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OBJECTIVE: Evidence for successful and sustainable models that systematically identify and address family stress in the pediatric intensive care unit (PICU) remains scarce. Using an integrated improvement science and family engagement framework, we implemented a standardized family stress screening tool and response protocol to improve family experience and reduce family crises through the timely coordination of parent support interventions. METHODS: We conducted this improvement initiative in the 12-bed PICU of a children's hospital within a large, urban academic medical center. Our team, which included 2 family advisors, adapted a validated Distress Thermometer for use in pediatric intensive care. A co-designed family stress screening tool and response protocol were iteratively tested, refined, and implemented in 2015-2017. Process and outcome measures included screening and response reliability, parent satisfaction, and security calls for distressed families. RESULTS: Over the 18 months, the percentage of families screened for stress increased from 0% to 100%. Among families who rated stress levels ≥5, 100% received the recommended response protocol, including family support referrals made and completed within 24 hours of an elevated stress rating. From 2015 to 2017, PICU parent satisfaction scores regarding emotional support increased from a mean score of 81.7-87.0 (P < 0.01; 95% CI). The number of security calls for distressed families decreased by 50%. CONCLUSIONS: The successful implementation of a co-designed family stress screening tool and response protocol led to the timely coordination of parent support interventions, the improved family perception of emotional support, and reduced family crises in the PICU.
RESUMO
BACKGROUND: Central venous catheters are crucial devices in the care of hospitalized children, both in and out of critical care units, but the concomitant risk of central line-associated bloodstream infection (CLABSI) affects 15,000 Americans annually. In 2012, CLABSI rates varied among units from 6.8/1,000 to 1.0/1,000 in a 109-bed children's service within NYU Langone Medical Center (NYULMC; New York City), a 1,069-bed tertiary care academic medical center. In response to variation in central line-related practices and infection prevention rates, a CLABSI Prevention Core Team began an effort to standardize central venous catheter (CVC) care across all pediatric units (ICU and non-ICU). Momentum in this quality improvement (QI) work was interrupted when Superstorm Sandy shuttered the flagship hospital, but the relatively decreased clinical load provided a "downtime" opportunity to address CLABSI prevention. METHODS: The first phase of the collaborative effort, Booster 1, Planning/Initial Phase: Development of a Pediatric Central Venous Catheter Working Group, was followed by Booster 2, Maintenance/Sustaining Phase: Transitioning for Sustainability and Adopting Model for Improvement. RESULTS: Data in the subsequent 21 months after the temporary closure of the facility (January 2013-September 2014) showed an increase in maintenance bundle reliability. The inpatient CLABSI rate for patients<18 years decreased from an annual rate of 2.7/1,000 line days (2012) to 0.6/1,000 line days (2013) to 0.5/1,000 line days as of August 2014. There was a decrease in pediatric CLABSI events and no significant change in line days. CONCLUSIONS: Key elements contributing to initial success with evolving QI capacity and resources were likely multi-factorial, including staff and leadership engagement, culture change, consistent guidelines, and accountability by individuals and by our multidisciplinary core team.
