatient setting for lack of screening for patients. Seventy-three percent of participants appreciated the screening processes. Sixty percent had greater than one or more unmet social needs. And all patients with identified needs required social work evaluation or involvement, which is leading to further QI work on pairing resources to these unmet needs. And with that, I will say thank you. My apologies for going a little bit over.

pediatric intensive care unit

quality improvement studies

cardiac arrests

situation awareness intervention

mortality