Caregivers' and providers' perspectives of social and medical care after pediatric liver transplant: Results from the multicenter SOCIAL-Tx study.

Disparities exist in pediatric liver transplant (LT). We characterized barriers and facilitators to providing transplant and social care within pediatric LT clinics. This was a multicenter qualitative study. We oversampled caregivers reporting household financial strain, material economic hardship, or demonstrating poor health literacy. We also enrolled transplant team members. We conducted semistructured interviews with participants. Caregiver interviews focused on challenges addressing transplant and household needs. Transplant provider interviews focused on barriers and facilitators to providing social care within transplant teams. Interviews were recorded, transcribed, and coded according to the Capability, Opportunity, Motivation-Behavior model. We interviewed 27 caregivers and 27 transplant team members. Fifty-two percent of caregivers reported a household income <$60,000, and 62% reported financial resource strain. Caregivers reported experiencing (1) high financial burdens after LT, (2) added caregiving labor that compounds the financial burden, (3) dependency on their social network's generosity for financial and logistical support, and (4) additional support being limited to the perioperative period. Transplant providers reported (1) relying on the pretransplant psychosocial assessment for identifying social risks, (2) discomfort initiating social risk discussions in the post-transplant period, (3) reliance on social workers to address new social risks, and (4) social workers feeling overburdened by quantity and quality of the social work referrals. We identified barriers to providing effective social care in pediatric LT, primarily a lack of comfort in assessing and addressing new social risks in the post-transplant period. Addressing these barriers should enhance social care delivery and improve outcomes for these children.

Caregiver perspectives on the everyday medical and social needs of long-term pediatric liver transplant patients.

Using in-depth interviews, we sought to characterize the everyday medical and social needs of pediatric liver transplant caregivers to inform the future design of solutions to improve care processes. Participants (parents/caregivers of pediatric liver transplant recipients) completed a survey (assessing socioeconomic status, economic hardship, health literacy, and social isolation). We then asked participants to undergo a 60-min virtual, semistructured qualitative interview to understand the everyday medical and social needs of the caregiver and their household. We intentionally oversampled caregivers who reported a social or economic hardship on the survey. Transcripts were analyzed using thematic analysis and organized around the Capability, Opportunity, Motivation-Behavior model. A total of 18 caregivers participated. Of the participants, 50% reported some form of financial strain, and about half had less than 4 years of college education. Caregivers had high motivation and capability in executing transplant-related tasks but identified several opportunities for improving care. Caregivers perceived the health system to lack capability in identifying and intervening on specific family social needs. Caregiver interviews revealed multiple areas in which family supports could be strengthened, including (1) managing indirect costs of prolonged hospitalizations (e.g., food, parking), (2) communicating with employers to support families' needs, (3) coordinating care across hospital departments, and (4) clarifying care team roles in helping families reduce both medical and social barriers. This study highlights the caregiver perspective on barriers and facilitators to posttransplant care. Future work should identify whether these themes are present across transplant centers. Caregiver perspectives should help inform future interventions aimed at improving long-term outcomes for children after liver transplantation.

Racial/ethnic disparities in wait-list outcomes are only partly explained by socioeconomic deprivation among children awaiting liver transplantation.

