Children's Hospital Ambulatory Response to the 2019 Novel Coronavirus Disease (COVID-19) Pandemic.

The 2019 novel coronavirus disease (COVID-19) pandemic produced an abrupt and near shutdown of nonemergent patient care. Children's National Hospital (CNH) mounted a multidisciplinary, coordinated ambulatory response that included supply chain management, human resources, risk management, infection control, and information technology. To ensure patient access, CNH expanded telemedicine and instituted operational innovations for outpatient procedures. While monthly in-person ambulatory subspecialty visits decreased from 25 889 pre-COVID-19 to 4484 at nadir of the COVID-19 pandemic, telemedicine visits increased from 70 to 13 539. Further studies are needed to assess the impact of innovations in health care delivery and operations that the crisis prompted.

A Multimodal Quality Improvement Curriculum for Pediatric GME Program Directors.

The 2016 Accreditation Council for Graduate Medical Education Clinical Learning Environment Review report identified knowledge gaps for quality in the clinical environment. It suggested quality improvement (QI) training is necessary to develop skills to improve health care quality. However, at the authors' institution, there is limited department-level QI mentorship and engagement, thus limiting QI experiences for residents and fellows. The authors developed pediatric graduate medical education program director (PD) proficiency in QI through a fellowship-focused QI project. PDs underwent an 18-month QI curriculum consisting of focused online QI education, a half-day workshop, additional QI didactic sessions, project presentations, and individual QI coaching. QI knowledge in 9 domains and participants' confidence were assessed. Participants' self-perceived confidence and skills increased by at least 20% in most domains. Overall, PDs felt prepared to help with their fellows' future QI projects. Fellowship-focused QI projects and individual coaching were key to course engagement.

A Quality Improvement Project to Improve Documentation and Awareness of Limitations of Life-Sustaining Therapies.

PURPOSE: Poor documentation and understanding of the limitations of life-sustaining therapies upon admission to the pediatric intensive care unit (PICU) can result in moral distress for both providers and families. Limitations of life-sustaining treatments are often not documented and/or understood by members of the health care team. METHODS: We performed a quality improvement initiative to improve the care teams' understanding and paper documentation of the limitations of life-sustaining therapies in the PICU of a quaternary children's hospital from January 2018 to March 2019. We implemented a series of plan-do-study-act cycles, including initiation of an updated rounding tool that included limitations of interventions, in-person and electronic information sessions, and implementation of a visual bedside tool to remind providers when limitations were present. Pre- and postintervention surveys were administered. RESULTS: Nursing paper documentation of limitations of life-sustaining therapies increased sequentially from 0% to 88% during plan-do-study-act cycles. Creating a specific area to document limitations on the nursing sheet resulted in the most significant increase in documentation (36.6 points). Nurses reported that they "always" document limitations, which increased from 10% to 38%. The percentage of nurses who understood patients' intervention limitations increased from 28% to 33%. CONCLUSIONS: Limitations of life-sustaining therapies in the PICU are nuanced and involve multiple stakeholders. Nursing education and designation of a section of intervention limitations in nursing daily goal paper documentation can increase comfort with therapeutic limitations in the PICU. Future studies should explore impacts on patient care and serve as a framework for the ultimate goal of improving documentation of care limitations and code status in the electronic medical record.

Correction to: Methods in the design and implementation of the Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) clinical trial.

AbstractFollowing publication of the original article [1], the authors notified us of a typing error in spelling Dr. Asario's name. The original publication has been corrected.

Methods in the design and implementation of the Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) clinical trial.

BACKGROUND: Few papers discuss the pragmatics of conducting large, cluster randomized clinical trials. Here we describe the sequential steps taken to develop methods to implement the Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) trial that tested the effect of a nurse-implemented, goal-directed, comfort algorithm on clinical outcomes in pediatric patients with acute respiratory failure. METHODS: After development in a single institution, the RESTORE intervention was pilot-tested in two pediatric intensive care units (PICUs) to evaluate safety and feasibility. After the pilot, the RESTORE intervention was simplified to enhance reproducibility across multiple PICUs. The final RESTORE trial was developed as a cluster randomized clinical trial where the unit of randomization was the PICU, stratified by PICU size, and the unit of inference was the patient. Study execution was revised based on our Data and Safety Monitoring Board's recommendation to consult with the Department of Health and Human Services' Office of Human Research Protection (OHRP) on how best to consent eligible subjects. OHRP deemed that the RESTORE intervention posed greater than minimal risk and that all enrolled subjects provide consent reflecting their level of participation. RESULTS: Thirty-one PICUs of varying size, organization and academic affiliation participated and over 2800 critically ill infants and children supported on mechanical ventilation for acute pulmonary disease were enrolled. The primary outcome for the trial was the duration of mechanical ventilation; secondary outcomes included time awake and comfortable, total sedative exposure and iatrogenic withdrawal symptoms. Throughout the clinical trial the investigative team worked to maintain treatment fidelity, enrollment milestones and co-investigator enthusiasm. We considered the potential impact of competing clinical trials through a decision-making framework. CONCLUSIONS: The RESTORE clinical trial was a large and complex multicenter study that has provided the necessary evidence to guide sedation practices in the field of pediatric critical care. Specific issues that were unique to this trial included level of consent, adding clinical sites to augment enrollment and evaluating the potential impact of competing clinical trials. TRIAL REGISTRATION: ClinicalTrials.gov , Identifiers: Pilot trial: NCT00142766 ; Retrospectively registerd on 2 September 2005. Cluster randomized trial: NCT00814099 . Registered on 23 December 2008.

Standardization of Postoperative Transitions of Care to the Pediatric Intensive Care Unit Enhances Efficiency and Handover Comprehensiveness.

INTRODUCTION: To determine the impact of standardization of postoperative transitions of care to the pediatric intensive care unit on handover efficiency and the quality of healthcare data exchange. METHODS: This was a prospective, pre-post observational study after standardization of postoperative transitions in a 44-bed pediatric intensive care unit in a 313-bed tertiary care pediatric hospital from April to July 2015. Standardization was completed using a multidisciplinary handover checklist. Primary outcomes were efficiency expressed as mean handover duration and the comprehensiveness of healthcare data exchange. RESULTS: Forty-seven postoperative transitions were observed of which 23 were preintervention and 24 were postintervention. After standardization, efficiency improved from 10.5 ± 5.4 to 7.8 ± 2.7 minutes (P < 0.05). Healthcare data exchanged between surgical, anesthesia, and critical care providers were more robust including intraoperative, historical, and anticipatory guidance (all P < 0.05). After intervention, attendance through completion of handover for surgical services increased from 13% to 88% (P < 0.05). CONCLUSIONS: Standardization of postoperative transitions improved efficiency, healthcare data exchange, and anticipatory planning. Future research is required to link standardization of transitions to improved patient outcomes and measure the development of shared mental models.