Microlearning: A Concept Analysis.

With an overall rise in technology adoption, the information-seeking behaviors of today have become instant and single-focused, and demand convenience for learning and the acquisition of knowledge. Digital technologies expand the reach of learning and allow for the development of innovative and creative methods of teaching. The use of microlearning has been gaining popularity in academic and professional development settings and corporate training. Currently, there is no standardized definition of microlearning. Using Walker and Avant's method of concept analysis, a comprehensive overview of microlearning is provided through identifying the concept and describing its uses, attributes, exemplary cases, antecedents, consequences, and empirical referents. Seven attributes associated with microlearning are single focus, bite-sized, asynchronistic, accessibility, flexibility, interactivity, and multimodal delivery. A proposed definition is a self-directed, on-demand, teaching strategy where small single-focused interactive content is presented to learners asynchronously, using technologies that accommodate multimodal delivery, and access where and when convenient for the learner. This analysis will assist informatics and nursing educators in understanding how microlearning, as a strategy, fits into the electronic learning landscape, is supported by digital technologies, and adds portability to leverage in an on-demand asynchronous way providing targeted learning for use in all areas of clinical practice.

Sustainability Standards in Pediatric Anesthesia: Quality Initiative to Reduce Costly Environmentally Harmful Volatile Anesthetics.

Background: The emission and entrapment of greenhouse gases (GHG) inside the atmosphere is one of the leading causes of global warming. Commonly administered anesthetics have global warming potential up to 2,000 times greater than carbon dioxide. This Quality Improvement (QI) initiative aimed to develop a set of sustainability standards to reduce volatile anesthetic GHG emissions and costs at a children's hospital. Methods: In January 2020, the QI project team implemented education sessions for clinical staff on the environmental impact of volatile anesthetics, bedside clinical reminders, resource guides on sustainable anesthesia practices, preset low-flow gas levels on anesthesia machines, relocated and reduced the number of available vaporizers, and implemented policies to standardize clinical practice. Using hospital pharmacy purchase order data between 2018 and 2022, GHG emissions and costs from three commonly used volatile anesthetics (Isoflurane, Sevoflurane, and Desflurane) were compared using metric ton carbon dioxide equivalents. Results: During 3 years, GHG emissions from volatile anesthetics were significantly reduced by 77%, with most of the reduction attributed to the reduced use and eventual elimination of Desflurane. Purchase costs were also significantly reduced during this period by 41%. Conclusions: This QI project successfully decreased GHG emissions over 3 years by simultaneously reducing the use of costly and environmentally harmful volatile anesthetic, Desflurane, and increasing the use of low-flow anesthesia. This study addresses our anesthesia practices and healthcare system's impact on the pediatric population and proposes simple interventions to mitigate the negative consequences of current practices.

A dedicated surgical team for posterior spinal fusion in patients with adolescent idiopathic scoliosis improves OR efficiency.

PURPOSE: Standardized care pathways for adolescent idiopathic scoliosis (AIS) patients undergoing PSF improve clinical outcomes. We hypothesized that having dedicated spine personnel would decrease surgical time and improve clinical outcomes. METHODS: 367 patients with AIS had a PSF within a standardized perioperative care pathway. Cases with 1-3 dedicated spine team members (any combination of circulating nurse, surgical technologist, and anesthesiologist) were compared to teams with none. The impact of individual members was also analyzed. Parametric or non-parametric tests were used for each outcome based on the distribution of the data points. These included one-way ANOVA models, Kruskal-Wallis tests, and Fisher's exact tests. RESULTS: Surgical time and total OR time were significantly decreased with the participation of each additional dedicated team member resulting in 43.86 min less surgical time and 50.8 min less total OR time when three team members were present compared to no team members. If the nurse was a spine member, the surgical time was lower (p = 0.037). If the technologist was a team member, the surgical time and total OR time were lower (p = 0.002 and p = 0.001, respectively). Lastly, if the anesthesiologist was a member of the team, the anesthesia time was lower (p = 0.003). No significant clinical differences were observed. CONCLUSION: Having dedicated surgical team members decreases surgical and total OR time for AIS patients undergoing PSF, and this OR efficiency improves as the dedicated team is more robust. OR surgical teams did not influence clinical outcomes. Hospitals should strongly consider developing surgical teams to improve OR efficiency of PSF cases.

