Bundled Care to Reduce Sepsis Mortality: The Improving Pediatric Sepsis Outcomes (IPSO) Collaborative.

OBJECTIVES: We sought to improve utilization of a sepsis care bundle and decrease 3- and 30- day sepsis-attributable mortality, as well as determine which care elements of a sepsis bundle are associated with improved outcomes. METHODS: Children's Hospital Association formed a QI collaborative to Improve Pediatric Sepsis Outcomes (IPSO) (January 2017-March 2020 analyzed here). IPSO Suspected Sepsis (ISS) patients were those without organ dysfunction where the provider "intended to treat" sepsis. IPSO Critical Sepsis (ICS) patients approximated those with septic shock. Process (bundle adherence), outcome (mortality), and balancing measures were quantified over time using statistical process control. An original bundle (recognition method, fluid bolus < 20 min, antibiotics < 60 min) was retrospectively compared with varying bundle time-points, including a modified evidence-based care bundle, (recognition method, fluid bolus < 60 min, antibiotics < 180 min). We compared outcomes using Pearson χ-square and Kruskal Wallis tests and adjusted analysis. RESULTS: Reported are 24 518 ISS and 12 821 ICS cases from 40 children's hospitals (January 2017-March 2020). Modified bundle compliance demonstrated special cause variation (40.1% to 45.8% in ISS; 52.3% to 57.4% in ICS). The ISS cohort's 30-day, sepsis-attributable mortality dropped from 1.4% to 0.9%, a 35.7% relative reduction over time (P < .001). In the ICS cohort, compliance with the original bundle was not associated with a decrease in 30-day sepsis-attributable mortality, whereas compliance with the modified bundle decreased mortality from 4.75% to 2.4% (P < .01). CONCLUSIONS: Timely treatment of pediatric sepsis is associated with reduced mortality. A time-liberalized care bundle was associated with greater mortality reductions.

Ultrasound assessment of peripheral intravenous catheters by nurses in the pediatric intensive care unit.

OBJECTIVE: Establish the feasibility of pediatric intensive care unit (PICU) nurse-directed ultrasound assessment (UA) of peripheral intravenous (PIV) catheters, compare the results of UA to traditional assessment (TA), and determine PIV survival after UA. DESIGN: Prospective observational cohort study. SETTING: PICU within a children's hospital. PATIENTS: PICU patients with a PIV. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Eight nurses performed UA on 131 PIVs in 85 patients. Median age was 3.0 years (IQR 1.0-13.8) and median weight was 15.0 kg (IQR 9.6-59.3). The most common PIV location was the arm (43%) and extravasation occurred in 15% of PIVs. Agreement between TA and UA was moderate with a Kappa of 0.47 (95% CI 0.28-0.66). Nursing confidence in the UA was significantly higher than TA (92% vs 21% very confident, p < 0.0001). In 106 PIVs with a UA that indicated the PIV was intravascular (i.e. negative UA), the median survival was 50.0 h (IQR 21.8-100.3). CONCLUSIONS: Nurses can perform UA of PIV status in PICU patients and express greater confidence in the findings of UA than TA. Further study is necessary to determine the impact of UA on the rate of PIV complications.

Confidence-weighted Testing as an Impactful Education Intervention within a Pediatric Sepsis Quality Improvement Initiative.

INTRODUCTION: Confidence-weighted testing assesses learners' beliefs about their knowledge and skills. As part of a hospital-wide quality improvement initiative to enhance care for pediatric patients with suspected sepsis, we developed a novel intervention using confidence-weighted testing to identify institutional areas of misinformation and knowledge gaps while also providing real-time feedback to individual learners. METHODS: We developed pediatric sepsis eLearning modules incorporating confidence-weighted testing. We distributed them to nurses, advanced practitioners, and physicians in emergency departments and acute care/non-intensive care unit inpatient settings in our hospital system. We analyzed completion and response data over 2 years following module distribution. Our outcomes included completion, confidently held misinformation (CHM; when a learner answers a question confidently but incorrectly), struggle (when a learner repeatedly answers a question incorrectly or with low confidence), and mastery (when a learner initially answers a question correctly and confidently). RESULTS: Eighty-three percent of assigned learners completed the modules (1,463/1,754). Although nurses had significantly more misinformation and struggled more than physicians and advanced practitioners, learners of all roles achieved 100% mastery as part of module completion. The greatest CHM and struggle were found in serum lactate interpretation's nuances and the hemodynamic shock states commonly seen in sepsis. CONCLUSIONS: Our novel application of confidence-weighted testing enhanced learning by correcting learners' misinformation. It also identified systems issues and institutional knowledge gaps as targets for future improvement.