BACKGROUND AND AIMS: Racial/ethnic minority children have worse liver transplant (LT) outcomes. We evaluated whether neighborhood socioeconomic deprivation affected associations between race/ethnicity and wait-list mortality. APPROACH AND RESULTS: We included children (age <18) listed 2005-2015 in the Scientific Registry of Transplant Recipients. We categorized patients as non-Hispanic White, Black, Hispanic, and other. We matched patient ZIP codes to a neighborhood socioeconomic deprivation index (range, 0-1; higher values indicate worse deprivation). Primary outcomes were wait-list mortality, defined as death/delisting for too sick, and receipt of living donor liver transplant (LDLT). Competing risk analyses modeled the association between race/ethnicity and wait-list mortality, with deceased donor liver transplant (DDLT) and LDLT as competing risks, and race/ethnicity and LDLT, with wait-list mortality and DDLT as competing risks. Of 7716 children, 17% and 24% identified as Black and Hispanic, respectively. Compared to White children, Black and Hispanic children had increased unadjusted hazard of wait-list mortality (subhazard ratio [sHR], 1.44; 95% CI, 1.18, 1.75 and sHR, 1.48; 95% CI, 1.25, 1.76, respectively). After adjusting for neighborhood deprivation, insurance, and listing laboratory Model for End-Stage Liver Disease/Pediatric End-Stage Liver Disease, Black and Hispanic children did not have increased hazard of wait-list mortality (sHR, 1.12; 95% CI, 0.91, 1.39 and sHR, 1.21; 95% CI, 1.00, 1.47, respectively). Similarly, Black and Hispanic children had a decreased likelihood of LDLT (sHR, 0.58; 95% CI, 0.45, 0.75 and sHR, 0.61; 95% CI, 0.49, 0.75, respectively). Adjustment attenuated the effect of Black and Hispanic race/ethnicity on likelihood of LDLT (sHR, 0.79; 95% CI, 0.60, 1.02 and sHR, 0.89; 95% CI, 0.70, 1.11, respectively). CONCLUSIONS: Household and neighborhood socioeconomic factors and disease severity at wait-list entry help explain racial/ethnic disparities for children awaiting transplant. A nuanced understanding of how social adversity contributes to wait-list outcomes may inform strategies to improve outcomes.

Center variation in long-term outcomes for socioeconomically deprived children.

Neighborhood socioeconomic deprivation is associated with adverse outcomes after pediatric liver transplant. We sought to determine if this relationship varies by transplant center. Using SRTR, we included patients <18 years transplanted 2008-2013 (N = 2804). We matched patient ZIP codes to a deprivation index (range [0,1]; higher values indicate increased socioeconomic deprivation). A center-level patient-mix deprivation index was defined by the distribution of patient-level deprivation. Centers (n = 66) were classified as high or low deprivation if their patient-mix deprivation index was above or below the median across centers. Center quality was classified as low or high graft failure if graft survival rates were better or worse than the overall 10-year graft survival rate. Primary outcome was patient-level graft survival. We used random-effect Cox models to evaluate center-level covariates on graft failure. We modeled center quality using stratified Cox models. In multivariate analysis, each 0.1 increase in the patient-mix deprivation index was associated with increased hazard of graft failure (HR 1.32; 95%CI: 1.05, 1.66). When stratified by center quality, patient-mix deprivation was no longer significant (HR 1.07, 95%CI: 0.89, 1.28). Some transplant centers care for predominantly high deprivation children and maintain excellent outcomes. Revealing and replicating these centers' practice patterns should enable more equitable outcomes.

Neighborhood socioeconomic deprivation is associated with worse patient and graft survival following pediatric liver transplantation.

Long-term outcomes remain suboptimal following pediatric liver transplantation; only one third of children have normal biochemical liver function without immunosuppressant comorbidities 10 years posttransplant. We examined the association between an index of neighborhood socioeconomic deprivation with graft and patient survival using the Scientific Registry of Transplant Recipients. We included children <19 years who underwent liver transplantation between January 1, 2008 to December 31, 2013 (n = 2868). Primary exposure was a neighborhood socioeconomic deprivation index-linked via patient home ZIP code-with a range of 0-1 (values nearing 1 indicate neighborhoods with greater socioeconomic deprivation). Primary outcome measures were graft failure and death, censored at 10 years posttransplant. We modeled survival using Cox proportional hazards. In univariable analysis, each 0.1 increase in the deprivation index was associated with a 14.3% (95% confidence interval [CI]): 3.8%-25.8%) increased hazard of graft failure and a 12.5% (95% CI: 2.5%-23.6%) increased hazard of death. In multivariable analysis adjusted for race, each 0.1 increase in the deprivation index was associated with a 11.5% (95% CI: 1.6%-23.9%) increased hazard of graft failure and a 9.6% (95% CI: -0.04% to 20.7%) increased hazard of death. Children from high deprivation neighborhoods have diminished graft and patient survival following liver transplantation. Greater attention to neighborhood context may result in improved outcomes for children following liver transplantation.