Postanesthesia complications in pediatric patients with previous SARS-CoV-2 infection: A cohort study.

BACKGROUND: Children with SARS-CoV-2 infection are at increased risk for postanesthesia complications. There is minimal data regarding how long that elevated complication risk persists beyond initial SARS-CoV-2 diagnosis. AIMS: We investigated postanesthesia complications in children with SARS-CoV-2 infection within 90 days of diagnosis. METHODS: We completed a single-center, retrospective, case-control study of pediatric patients with confirmed SARS-CoV-2 infection within 90 days undergoing anesthesia between January 3-October 7, 2020. Each SARS-CoV-2 positive patient was matched 1:2 by age and type of procedure with a non-SARS-CoV-2 cohort. The primary outcome was the rate of all postanesthesia complications within 30 days of the procedure, defined as unplanned escalations of care within 48 h, cardiac, respiratory, thrombotic, and hemorrhagic events within 30 days. Secondary outcomes were 30-day mortality and hospital length of stay. RESULTS: Of the 341 patients included, 114 patients were SARS-CoV-2 positive and 227 were SARS-CoV-2 negative. Patients with a positive test 0-7 days prior to anesthesia had an increased risk difference in all postanesthesia complications within 30 days (19.9, 95% CI [4.7, 35.1], p = .001) and increased risk difference in length of hospital stay (7.8, 95% CI [1.2, 14.4], p < .001). Patients who underwent anesthesia greater than 42 days from SARS-CoV-2 diagnosis had an increased risk difference in cardiac complications within 30 days (4.3, 95% CI [0.9, 10.0], p = .029). There was no increased hospital length of stay among SARS-CoV-2 positive patients diagnosed greater than 8 days before anesthetic. There were no deaths within 30 days of anesthetic. CONCLUSIONS: Postanesthesia complications are higher in children who undergo anesthesia within 7 days of SARS-CoV-2 diagnosis. Additional cardiac risk may persist beyond the immediate period of initial diagnosis. Larger samples are needed to further evaluate the risk of delayed postanesthesia complications and guide optimal timing of surgery.

Improving Outcomes through Implementation of an Infant Spinal Anesthesia Program for Urologic Surgery Patients.

Introduction: Spinal anesthesia has a long history as an effective and safe technique to avoid general anesthesia in infants undergoing surgery. However, spinal anesthesia was rarely used as the primary anesthetic in this population at our institution. This healthcare improvement initiative aimed to increase the percentage of successful spinal placements as the primary anesthetic in infants undergoing circumcision, open orchidopexy, or hernia repair from 11% to 50% by December 31, 2019, and sustain that rate for 6 months. Methods: An interdisciplinary team created a key driver diagram and implemented the following interventions: education of nurses, surgeons, and patient families; focused anesthesiologist training on the infant spinal procedure; premedication; availability of supplies; and surgical schedule optimization. The team collected data retrospectively by reviewing electronic medical records (Cerner, North Kansas City, Mo.). The primary outcome was the percentage of infants undergoing circumcision, open orchidopexy, or hernia repair who received a successful spinal as the primary anesthetic. The team tracked this measure and evaluated using a statistical process control chart. Results: Between August 1, 2018, and February 29, 2020, researchers identified 470 infants (235 preintervention and 235 postintervention) who underwent circumcision, open orchidopexy, or inguinal hernia repair. Following the interventions in this project, there was a statistically significant increase in successful spinal placement from 11% to 45% (P < 0.0001). Conclusion: This quality improvement project successfully increased the percentage of patients receiving spinal anesthesia for specific surgical procedures by increasing the number of patients who underwent successful spinal anesthesia placement.

Engagement and Bundle Compliance during COVID-19: A Virtual Strategy.