An Acute Care Sepsis Response System Targeting Improved Antibiotic Administration.

BACKGROUND AND OBJECTIVES: Pediatric sepsis quality improvement in emergency departments has been well described and associated with improved survival. Acute care (non-ICU inpatient) units differ in important ways, and optimal approaches to improving sepsis processes and outcomes in this setting are not yet known. Our objective was to increase the proportion of acute care sepsis cases in our health system with initial antibiotic order-to-administration time ≤60 minutes by 20% from a baseline of 43% to 52% by December 2020. METHODS: Employing the Model for Improvement with broad stakeholder engagement, we developed and implemented interventions aimed at effective intervention for sepsis cases on acute care units. We analyzed process and outcome metrics over time using statistical process control charts. We used descriptive statistics to explore differences in antibiotic order-to-administration time and inform ongoing improvement. RESULTS: We cared for 187 patients with sepsis over the course of our initiative. The proportion within our goal antibiotic order-to-administration time rose from 43% to 64% with evidence of special cause variation after our interventions. Of all patients, 66% experienced ICU transfer and 4% died. CONCLUSIONS: We successfully decreased antibiotic order-to-administration time. We also introduced a novel model for sepsis response systems that integrates interventions designed for the complexities of acute care settings. We demonstrated impactful local improvements in the acute care setting where quality improvement reports and success have previously been limited.

Comparison of electromagnetic guided imagery to standard confirmatory methods for ascertaining nasogastric tube placement in children.

PURPOSE: Evaluate the accuracy of an electromagnetic device (EMD) guided nasogastric tube (NGT) placement compared with standard confirmation methods. A secondary aim was to determine if EMD guided NGT placement would avert potential pulmonary misplacements of the tube. DESIGN AND METHODS: Pediatric Intensive Care Unit (PICU) patients were enrolled if they had an NGT order during the study period of April 2014 through December 2016. Patients were included if they were one through 18 years of age. An EMD trained nurse inserted the NGT using EMD guidance. An insertion questionnaire, confirming if the nurse determined the NGT to be gastric per EMD, was completed immediately after NGT placement and before confirmation via either pH testing or radiographic imaging. RESULTS: Forty-five patients were enrolled in the study. Nurses reported, based on EMD, that 86.7% (n = 39) of placements were gastric. Overall agreement between EMD guided tube placement and pH testing was 58% (n = 26). The marginal distribution was significantly different between the two methods (p = .0029). When compared to radiographic confirmation, sensitivity of the pH method was 32% (95% confidence interval [CI]: 17%-51%) compared with 85% (95% CI 69%-95%) for the EMD method. CONCLUSIONS: EMD guidance was superior to pH testing when compared with radiographic confirmation of nasogastric tube placement in children. PRACTICE IMPLICATIONS: EMD guided NGT placement is a potentially viable method for confirming nasogastric tube placement in children when done by appropriately trained clinicians. More research on EMD guided NGT placement in children is needed before any practice recommendation can be made.

Metric Development for the Multicenter Improving Pediatric Sepsis Outcomes (IPSO) Collaborative.