Cooling The Hot Spots Where Child Hospitalization Rates Are High: A Neighborhood Approach To Population Health.

Improving population health requires a focus on neighborhoods with high rates of illness. We aimed to reduce hospital days for children from two high-morbidity, high-poverty neighborhoods in Cincinnati, Ohio, to narrow the gap between their neighborhoods and healthier ones. We also sought to use this population health improvement initiative to develop and refine a theory for how to narrow equity gaps across broader geographic areas. We relied upon quality improvement methods and a learning health system approach. Interventions included the optimization of chronic disease management; transitions in care; mitigation of social risk; and use of actionable, real-time data. The inpatient bed-day rate for the two target neighborhoods decreased by 18 percent from baseline (July 2012-June 2015) to the improvement phase (July 2015-June 2018). Hospitalizations decreased by 20 percent. There was no similar decrease in demographically comparable neighborhoods. We see the neighborhood as a relevant frame for achieving equity and building a multisector culture of health.

Using a network organisational architecture to support the development of Learning Healthcare Systems.

The US National Academy of Sciences has called for the development of a Learning Healthcare System in which patients and clinicians work together to choose care, based on best evidence, and to drive discovery as a natural outgrowth of every clinical encounter to ensure innovation, quality and value at the point of care. However, the vision of a Learning Healthcare System has remained largely aspirational. Over the last 13 years, researchers, clinicians and families, with support from our paediatric medical centre, have designed, developed and implemented a network organisational model to achieve the Learning Healthcare System vision. The network framework aligns participants around a common goal of improving health outcomes, transparency of outcome measures and a flexible and adaptive collaborative learning system. Team collaboration is promoted by using standardised processes, protocols and policies, including communication policies, data sharing, privacy protection and regulatory compliance. Learning methods include collaborative quality improvement using a modified Breakthrough Series approach and statistical process control methods. Participants observe their own results and learn from the experience of others. A common repository (a 'commons') is used to share resources that are created by participants. Standardised technology approaches reduce the burden of data entry, facilitate care and result in data useful for research and learning. We describe how this organisational framework has been replicated in four conditions, resulting in substantial improvements in outcomes, at scale across a variety of conditions.

Coughing, sneezing, and aching online: Twitter and the volume of influenza-like illness in a pediatric hospital.

This study investigates the relation of the incidence of georeferenced tweets related to respiratory illness to the incidence of influenza-like illness (ILI) in the emergency department (ED) and urgent care clinics (UCCs) of a large pediatric hospital. We collected (1) tweets in English originating in our hospital's primary service area between 11/1/2014 and 5/1/2015 and containing one or more specific terms related to respiratory illness and (2) the daily number of patients presenting to our hospital's EDs and UCCs with ILI, as captured by ICD-9 codes. A Support Vector Machine classifier was applied to the set of tweets to remove those unlikely to be related to ILI. Time series of the pooled set of remaining tweets involving any term, of tweets involving individual terms, and of the ICD-9 data were constructed, and temporal cross-correlation between the social media and clinical data was computed. A statistically significant correlation (Spearman ρ = 0.23) between tweets involving the term flu and ED and UCC volume related to ILI 11 days in the future was observed. Tweets involving the terms coughing (Spearman ρ = 0.24) and headache (Spearman ρ = 0.19) individually were also significantly correlated to ILI-related clinical volume four and two days in the future, respectively. In the 2014-2015 cold and flu season, the incidence of local tweets containing the terms flu, coughing, and headache were early indicators of the incidence of ILI-related cases presenting to EDs and UCCs at our children's hospital.