COVID-19 forced industries to change work processes; this was no different for those working to improve patient outcomes in healthcare. Due to competing priorities, many hospitals struggled with the upkeep of hospital-acquired condition (HAC) auditing and engagement. Children's National hospital developed a three-pronged approach for virtual engagement and sustainment of the processes necessary to achieve and maintain goal auditing and bundle compliance in three HACs: unplanned extubation, central line-associated bloodstream infections, and employee staff safety overexertion injuries. Methods: The overall goal was to create a flexible approach to maintaining engagement while relying on virtual communication. Aim: To maintain, without a decrease of more than 20%, the baseline bundle compliance per month for each HAC (unplanned extubation, central line-associated bloodstream infections, and employee staff safety) from March 2020 to March 2021. Our approach to increasing bundle compliance (primary outcome measure) and audits (process measure) included: regular leadership meetings using multiple virtual modalities, improving the audit process, and ensuring fidelity to bundle elements. Results: Qualitatively, we have found that microsystem leaders regularly engage with quality improvement staff and their teams using virtual touchpoints and ongoing communication. We exceeded the goal of maintaining our monthly bundle compliance, and we saw a significant positive change in the rate of audits after COVID-19. Conclusions: In a time of change during a pandemic, increased engagement in HAC work can adapt structure and processes. Our results are generalizable by increasing touchpoints using multiple virtual modalities.

Telemedicine for the pediatric preoperative assessment during the COVID-19 pandemic: Evaluating patient and provider satisfaction.

The COVID-19 pandemic has presented unprecedented challenges in delivering healthcare to surgical patients. To avoid delays in patient care while still minimizing COVID-19 infection risk to patients and providers, anesthesiology preoperative clinics were presented with the opportunity to implement telemedicine to assess patients' risks prior to surgery. This study explores patient and provider satisfaction with video-based telemedicine preoperative clinic visits during the COVID-19 pandemic via a patient and provider satisfaction survey. A vast majority (>93%) of patients expressed overall satisfaction with telemedicine visits. Similarly, >85% of providers agreed with the benefits of and expressed overall satisfaction with the preoperative telemedicine visits. Overall, patient and provider study participants had positive feedback in response to anesthesia preoperative telemedicine visits. Future studies could assess the preference of telemedicine to in-person visits once the fears of COVID-19 spread have been mitigated, as well as an assessment of outcomes comparing telemedicine and in-person visits.

What a Waste: Perioperative Fentanyl Wastage at a Pediatric Hospital.

The purpose of this study was to quantify the wasted IV fentanyl in the perioperative period at a pediatric hospital. Data collected from electronic charting were used to calculate the amount of wasted medication. We show significant wastage of IV fentanyl during the perioperative period, and propose medication formulations that prevent financial, environmental, and supply-chain complications.

Association between implementation of a coordinated care pathway in idiopathic scoliosis patients and a reduction in perioperative outcome disparities.

BACKGROUND: There are well-documented racial and ethnic disparities in treatment and perioperative outcomes for patients with adolescent idiopathic scoliosis. AIMS: We hypothesize that the implementation of a coordinated care pathway for pediatric patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis may be associated with a reduction in racial and ethnic disparities in perioperative outcomes. METHODS: This is a retrospective pre- and post-test cohort study of patients who underwent posterior spinal fusion for adolescent idiopathic scoliosis at our institution between July 1, 2013 and August 5, 2019. We implemented a coordinated care pathway in March 2015. Patient demographics included age, race, ethnicity, weight, gender, insurance status, ASA class, time between the date surgery was ordered and the date surgery occurred, degree of scoliosis, and the number of spinal levels fused. The primary outcome was length of stay. The secondary outcomes included transfusion rates, pain scores, and postoperative complications. Multivariable regression models compared outcome medians across race/ethnicity. Disparities were defined as the difference in adjusted outcomes by race/ethnicity. RESULTS: Four hundred twenty-four patients underwent posterior spinal fusion for adolescent idiopathic scoliosis at our institution (116 prepathway and 308 postpathway). The median length of stay of Black patients was 1.0 day (95% CI: 0.4, 1.5; p = .006) longer than White patients prepathway. Prepathway patients who self-identified as Other had a 1.2 (95% CI: 0.5, 1.9; p = .004) higher median average pain score on postoperative day 1 compared with White patients. On postoperative day 2, patients who identified as Other had 2.0 (95% CI: 0.8, 3.2; p = .005) higher pain score compared with White patients prepathway. Postpathway, there were no significant differences in outcomes by race/ethnicity. CONCLUSIONS: Our study supports the hypothesis that use of a coordinated care pathway is associated with a reduction in racial and ethnic disparities in length of stay and pain scores in pediatric patients undergoing posterior spinal fusion.