BACKGROUND: A 56 US hospital collaborative, Improving Pediatric Sepsis Outcomes, has developed variables, metrics and a data analysis plan to track quality improvement (QI)-based patient outcomes over time. Improving Pediatric Sepsis Outcomes expands on previous pediatric sepsis QI efforts by improving electronic data capture and uniformity across sites. METHODS: An expert panel developed metrics and corresponding variables to assess improvements across the care delivery spectrum, including the emergency department, acute care units, hematology and oncology, and the ICU. Outcome, process, and balancing measures were represented. Variables and statistical process control charts were mapped to each metric, elucidating progress over time and informing plan-do-study-act cycles. Electronic health record (EHR) abstraction feasibility was prioritized. Time 0 was defined as time of earliest sepsis recognition (determined electronically), or as a clinically derived time 0 (manually abstracted), identifying earliest physiologic onset of sepsis. RESULTS: Twenty-four evidence-based metrics reflected timely and appropriate interventions for a uniformly defined sepsis cohort. Metrics mapped to statistical process control charts with 44 final variables; 40 could be abstracted automatically from multiple EHRs. Variables, including high-risk conditions and bedside huddle time, were challenging to abstract (reported in <80% of encounters). Size or type of hospital, method of data abstraction, and previous QI collaboration participation did not influence hospitals' abilities to contribute data. To date, 90% of data have been submitted, representing 200 007 sepsis episodes. CONCLUSIONS: A comprehensive data dictionary was developed for the largest pediatric sepsis QI collaborative, optimizing automation and ensuring sustainable reporting. These approaches can be used in other large-scale sepsis QI projects in which researchers seek to leverage EHR data abstraction.

Characteristics of Pediatric Rapid Response Systems: Results From a Survey of PRIS Hospitals.

BACKGROUND: Many hospitals use rapid response systems (RRSs) to identify and intervene on hospitalized children at risk for deterioration. OBJECTIVES: To describe RRS characteristics across hospitals in the Pediatric Research in Inpatient Settings (PRIS) network. METHODS: We developed the survey through a series of prospective respondent, expert, and cognitive interviews. One institutional expert per PRIS hospital (n = 109) was asked to complete the web survey. We summarized responses using descriptive statistics with a secondary analysis of univariate associations between RRS characteristics and perceived effectiveness. RESULTS: The response rate was 72% (79 of 109). Respondents represented diverse hospital types and were primarily physicians (97%) with leadership roles in care escalation. Many hospitals used an early warning score (77%) for identification with variable characteristics (46% automated versus 54% full or partially manual calculation; inputs included vital signs [98%], physical examination findings [88%], diagnoses [23%], medications [19%], and diagnostic tests [14%]). Few incorporated a validated prediction model (9%). Similarly, many RRSs used a rapid response team for intervention (93%) with variable team composition (respiratory therapists [94%], ICU nurses [93%], ICU providers [67%], and pharmacists [27%]). Some used the early warning score to trigger the rapid response team (50%). Only a few staffed a clinician to proactively surveil hospitalized children for risk of deterioration (18%), and these tended to be larger hospitals (annual admissions 12 000 vs 6000, P = .007). Most responding experts stated their RRSs improved patient outcomes (92%). CONCLUSIONS: RRS characteristics varied across PRIS hospitals.

Development of a Quality Improvement Learning Collaborative to Improve Pediatric Sepsis Outcomes.

Pediatric sepsis is a major public health problem. Published treatment guidelines and several initiatives have increased adherence with guideline recommendations and have improved patient outcomes, but the gains are modest, and persistent gaps remain. The Children's Hospital Association Improving Pediatric Sepsis Outcomes (IPSO) collaborative seeks to improve sepsis outcomes in pediatric emergency departments, ICUs, general care units, and hematology/oncology units. We developed a multicenter quality improvement learning collaborative of US children's hospitals. We reviewed treatment guidelines and literature through 2 in-person meetings and multiple conference calls. We defined and analyzed baseline sepsis-attributable mortality and hospital-onset sepsis and developed a key driver diagram (KDD) on the basis of treatment guidelines, available evidence, and expert opinion. Fifty-six hospital-based teams are participating in IPSO; 100% of teams are engaged in educational and information-sharing activities. A baseline, sepsis-attributable mortality of 3.1% was determined, and the incidence of hospital-onset sepsis was 1.3 cases per 1000 hospital admissions. A KDD was developed with the aim of reducing both the sepsis-attributable mortality and the incidence of hospital-onset sepsis in children by 25% from baseline by December 2020. To accomplish these aims, the KDD primary drivers focus on improving the following: treatment of infection; recognition, diagnosis, and treatment of sepsis; de-escalation of unnecessary care; engagement of patients and families; and methods to optimize performance. IPSO aims to improve sepsis outcomes through collaborative learning and reliable implementation of evidence-based interventions.