Significant and Sustained Reduction in Chemotherapy Errors Through Improvement Science.

PURPOSE: A majority of children with cancer are now cured with highly complex chemotherapy regimens incorporating multiple drugs and demanding monitoring schedules. The risk for error is high, and errors can occur at any stage in the process, from order generation to pharmacy formulation to bedside drug administration. Our objective was to describe a program to eliminate errors in chemotherapy use among children. METHODS: To increase reporting of chemotherapy errors, we supplemented the hospital reporting system with a new chemotherapy near-miss reporting system. After the model for improvement, we then implemented several interventions, including a daily chemotherapy huddle, improvements to the preparation and delivery of intravenous therapy, headphones for clinicians ordering chemotherapy, and standards for chemotherapy administration throughout the hospital. RESULTS: Twenty-two months into the project, we saw a centerline shift in our U chart of chemotherapy errors that reached the patient from a baseline rate of 3.8 to 1.9 per 1,000 doses. This shift has been sustained for > 4 years. In Poisson regression analyses, we found an initial increase in error rates, followed by a significant decline in errors after 16 months of improvement work ( P < .001). CONCLUSION: After the model for improvement, our improvement efforts were associated with significant reductions in chemotherapy errors that reached the patient. Key drivers for our success included error vigilance through a huddle, standardization, and minimization of interruptions during ordering.

Applying the Chronic Care Model to Improve Care and Outcomes at a Pediatric Medical Center.

BACKGROUND: Cincinnati Children's Hospital Medical Center launched the Condition Outcomes Improvement Initiative in 2012 to help disease-based teams use the principles of improvement science to implement components of the Chronic Care Model and improve outpatient care delivery for populations of children with chronic and complex conditions. The goal was to improve outcomes by 20% from baseline. METHODS: Initiative activities included review of the evidence to choose and measure outcomes, development of condition-specific patient registries and tools for data collection, patient stratification, planning and coordinating care before and after visits, and self-management support. RESULTS: Eighteen condition teams, in sequenced cohorts, fully participated in the three-year initiative. As of October 1, 2015, data from 27,221 active patients with chronic conditions were entered into registries within the electronic health record and being used to inform quality improvement and population management. Overall, 13,601 of these children had an improved outcome. Seven of the teams had implemented their evidence-based interventions with ≥ 90% reliability, 83% of teams were regularly using an electronic template to plan care for a child's condition before an encounter, 89% had stratified their population by severity of medical/psychosocial needs, 56% were using registry care gap data for population management, and 72% were doing self-management assessments. Eleven teams achieved the numeric goal of 20% improvement in their chosen outcome. CONCLUSION: The results suggest that, by implementing quality improvement methods with multidisciplinary support, clinical teams can manage chronic condition populations and improve clinical, functional, and patient-reported outcomes. This work continues to be spread across the institution.

Rapid cycle development of a multifactorial intervention achieved sustained reductions in central line-associated bloodstream infections in haematology oncology units at a children's hospital: a time series analysis.

BACKGROUND: Immunocompromised children are at high risk for central line-associated bloodstream infections (CLABSIs) and its associated morbidity and mortality. Prevention of CLABSIs depends on highly reliable care. PURPOSE: Since the summer of 2013, we saw an increase in patient volume and acuity in our centre. Additionally, CLABSIs rates more than tripled during this period. The purpose of this initiative was to rapidly identify and mitigate potential underlying drivers to the increased CLABSI rate. METHODS: Through small tests of change, we implemented a standard process for daily hygiene; increased awareness of high-risk patients with CLABSI; improved education/assistance for nurses performing high-risk central venous catheter procedures; and developed a system to improve allocation of resources to de-escalate system stress. RESULTS: The CLABSI rate from June 2013 to May 2014 was 2.03 CLABSIs/1000 line days. After implementation of our interventions, we saw a significant decrease in the CLABSI rate to 0.39 CLABSIs/1000 line days (p=0.008). Key processes have become more reliable: 100% of dressing changes are completed with the new two-person standard; daily hygiene adherence has increased from 25% to 70%; 100% of nurses are approached daily by senior nursing for assistance with high-risk procedures; and patients at risk for a CLABSI are identified daily. CONCLUSIONS: Stress to a complex system caring for high-risk patients can challenge CLABSI rates. Identifying key processes and executing them reliably can stabilise outcomes during times of system stress.

