Caring for hearts and minds: a quality improvement approach to individualized developmental care in the cardiac intensive care unit.

Introduction: Infants with congenital heart disease (CHD) are at high risk for developmental differences which can be explained by the cumulative effect of medical complications along with sequelae related to the hospital and environmental challenges. The intervention of individualized developmental care (IDC) minimizes the mismatch between the fragile newborn brain's expectations and the experiences of stress and pain inherent in the intensive care unit (ICU) environment. Methods: A multidisciplinary group of experts was assembled to implement quality improvement (QI) to increase the amount of IDC provided, using the Newborn Individualized Developmental Care and Assessment Program (NIDCAP), to newborn infants in the cardiac ICU. A Key Driver Diagram was created, PDSA cycles were implemented, baseline and ongoing measurements of IDC were collected, and interventions were provided. Results: We collected 357 NIDCAP audits of bedside IDC. Improvement over time was noted in the amount of IDC including use of appropriate lighting, sound management, and developmentally supportive infant bedding and clothing, as well as in promoting self-regulation, therapeutic positioning, and caregiving facilitation. The area of family participation and holding of infants in the CICU was the hardest to support change over time, especially with the most ill infants. Infants with increased medical complexity were less likely to receive IDC. Discussion: This multidisciplinary, evidence-based QI intervention demonstrated that the implementation of IDC in the NIDCAP model improved over time using bedside auditing of IDC.

Navigating Communication Challenges in Clinical Practice: A New Approach to Team Education.

BACKGROUND: Cultivating a healthy work environment and upholding patient safety are important priorities in health care. Challenges in workplace communication are common and affect staff well-being and patient outcomes. Previous interventions have focused on organizational issues and work-life balance. OBJECTIVE: To assess the feasibility of monthly interdisciplinary educational rounds that support clinicians' ability to navigate workplace clinical and communication challenges while promoting interprofessional teamwork and self-care. METHODS: The Program to Enhance Relational and Communication Skills rounds are an educational initiative within a large pediatric tertiary care hospital. Participation is voluntary and offered to inter-professional clinicians from 4 critical care units, cardiac catheterization unit, and intermediate care unit. Topics of monthly hour-long sessions are developed collaboratively. Feasibility is assessed by ongoing documentation of attendance. Postintervention questionnaires are used to evaluate the program's value. RESULTS: Between April 2010 and December 2016, a total of 1156 clinicians participated (median, 18 per seminar): 653 nurses (56%), 103 social workers (9%), 102 child life specialists (9%), 32 psychologists (3%), 40 chaplains (3%), 18 physicians (2%), 18 ethicists (2%), and 190 others (16%), including medical interpreters, nursing students, and administrative staff. Ninety-two percent of participants rated their participation as "quite valuable" or "very valuable." Programs of highest interest included child assent, bereavement, social media, and workplace bullying. Evolution into actual clinical practice change remains a challenge for the future. CONCLUSION: Our approach to communication and workplace challenges is relevant, user-friendly, and feasible. Difficult topics are addressed in real time, with clinicians learning interprofessionally.

Health care failure mode and effect analysis to reduce NICU line-associated bloodstream infections.

OBJECTIVE: Central line-associated bloodstream infections (CLABSIs) in NICU result in increased mortality, morbidity, and length of stay. Our NICU experienced an increase in the number of CLABSIs over a 2-year period. We sought to reduce risks for CLABSIs using health care failure mode and effect analysis (HFMEA) by analyzing central line insertion, maintenance, and removal practices. METHODS: A multidisciplinary team was assembled that included clinicians from nursing, neonatology, surgery, infection prevention, pharmacy, and quality management. Between March and October 2011, the team completed the HFMEA process and implemented action plans that included reeducation, practice changes, auditing, and outcome measures. RESULTS: The HFMEA identified 5 common failure modes that contribute to the development of CLABSIs. These included contamination, suboptimal environment of care, improper documentation and evaluation of central venous catheter dressing integrity, issues with equipment and suppliers, and lack of knowledge. Since implementing the appropriate action plans, the NICU has experienced a significant decrease in CLABSIs from 2.6 to 0.8 CLABSIs per 1000 line days. CONCLUSIONS: The process of HFMEA helped reduce the CLABSI rate and reinforce the culture of continuous quality improvement and safety in the NICU.

Parent presence during invasive procedures and resuscitation: evaluating a clinical practice change.

RATIONALE: Parent presence during invasive procedures and/or resuscitation is a relatively underdeveloped and controversial practice. Much of the concern stems from the apprehension of the medical community. OBJECTIVES: To evaluate whether implementation of formal practice guidelines and corresponding interprofessional education would improve clinicians' sense of preparation and comfort in providing parents with options during their children's procedures. METHODS: Multiphase pre-post survey of (1) clinician perceptions and (2) practice from the perspective of clinicians and parents experiencing the same procedure. Data were collected over 4 years from a cardiovascular and critical care program in one U.S. children's hospital. MEASUREMENTS AND MAIN RESULTS: More than 70% of clinicians participated in the perception surveys (n = 782) and 538 clinicians and 274 parents participated in the practice surveys. After the intervention, clinicians reported that parents were present during more invasive procedures and reported higher levels of comfort with the practice of providing options to parents during resuscitative events. Levels of comfort were higher in clinicians who had practiced skills in a simulated learning environment. During both phases, few clinicians reported that parent presence affected their technical performance (4%), therapeutic decision-making (5%), or ability to teach (9%). During the post phase, clinicians reported more active parent behaviors during procedures. Parents who reported receiving information to help them prepare for their children's procedures reported higher levels of procedural understanding and emotional support. CONCLUSIONS: Implementation of practice guidelines and interprofessional education had a positive impact on clinicians' perceptions and practice when providing parents with options and support during their children's invasive procedures and/or resuscitation.