Managing Diagnostic Uncertainty in Pediatric Sepsis Quality Improvement with a Two-Tiered Approach.

Severe sepsis requires timely, resource-intensive resuscitation, a challenge when a sepsis diagnosis is not confirmed. The overall goals were to create a pediatric sepsis program that provided high-quality critical care in severe sepsis (Sepsis Stat), and, in possible sepsis, flexible evaluation and treatment that promoted stewardship (Sepsis Yellow). The primary aims were to decrease time to antibiotics and the intensive care unit requirement. METHODS: A 2-tiered clinical pathway was implemented at 6 pediatric emergency departments and urgent care centers, incorporating order sets, education, paging. The Sepsis Stat pathway included 2 nurses, hand delivery of antibiotics, resuscitation room use. The Sepsis Yellow pathway included prioritized orders, standardized procedures, close monitoring, and evaluation of whether antibiotics were warranted. RESULTS: From April 2012 to December 2017, we treated 3,640 patients with suspected and confirmed sepsis. Among the 932 severe sepsis patients, the 30-day, in-hospital mortality was 0.9%. Arrival to recognition time improved from 50 to 4 minutes. Recognition to antibiotic time demonstrated an in-control process in our goal range with a median of 43 minutes for Sepsis Stat patients, 59 minutes for Sepsis Yellow patients. The proportion of severe sepsis patients requiring intensive care unit care declined from 45% to 34%. On the Sepsis Yellow pathway, 23% were de-escalated with discharge to home without antibiotics. CONCLUSIONS: This novel 2-tiered approach to pediatric sepsis quality improvement in varied emergency care settings improved process and outcome measures in severe sepsis while promoting stewardship and de-escalation where appropriate. Matching resources to the degree of illness was important in supporting quality care in potentially septic children.

AutoPEWS: Automating Pediatric Early Warning Score Calculation Improves Accuracy Without Sacrificing Predictive Ability.

INTRODUCTION: Pediatric early warning scores (PEWS) identify hospitalized children at risk for deterioration. Manual calculation is prone to human error. Electronic health records (EHRs) enable automated calculation, removing human error. This study's objective was to compare the accuracy of automated EHR-based PEWS calculation (AutoPEWS) to manual calculation and evaluate the non-inferiority of AutoPEWS in predicting deterioration. METHODS: We performed a retrospective cohort study inclusive of non-intensive care unit inpatients at a freestanding children's hospital over 4.5 months in Fall 2018. AutoPEWS mapped the historical manual PEWS scoring rubric to frequently used EHR documentation. We determined accuracy by comparing the expected respiratory subset score based on the current respiratory rate to the actual respiratory score of AutoPEWS and the manual PEWS. The agreement was determined using kappa statistics. We used predicted probabilities from a generalized linear mixed model to calculate areas under the curve for each combination of scores (AutoPEWS, manual) and deterioration outcome (rapid response team activation, unplanned intensive care unit transfer, critical deterioration event). We compared the adjusted difference in areas under the curves between the scores. Non-inferiority was defined as a difference of <0.05. RESULTS: There were 23,514 total PEWS representative of 5,384 patients. AutoPEWS respiratory scores were 99.97% accurate, while the manual PEWS respiratory scores were 86% accurate. AutoPEWS were higher overall than the manual PEWS (mean 0.65 versus 0.34). They showed a fair-to-good agreement (weighted kappa 0.42). Non-inferiority of AutoPEWS compared with the manual PEWS was demonstrated for all deterioration outcomes. CONCLUSIONS: Automation of PEWS calculation improved accuracy without sacrificing predictive ability.