Developing and evaluating the success of a family activated medical emergency team: a quality improvement report.

BACKGROUND: Family-activated medical emergency teams (MET) have the potential to improve the timely recognition of clinical deterioration and reduce preventable adverse events. Adoption of family-activated METs is hindered by concerns that the calls may substantially increase MET workload. We aimed to develop a reliable process for family activated METs and to evaluate its effect on MET call rate and subsequent transfer to the intensive care unit (ICU). METHODS: The setting was our free-standing children's hospital. We partnered with families to develop and test an educational intervention for clinicians and families, an informational poster in each patient room and a redesigned process with hospital operators who handle MET calls. We tracked our primary outcome of count of family-activated MET calls on a statistical process control chart. Additionally, we determined the association between family-activated versus clinician-activated MET and transfer to the ICU. Finally, we compared the reason for MET activation between family calls and a 2:1 matched sample of clinician calls. RESULTS: Over our 6-year study period, we had a total of 83 family-activated MET calls. Families made an average of 1.2 calls per month, which represented 2.9% of all MET calls. Children with family-activated METs were transferred to the ICU less commonly than those with clinician MET calls (24% vs 60%, p<0.001). Families, like clinicians, most commonly called MET for concerns of clinical deterioration. Families also identified lack of response from clinicians and a dismissive interaction between team and family as reasons. CONCLUSIONS: Family MET activations were uncommon and not a burden on responders. These calls recognised clinical deterioration and communication failures. Family activated METs should be tested and implemented in hospitals that care for children.

Using quality improvement to optimise paediatric discharge efficiency.

BACKGROUND: Bed capacity management is a critical issue facing hospital administrators, and inefficient discharges impact patient flow throughout the hospital. National recommendations include a focus on providing care that is timely and efficient, but a lack of standardised discharge criteria at our institution contributed to unpredictable discharge timing and lengthy delays. Our objective was to increase the percentage of Hospital Medicine patients discharged within 2 h of meeting criteria from 42% to 80%. METHODS: A multidisciplinary team collaborated to develop medically appropriate discharge criteria for 11 common inpatient diagnoses. Discharge criteria were embedded into electronic medical record (EMR) order sets at admission and could be modified throughout a patient's stay. Nurses placed an EMR time-stamp to signal when patients met all discharge goals. Strategies to improve discharge timeliness emphasised completion of discharge tasks prior to meeting criteria. Interventions focused on buy-in from key team members, pharmacy process redesign, subspecialty consult timeliness and feedback to frontline staff. A P statistical process control chart assessed the impact of interventions over time. Length of stay (LOS) and readmission rates before and after implementation of process measures were compared using the Wilcoxon rank-sum test. RESULTS: The percentage of patients discharged within 2 h significantly improved from 42% to 80% within 18 months. Patients studied had a decrease in median overall LOS (from 1.56 to 1.44 days; p=0.01), without an increase in readmission rates (4.60% to 4.21%; p=0.24). The 12-month rolling average census for the study units increased from 36.4 to 42.9, representing an 18% increase in occupancy. CONCLUSIONS: Through standardising discharge goals and implementation of high-reliability interventions, we reduced LOS without increasing readmission rates.

A comprehensive model to build improvement capability in a pediatric academic medical center.

