Reducing Ischemic Injury From Indwelling Peripheral Arterial Catheters in a Pediatric Cardiac ICU: A Quality Improvement Initiative.

OBJECTIVES: To reduce the number of ischemic arterial catheter injuries in children with congenital or acquired heart disease. DESIGN: This is a quality improvement study with pre- and postintervention groups. SETTING: University-affiliated pediatric cardiac center in a quaternary care freestanding children's hospital. PATIENTS: All patients with an indwelling peripheral arterial catheter placed in the Children's Hospital of Philadelphia Cardiac Center associated with an admission to the Cardiac Intensive Cardiac Unit from January 2015 to July 2017 are included. Patients with umbilical arterial catheters were excluded from the cohort. The rate of arterial catheter injury is reported per 1,000 catheter days. The rate of "concerning" arterial catheter assessments is reported as a percentage of catheters per month. INTERVENTION: Initial intervention replaced intermittent manual arterial catheter flushing with a continuous arterial catheter infusion system during the delivery of anesthesia. The second intervention implemented a daily arterial catheter safety assessment during cardiac ICU rounds with documentation of the assessment in the cardiac ICU daily attending progress note. MEASUREMENTS AND MAIN RESULTS: Our project included 1,945 arterial catheters encompassing 7,197 catheter days. During the preintervention period, on average, 3.1 patients per month experienced an arterial catheter-related injury compared with 1.9 patients per month following intervention, a reduction of 38.7% (3.1 vs 1.9; p = 0.01). The rate of injury per 1,000 arterial catheter days was reduced from 16.7 pre intervention to 7.52 post intervention, a 55% overall reduction (16.7 vs 7.52; p = 0.0001). The rate of concerning arterial catheter nursing assessment based on our definition was reduced by 18.0% following our intervention cycles (25.5% vs 20.9%; p = 0.001) CONCLUSIONS:: Implementation of a quality improvement initiative and changing local practices reduced arterial catheter-associated harm in children with congenital and acquired heart disease requiring care in a cardiac ICU.

Improving Cardiac Surgical Site Infection Reporting and Prevention By Using Registry Data for Case Ascertainment.

BACKGROUND: The use of administrative data for surgical site infection (SSI) surveillance leads to inaccurate reporting of SSI rates [1]. A quality improvement (QI) initiative was conducted linking clinical registry and administrative databases to improve reporting and reduce the incidence of SSI [2]. METHODS: At our institution, The Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD) and infection surveillance database (ISD) were linked to the enterprise data warehouse containing electronic health record (EHR) billing data. A data visualization tool was created to (1) use the STS-CHSD for case ascertainment, (2) resolve discrepancies between the databases, and (3) assess impact of QI initiatives, including wound alert reports, bedside reviews, prevention bundles, and billing coder education. RESULTS: Over the 24-month study period, 1,715 surgical cases were ascertained according to the STS-CHSD clinical criteria, with 23 SSIs identified through the STS-CHSD, 20 SSIs identified through the ISD, and 32 SSIs identified through the billing database. The rolling 12-month STS-CHSD SSI rate decreased from 2.73% (21 of 769 as of January 2013) to 1.11% (9 of 813 as of December 2014). Thirty reporting discrepancies were reviewed to ensure accuracy. Workflow changes facilitated communication and improved adjudication of suspected SSIs. Billing coder education increased coding accuracy and narrowed variation between the 3 SSI sources. The data visualization tool demonstrated temporal relationships between QI initiatives and SSI rate reductions. CONCLUSIONS: Linkage of registry and infection control surveillance data with the EHR improves SSI surveillance. The visualization tool and workflow changes facilitated communication, SSI adjudication, and assessment of the QI initiatives. Implementation of these initiatives was associated with decreased SSI rates.

Just-in-Time Training for High-Risk Low-Volume Therapies: An Approach to Ensure Patient Safety.

High-risk low-volume therapies are those therapies that are practiced infrequently and yet carry an increased risk to patients because of their complexity. Staff nurses are required to competently manage these therapies to treat patients' unique needs and optimize outcomes; however, maintaining competence is challenging. This article describes implementation of Just-in-Time Training, which requires validation of minimum competency of bedside nurses managing high-risk low-volume therapies through direct observation of a return-demonstration competency checklist.

Development and Preliminary Testing of the Coordination Process Error Reporting Tool (CPERT), a Prospective Clinical Surveillance Mechanism for Teamwork Errors in the Pediatric Cardiac ICU.

BACKGROUND: Patient safety reporting systems (PSRSs) may not detect teamwork or coordination process errors that affect all dimensions of quality defined by the Institute of Medicine. This study aimed to develop and observe the performance of a novel tool, the Coordination Process Error Reporting Tool (CPERT), as a prospective clinical surveillance mechanism for teamwork errors in the pediatric cardiac ICU. METHODS: Providers and parents used the qualitative nominal group technique to identify coordination process error examples. Using categories developed from these discussions, the CPERT was designed and observed to assess agreement among providers and with the PSRS. For each patient at the end of each observed shift, the nurse, frontline clinician, and attending physician were invited to complete the CPERT online. Responses among providers were compared to assess interobserver agreement. Patients with errors identified by the CPERT were matched 1:1 with patients without CPERT errors within the same shift. The PSRS and medical record were reviewed to judge whether a coordination process error occurred and whether patients with CPERT errors differed from controls. RESULTS: Eight categories of errors were identified and incorporated into the CPERT. During 10 shifts (218 patients), the CPERT completion rate was 74%. Fifty-one patient shifts had errors identified by the CPERT (23%); these patients did not differ significantly from those without CPERT- reported errors. Only 5 CPERT-reported errors (10%) were identified by two or more providers. Of the 51 CPERT- reported errors, 43 (84%) were not documented in the PSRS. CONCLUSION: The CPERT detects coordination process errors not identified through PSRS, making it or similar tools potentially useful for improvement efforts.