The Association Between Fever and Subsequent Deterioration Among Hospitalized Children With Elevated PEWS.

OBJECTIVES: To evaluate the association between fever and subsequent deterioration among patients with Pediatric Early Warning Score (PEWS) elevations to ≥4 to inform improvements to care escalation processes at our institution. METHODS: We performed a cohort study of hospitalized children at a single quaternary children's hospital with PEWS elevations to ≥4 between January 1, 2014 and March 31, 2014. Bivariable analysis was used to compare characteristics between patients with and without unplanned ICU transfers and critical deterioration events (CDEs) (ie, unplanned ICU transfers with life-sustaining interventions initiated in the first 12 ICU hours). A multivariable Poisson regression was used to assess the relative risk of unplanned ICU transfers and CDEs. RESULTS: The study population included 220 PEWS elevations from 176 unique patients. Of those, 33% had fever (n = 73), 40% experienced an unplanned ICU transfer (n = 88), and 19% experienced CDEs (n = 42). Bivariable analysis revealed that febrile patients were less likely to experience an unplanned ICU transfer than those without fever. The same association was found in multivariable analysis with only marginal significance (adjusted relative risk 0.68; 95% confidence interval 0.45-1.01; P = .058). There was no difference in the CDE risk for febrile versus afebrile patients (adjusted relative risk 0.79; 95% confidence interval 0.43-1.44; P = .44). CONCLUSIONS: At our institution, patients with an elevated PEWS appeared less likely to experience an unplanned ICU transfer if they were febrile. We were underpowered to evaluate the effect on CDEs. These findings contributed to our recognition that (1) PEWS may not include all relevant clinical factors used for clinical decision-making regarding care escalation and (2) further study is needed in this area.

A Quality Improvement Collaborative for Pediatric Sepsis: Lessons Learned.

BACKGROUND: Sepsis is a leading cause of morbidity and mortality in children worldwide. Barriers exist for timely recognition and management in emergency care settings. This 1-year quality improvement collaborative sought to reduce mortality from sepsis. METHODS: Fifteen hospitals participated initially. We included children with a spectrum of illness from sepsis to septic shock. The intervention bundle focused on recognition, escalation of care, and the first hour of resuscitation. We conducted monthly learning sessions and disseminated data reports of site-specific and aggregated metrics to drive rapid cycle improvement. RESULTS: Seven sites contributed enough data to be analyzed. Of the 1,173 pediatric patients in the total cohort, 506 presented with severe sepsis/septic shock. Quarterly data demonstrated a mean improvement in initial clinical assessment from 46% to 60% (P < 0.001) and in adherence to the administration of first fluid bolus within 15 minutes from 38% to 46% (P < 0.015). There was no statistically significant improvement in other process metrics. There was no statistically significant improvement in mortality for the total cohort (sepsis to septic shock) or either of the subgroups in either 3- or 30-day mortality. CONCLUSIONS: A quality improvement collaborative focused on improving timely recognition and management of pediatric sepsis to septic shock led to some process improvements but did not show improvement in mortality. Future national efforts should standardize definitions and processes of care for sepsis to septic shock, including the identification of a "time zero" for measuring the timeliness of treatment.

Low-Dose Epinephrine Boluses for Acute Hypotension in the PICU.