Association Between Exogenous Nitric Oxide Given During Cardiopulmonary Bypass and the Incidence of Postoperative Kidney Injury in Children.

OBJECTIVE: To compare the incidence and severity of acute kidney injury (AKI) after cardiac surgery with cardiopulmonary bypass and the administration of exogenous nitric oxide in children. DESIGN: A retrospective cohort study. SETTING: A single institution, university hospital. PARTICIPANTS: All children younger than 18 years of age who underwent surgery with cardiopulmonary bypass. INTERVENTIONS: Medical records of all eligible patients between January 4, 2017, and June 28, 2019, were reviewed. Patients were divided into two groups based on whether they received exogenous nitric oxide. MEASUREMENTS AND MAIN RESULTS: The primary endpoint was a change in serum creatinine level, defined as the difference between the preoperative creatinine and peak postoperative creatinine. The secondary endpoint was the incidence and severity of postoperative AKI. A difference-in-difference method using fixed-effect multiple linear regression was carried out to compare the difference in maximum serum creatinine changes between the control and intervention groups. Five hundred ninety-one patients were included in the analysis: 298 (50.5%) in the control group and 293 (49.5%) in the intervention group. Control and intervention groups did not vary significantly in terms of baseline characteristics except for bypass time. After adjusting for all baseline variables, there was no statistically significant difference in the increase in serum creatinine between the control and the intervention groups (0.01 [95% CI: -0.03, 0.05], p = 0.545). CONCLUSIONS: This single-center, retrospective, cohort study found no change in the incidence and severity of postoperative AKI after the administration of nitric oxide into the cardiopulmonary bypass circuit in children.

Making the Business Case for Quality and Safety.

There is broad understanding and appreciation that quality and safety are indispensable parts of the business enterprise of delivering care. However, because health care organizations have resource constraints and competing priorities, leaders and managers must create, demonstrate, and articulate a business case for continuing to prioritize investments in quality and safety. To accomplish this, one must leverage financial principles with compelling story-telling. Success creates a virtuous cycle whereby ongoing investments in robust structures increase returns (value defined as improvements in quality and safety outcomes), and cost savings are reinvested to continue to improve delivery of high-quality care.

A Quality Initiative for Reducing Postoperative Hypothermia for Neonatal Intensive Care Unit Surgical Patients.

INTRODUCTION: The association between hypothermia in the neonatal intensive care unit (NICU) patients and morbidity and mortality is well described. Neonates are at higher risk of perioperative hypothermia when compared to older children. Previous studies showed that quality improvement tools reduced postoperative hypothermia in NICU patients, but none showed sustained improvement at incidence rates of <10%. As a single institution, we aimed to reduce the percentage of postoperative temperatures < 36°C in NICU patients from 10% to 6% over 6 months and sustain for 6 months. METHODS: An interdisciplinary team created a key driver diagram and implemented interventions, including monthly reporting of postoperative hypothermia incidence to the anesthesiologists, individual feedback sessions with the anesthesiologists, use of a perioperative checklist, and continuous axillary temperature monitoring of the infant throughout the perioperative period. Data were collected retrospectively using a chart review of electronic medical records. The primary outcome was the percentage of hypothermic patients (T < 36°C) based on the first postoperative temperature taken in the NICU. We tracked this measure using a statistical control chart and evaluated it using Plan-Do-Study-Act cycles. RESULTS: From February 1, 2016 to May 30, 2018, data were collected for 554 patients (pre-intervention: 242 and post-intervention: 312). The percentage of surgical patients who returned to the NICU hypothermic decreased from 9.7% to 2.5% (P < 0.002)-a change sustained for greater than 12 months. CONCLUSIONS: Quality improvement tools are useful in reducing postoperative hypothermia in NICU surgical patients and in maintaining these results.