Cincinnati Children's Hospital Medical Center developed a comprehensive model to build quality improvement (QI) capability to support its goal to transform its delivery system through a series of training courses. Two online modules orient staff to basic concepts and terminology and prepare them to participate more effectively in QI teams. The basic program (Rapid Cycle Improvement Collaborative, RCIC) is focused on developing the capability to use basic QI tools and complete a narrow-scoped project in approximately 120 days. The Intermediate Improvement Science Series (I(2)S(2)) program is a leadership course focusing on improvement skills and developing a broader and deeper understanding of QI in the context of the organization and external environment. The Advanced Improvement Methods (AIM) course and Quality Scholars Program stimulate the use of more sophisticated methods and prepare Cincinnati Children's Hospital Medical Center (CCHMC) and external faculty to undertake QI research. The Advanced Improvement Leadership Systems (AILS) sessions enable interprofessional care delivery system leadership teams to effectively lead a system of care, manage a portfolio of projects, and to deliver on CCHMC's strategic plan. Implementing these programs has shown us that 1) a multilevel curricular approach to building improvement capability is pragmatic and effective, 2) an interprofessional learning environment is critical to shifting mental models, 3) repetition of project experience with coaching and feedback solidifies critical skills, knowledge and behaviors, and 4) focusing first on developing capable interprofessional improvement leaders, versus engaging in broad general QI training across the whole organization, is effective.

Effects of quality improvement in health facilities and community mobilization through women's groups on maternal, neonatal and perinatal mortality in three districts of Malawi: MaiKhanda, a cluster randomized controlled effectiveness trial.

BACKGROUND: Maternal, perinatal and neonatal mortality remains high in low-income countries. We evaluated community and facility-based interventions to reduce deaths in three districts of Malawi. METHODS: We evaluated a rural participatory women's group community intervention (CI) and a quality improvement intervention at health centres (FI) via a two-by-two factorial cluster randomized controlled trial. Consenting pregnant women were followed-up to 2 months after birth using key informants. Primary outcomes were maternal, perinatal and neonatal mortality. Clusters were health centre catchment areas assigned using stratified computer-generated randomization. Following exclusions, including non-birthing facilities, 61 clusters were analysed: control (17 clusters, 4912 births), FI (15, 5335), CI (15, 5080) and FI + CI (14, 5249). This trial was registered as International Standard Randomised Controlled Trial [ISRCTN18073903]. Outcomes for 14,576 and 20,576 births were recorded during baseline (June 2007-September 2008) and intervention (October 2008-December 2010) periods. RESULTS: For control, FI, CI and FI + CI clusters neonatal mortality rates were 34.0, 28.3, 29.9 and 27.0 neonatal deaths per 1000 live births and perinatal mortality rates were 56.2, 55.1, 48.0 and 48.4 per 1000 births, during the intervention period. Adjusting for clustering and stratification, the neonatal mortality rate was 22% lower in FI + CI than control clusters (OR = 0.78, 95% CI 0.60-1.01), and the perinatal mortality rate was 16% lower in CI clusters (OR = 0.84, 95% CI 0.72-0.97). We did not observe any intervention effects on maternal mortality. CONCLUSIONS: Despite implementation problems, a combined community and facility approach using participatory women's groups and quality improvement at health centres reduced newborn mortality in rural Malawi.

Rapid adoption of Lactobacillus rhamnosus GG for acute gastroenteritis.