OBJECTIVES: To describe the use of low-dose bolus epinephrine in critically ill children during an acute hypotensive episode or prearrest condition. DESIGN: Institutional Review Board approved, single-center, retrospective medical chart review. SETTING: Large medical-surgical PICU within a freestanding, tertiary care children's hospital. PATIENTS: Patients admitted to the PICU between June 1, 2015, and June 1, 2016, who received low-dose (≤ 5 µg/kg) IV bolus epinephrine. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: Twenty-four resuscitation episodes (63 doses; 19 patients) were analyzed. Median age and weight of patients were 9 years (interquartile range, 1-15 yr) and 38.5 kg (interquartile range, 12-54.8 kg). Median Pediatric Risk of Mortality III score was 17 (interquartile range, 10-27). Mean epinephrine dose was 1.3 ± 1.1 µg/kg. Median number of doses per patient was two. If more than one dose was provided, median dosing interval was 6.5 minutes. Heart rate and mean arterial blood pressure were compared at the time of epinephrine administration and 1-4 minutes (median = 1 min) following administration. Heart rate changed from 130 ± 41 to 150 ± 33 beats/min (p < 0.05), and mean arterial blood pressure changed from 51 ± 17 to 75 ± 27 mm Hg (p < 0.001). Variability in mean arterial blood pressure response was observed; nonresponders required extracorporeal membrane oxygenation; 66% of doses resulted in up to 100% mean arterial blood pressure increase, and 21% of doses resulted in greater than 100% mean arterial blood pressure increase. Doses below 1 µg/kg were associated with a lower mean arterial blood pressure increase than doses between 1 and 5 µg/kg (mean percent change in mean arterial blood pressure = 6.6% vs 60%, respectively). Children less than or equal to 2 years old had the greatest percentage increase in heart rate and mean arterial blood pressure. CONCLUSIONS: Provision of low-dose bolus epinephrine during periods of acute hypotension can result in a significant increase in mean arterial blood pressure and heart rate. This dosing strategy may provide temporary stabilization while other therapies are added or adjusted, but further research is needed.

Rapid Response Team Activations in Pediatric Surgical Patients.

Introduction The rapid response team (RRT) is a multidisciplinary team who evaluates hospitalized patients for concerns of nonemergent clinical deterioration. RRT evaluations are mandatory for children whose Pediatric Early Warning System (PEWS) score (assessment of child's behavior, cardiovascular and respiratory status) is ≥4. We aimed to determine if there were differences in characteristics of RRT calls between children who were admitted primarily to either medical or surgical services. We hypothesized that RRT activations would be called for less severely ill children with lower PEWS score on surgical services compared with children admitted to a medical service. Materials and Methods We performed a retrospective review of all children with RRT activations between January 2008 and April 2015 at a tertiary care pediatric hospital. We evaluated the characteristics of RRT calls and made comparisons between RRT calls made for children admitted primarily to medical or surgical services. Results A total of 2,991 RRT activations were called, and 324 (11%) involved surgical patients. Surgical patients were older than medical patients (median: 7 vs. 4 years; p < 0.001). RRT evaluations were called for lower PEWS score in surgical patients compared with medical (median: 3 vs. 4, p < 0.001). Surgical patients were more likely to remain on the inpatient ward following the RRT (51 vs. 39%, p < 0.001) and were less likely to require an advanced airway than medical patients (0.9 vs. 2.1%; p = 0.412). RRT evaluations did not differ between day and night shifts (52% day vs. 48% night; p = 0.17). All surgical patients and all but one medical patient survived the event; surgical patients were more likely to survive to hospital discharge (97 vs. 91%, p < 0.001) Conclusions RRT activations are rare events among pediatric surgical patients. When compared with medical patients, RRT evaluation is requested for surgical patients with a lower PEWS score and these children are less likely to require transfer to a higher level of care, suggesting that pediatric surgery team, families, and nursing staff may not be as comfortable with clinical deterioration.

An interdisciplinary initiative to reduce unplanned extubations in pediatric critical care units.