Factors affecting length of stay after posterior spinal fusion for adolescent idiopathic scoliosis.

STUDY DESIGN: Retrospective review of prospectively collected data. OBJECTIVE: Determine factors that influence hospital length of stay after posterior spinal fusion for adolescent idiopathic scoliosis. Standardized care pathways decrease variability in care, improve patient outcomes, and decrease cost. Specifically, global care pathway development using Lean process mapping for patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis (AIS) has been shown to lead to a significant decrease in postoperative length of stay. Assessment of variables that affect length of stay after pathway implementation may identify opportunities for additional process refinement to further decrease postoperative length of stay and improve pathway efficiency. METHODS: A standardized care pathway was implemented at our institution for all patients undergoing posterior spinal fusion for AIS. This pathway was developed using the Lean process mapping technique to create evidence-based protocols for the preoperative, operative, postoperative, and postdischarge care. Patient and care-related variables in these time periods were assessed to determine those factors that significantly affected postoperative length of stay. RESULTS: Preoperative factors associated with a prolonged postoperative length of stay included patient ethnicity (non-Hispanic > Hispanic, p = 0.035) and gender (female > male, p = 0.039). Significant intraoperative factors included longer surgical time (p < 0.001), increased number of fusion levels (p = 0.034), and higher volume of crystalloid administered (p = 0.011). Significant postoperative factors were higher average pain scores on the first postoperative day (p < 0.001) and higher cumulative morphine use (p < 0.001). CONCLUSIONS: Use of a standardized care pathway for the treatment of patients with AIS can decrease postoperative length of stay. Despite a carefully designed pathway, variability persists in aspects of care that can impact length of stay, including surgical efficiency, intraoperative fluid and blood management, and postoperative pain management. Continued process improvement focused on these variables will likely further improve the effectiveness of standardized pathways for patients with AIS. LEVEL OF EVIDENCE: Level III.

Perioperative Harm Index facilitates prioritization of improvement initiatives.

INTRODUCTION: Perioperative services constitute a significant portion of the care delivery, the impact, and the potential risk in healthcare organizations. Tremendous attention has been paid towards hospital-acquired conditions; however perioperative services have not received similar attention. There is a need for a standardized manner to report on conditions in perioperative services which facilitates prioritization of quality improvement initiatives. MATERIALS AND METHODS: Preventable harm and quality of care indicators were selected based on a review of the literature and available datasets, as well as from safety and quality measures in our organization. Metrics were derived from myriad national quality improvement initiatives and collaboratives. A structure was created to obtain the metrics in a near real-time manner and present the Perioperative Harm Index across the organization. Specific initiatives were targeted as necessitating immediate, short-term, or longer duration prioritization for improvement initiatives. RESULTS: A Perioperative Harm Index was created using 11 metrics that represent the spectrum of surgical care. The metrics facilitate prioritization of improvement initiatives and have resulted in improvement projects including perioperative normothermia in neonatal intensive care unit patients having procedures in the operating room, reduction of post-operative nausea and vomiting, and decrease in surgical site infections in selected procedures. CONCLUSIONS: A Perioperative Harm Index facilitates immediate shared understanding of the harm resulting from the care of surgical patients. As such, this index enables rapid and rationale prioritization for improvement activities. Our harm index is shared, is broadly generalizable, and has facilitated prioritization of improvement opportunities and appropriate allocation of improvement resources at our organization. LEVELS OF EVIDENCE: Level V.