BACKGROUND AND OBJECTIVES: A 2007 meta-analysis showed probiotics, specifically Lactobacillus rhamnosus GG (LGG), shorten diarrhea from acute gastroenteritis (AGE) by 24 hours and decrease risk of progression beyond 7 days. In 2005, our institution published a guideline recommending consideration of probiotics for patients with AGE, but only 1% of inpatients with AGE were prescribed LGG. The objective of this study was to increase inpatient prescribing of LGG at admission to >90%, for children hospitalized with AGE, within 120 days. METHODS: This quality improvement study included patients aged 2 months to 18 years admitted to general pediatrics with AGE with diarrhea. Diarrhea was defined as looser or ≥ 3 stools in the preceding 24 hours. Patients with complex medical conditions or with presumed bacterial gastroenteritis were excluded. Admitting and supervising clinicians were educated on the evidence. We ensured LGG was adequately stocked in our pharmacies and updated an AGE-specific computerized order set to include a default LGG order. Failure identification and mitigation were conducted via daily electronic chart review and e-mail communication. Primary outcome was the percentage of included patients prescribed LGG within 18 hours of admission. Intervention impact was assessed with run charts tracking our primary outcome over time. RESULTS: The prescribing rate increased to 100% within 6 weeks and has been sustained for 7 months. CONCLUSIONS: Keys to success were pharmacy collaboration, use of an electronic medical record for a standardized order set, and rapid identification and mitigation of failures. Rapid implementation of evidence-based practices is possible using improvement science methods.

Republished: developing capable quality improvement leaders.

BACKGROUND/OBJECTIVE: Cincinnati Children's Hospital Medical Center created the Intermediate Improvement Science Series (I(2)S(2)) training course to develop organisational leaders to do improvement, lead improvement and get results on specific projects. DESIGN METHODS: Each multidisciplinary class consists of 25-30 participants and 12 in-class training days over 6 months. Instructional methods include lectures, case studies, interactive application exercises and dialogue, participant reports and assigned readings. Participants demonstrate competence in improvement science by completing a project with improvement in outcome and/or process measures. They present on their projects and receive feedback during each session and one-on-one coaching between sessions. RESULTS: Since 2006, 279 participants in 11 classes have completed the I(2)S(2) course. Participant evaluations have consistently rated satisfaction, learning, application, impact and value very high. Large and statistically significant changes were observed in pre-course to post-course self-assessment of knowledge of five quality improvement topics. Approximately 85% of the projects demonstrated measurable improvement. At follow-up, 72% of improvement projects were completed and made a part of everyday operations in the participant's unit or were the focus of continuing improvement work. Many changes were spread to other units or programmes. Most (88%) responding graduates continued to participate in formal quality improvement efforts and many led other improvement projects. Nearly half of the respondents presented their results at one or more professional conference. CONCLUSIONS: Through the I(2)S(2) course, the authors are developing improvement leaders, accelerating the shift in the culture from a traditional academic medical centre to an improvement-focused culture, and building cross-silo relationships by developing leaders who understand the organisation as a large system of interdependent subsystems focused on improving health.

Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events.

BACKGROUND AND OBJECTIVE: Failure to recognize and treat clinical deterioration remains a source of serious preventable harm for hospitalized patients. We designed a system to identify, mitigate, and escalate patient risk by using principles of high-reliability organizations. We hypothesized that our novel care system would decrease transfers determined to be unrecognized situation awareness failures events (UNSAFE). These were defined as any transfer from an acute care floor to an ICU where the patient received intubation, inotropes, or ≥ 3 fluid boluses in first hour after arrival or before transfer. METHODS: The setting for our observational time series study was a quaternary care children's hospital. Before initiating tests of change, 2 investigators reviewed recent serious safety events (SSEs) and floor-to-ICU transfers. Collectively, 5 risk factors were associated with each event: family concerns, high-risk therapies, presence of an elevated early warning score, watcher/clinician gut feeling, and communication concerns. Using the model for improvement, an intervention was developed and tested to reliably and proactively identify patient risk and mitigate that risk through unit-based huddles. A 3-times daily inpatient huddle was added to ensure risks were escalated and addressed. Later, a "robust" and explicit plan for at-risk patients was developed and spread. RESULTS: The rate of UNSAFE transfers per 10,000 non-ICU inpatient days was significantly reduced from 4.4 to 2.4 over the study period. The days between inpatient SSEs also increased significantly. CONCLUSIONS: A reliable system to identify, mitigate, and escalate risk was associated with a near 50% reduction in UNSAFE transfers and SSEs.