OBJECTIVE: Unplanned extubations in pediatric critical care units can result in increased mortality, morbidity, and length of stay. We sought to reduce the incidence of these events by reliably measuring occurrences and instituting a series of coordinated interdisciplinary interventions. METHODS: This was an internal review board-approved quality improvement project. Data were prospectively collected from the electronic medical record, and analyzed over 24 months (January 1, 2009-December 2010), and divided into 3 periods: baseline (9 months), intervention with multiple rapid improvement cycles (8 months), and postintervention (7 months). Interventions included standardization of endotracheal tube taping practices upon admission, improved patient handoffs, systematic review of unplanned events, reexamination of sedation practices, and promotion of transparency of performance measures. RESULTS: The PICU experienced 21 events in the 9 months before the initiative, 13 events over the 8-month intervention period, and 5 events in the 7-month postintervention period. The cardiac intensive care unit (CICU) experienced 11, 4, and 0 events, respectively. Mean event rates per 100 patient days for each interval were 0.80, 0.50, and 0.29 for the PICU and 0.74, 0.44, and 0 for the CICU. Monthly event rates for the CICU were significantly different by using the Kruskal-Wallis test (P < .05) but not for the PICU (P = .36) CONCLUSIONS: Through accurate tracking, multiple practice changes, and promoting transparency of efforts and data, an interdisciplinary team reduced the number of unplanned extubations in both ICUs. This reduction has been sustained throughout the postintervention monitoring period.

A multicenter collaborative approach to reducing pediatric codes outside the ICU.

OBJECTIVES: The Child Health Corporation of America formed a multicenter collaborative to decrease the rate of pediatric codes outside the ICU by 50%, double the days between these events, and improve the patient safety culture scores by 5 percentage points. METHODS: A multidisciplinary pediatric advisory panel developed a comprehensive change package of process improvement strategies and measures for tracking progress. Learning sessions, conference calls, and data submission facilitated collaborative group learning and implementation. Twenty Child Health Corporation of America hospitals participated in this 12-month improvement project. Each hospital identified at least 1 noncritical care target unit in which to implement selected elements of the change package. Strategies to improve prevention, detection, and correction of the deteriorating patient ranged from relatively simple, foundational changes to more complex, advanced changes. Each hospital selected a broad range of change package elements for implementation using rapid-cycle methodologies. The primary outcome measure was reduction in codes per 1000 patient days. Secondary outcomes were days between codes and change in patient safety culture scores. RESULTS: Code rate for the collaborative did not decrease significantly (3% decrease). Twelve hospitals reported additional data after the collaborative and saw significant improvement in code rates (24% decrease). Patient safety culture scores improved by 4.5% to 8.5%. CONCLUSIONS: A complex process, such as patient deterioration, requires sufficient time and effort to achieve improved outcomes and create a deeply embedded culture of patient safety. The collaborative model can accelerate improvements achieved by individual institutions.

Thrombosis risk factor assessment and implications for prevention in critically ill children.

OBJECTIVES: To describe nursing compliance with a computer-based pediatric thrombosis risk assessment tool; to generate an estimate of risk factors present in our population; and to explore relationships between risk factors and confirmed thrombotic events. DESIGN: Institutional review board-approved prospective, observational cohort study. SETTING: Pediatric intensive care unit within a tertiary care children's hospital. PATIENTS: All infants and children admitted to the pediatric intensive care unit during a 6-month study period (January 1, 2010-June 30, 2010). MEASUREMENTS AND MAIN RESULTS: Eight hundred admissions were enrolled, representing 742 patients. Thrombosis risk assessment scores were recorded for 707 admissions (88% of total). Mean age = 6.95 ± 6 yrs, mean weight = 28 ± 23 kg, 45% female. A total of 32 thrombi (14 prehospital and 18 in-hospital) were present in the study group. This translated to an overall occurrence rate of 4.3% (1.9% for prehospital and 2.4% for in-hospital). Logistic regression identified that for every 1-point increase in total thrombosis score, the risk of developing a symptomatic thrombus increased by 1.57-fold (95% confidence interval 0.192-5.5) to 2.12-fold (95% confidence interval 0.175-18.34), for prehospital and in-hospital thrombi, respectively (p < .05). The most important risk factors identified for development of any thrombus were thrombophilia (acquired or inherited) (p < .001), presence of a central catheter (p = .01), and age <1 or >14 yrs (p = .052). CONCLUSIONS: Incorporation of a scoring system into the bedside nursing assessment flow sheet was successful and identified children at risk for in-hospital thrombosis. The overall score appears to be most indicative of thrombus risk. These data may serve as a platform for future development of routine screening and possible interventional trials in critically ill children.