A Model for a Standardized and Sustainable Pediatric Anesthesia-Intensive Care Unit Hand-Off Process.

BACKGROUND AND OBJECTIVES: The hand-off process between pediatric anesthesia and intensive care unit (ICU) teams involves the exchange of patient health information and plays a major role in reducing errors and increasing staff satisfaction. Our objectives were to (1) standardize the hand-off process in children's ICUs, and (2) evaluate the provider satisfaction, efficiency and sustainability of the improved hand-off process. METHODS: Following multidisciplinary discussions, the hand-off process was standardized for transfers of care between anesthesia-ICU teams. A pre-implementation and two post-implementation (6 months, >2 years) staff satisfaction surveys and audits were conducted to evaluate the success, quality and sustainability of the hand-off process. RESULTS: There was no difference in the time spent during the sign out process following standardization-median 5 min for pre-implementation versus 5 and 6 min for post-implementation at six months and >2 years, respectively. There was a significant decrease in the number of missed items (airway/ventilation, venous access, medications, and laboratory values pertinent events) post-implementation compared to pre-implementation (p ≤ 0.001). In the >2 years follow-up survey, 49.2% of providers felt that the hand-off could be improved versus 78.4% in pre-implementation and 54.2% in the six-month survey (p < 0.001). CONCLUSION: A standardized interactive hand-off improves the efficiency and staff satisfaction, with a decreased rate of missed information at the cost of no additional time.

Management of newborns exposed to mothers with confirmed or suspected COVID-19.

There is limited information about newborns with confirmed or suspected COVID-19. Particularly in the hospital after delivery, clinicians have refined practices in order to prevent secondary infection. While guidance from international associations is continuously being updated, all facets of care of neonates born to women with confirmed or suspected COVID-19 are center-specific, given local customs, building infrastructure constraints, and availability of protective equipment. Based on anecdotal reports from institutions in the epicenter of the COVID-19 pandemic close to our hospital, together with our limited experience, in anticipation of increasing numbers of exposed newborns, we have developed a triage algorithm at the Penn State Hospital at Milton S. Hershey Medical Center that may be useful for other centers anticipating a similar surge. We discuss several care practices that have changed in the COVID-19 era including the use of antenatal steroids, delayed cord clamping (DCC), mother-newborn separation, and breastfeeding. Moreover, this paper provides comprehensive guidance on the most suitable respiratory support for newborns during the COVID-19 pandemic. We also present detailed recommendations about the discharge process and beyond, including providing scales and home phototherapy to families, parental teaching via telehealth and in-person education at the doors of the hospital, and telehealth newborn follow-up.

A quality improvement project to reduce hypothermia in infants undergoing MRI scanning.

BACKGROUND: Hypothermia prevention strategies during MRI scanning under general anesthesia in infants may pose a challenge due to the MRI scanner's technical constraints. Previous studies have demonstrated conflicting results related to increase or decrease in post-scan temperatures in children. We noted occurrences of post-scan hypothermia in anesthetized infants despite the use of routine passive warming techniques. OBJECTIVE: The aims of our quality improvement project were (a) to identify variables associated with post-scan hypothermia in infants and (b) to develop and implement processes to reduce occurrence of hypothermia in neonatal intensive care unit (NICU) infants undergoing MRI. MATERIALS AND METHODS: One hundred sixty-four infants undergoing MRI scanning were prospectively audited for post-scan body temperatures. A multidisciplinary team identified potential variables associated with post-scan hypothermia and designed preventative strategies: protocol development, risk factor identification, vigilance and use of a vacuum immobilizer. Another audit was performed, specifically focusing on NICU infants. RESULTS: In the initial phase, we found that younger age (P = 0.002), lower weight (P = 0.005), lower pre-scan temperature (P < 0.01), primary anesthetic technique with propofol (P < 0.01), advanced airway devices (P = 0.02) and being in the NICU (P < 0.01) were associated with higher odds for developing post-scan decrease in body temperature. Quality improvement processes decreased the occurrence of hypothermia in NICU infants undergoing MRI scanning from 65% to 18% (95% confidence interval for the difference, 26-70%, P < 0.001). CONCLUSION: Several variables, including being in the NICU, are associated with a decrease in post-scan temperature in infants undergoing MRI scanning under sedation/general anesthesia. Implementation of strategies to prevent hypothermia in infants may be challenging in the high-risk MRI environment. We were able to minimize this problem in clinical practice by applying quality improvement principles.

Reducing unplanned extubations in the NICU.

BACKGROUND AND OBJECTIVES: Unplanned extubation can be a significant event that places the patient at risk for adverse events. Our goal was to reduce unplanned extubations to <1 unplanned extubation per 100 patient-intubated days. METHODS: All unplanned extubations in the NICU beginning in October 2009 were audited. Data collected included time of day, patient weight, and patient care activity at the time of the event. Bundles of potentially better practices were implemented in sequential Plan-Do-Study-Act cycles. Rates of unplanned extubation (number per patient-intubated day) for each month were analyzed by using control charts, and causes of unplanned extubation were analyzed by using Pareto charts. RESULTS: We found a significant decrease in the unplanned extubation rate after implementation of the first bundle of potentially better practices in May 2010 (2.38 to 0.41 per 100 patient-intubated days). Several more Plan-Do-Study-Act cycles were conducted to sustain this improvement. A persistent reduction in the unplanned extubation rate (0.58 per 100 patient-intubated days) began in February 2013. Causes included dislodgement during care and procedures and variation in the fixation of the endotracheal tube. The majority of events occurred in very low birth weight infants during the daytime shift. CONCLUSIONS: Unplanned extubations in the NICU can be reduced by education of staff and by implementing standard practices of care. Sustainability of any practice change to improve quality is critically dependent on culture change within the NICU. We suggest that the benchmark for unplanned extubation should be a rate <1 per 100 patient-intubated days.

Evaluation, development, and implementation of potentially better practices in neonatal intensive care nutrition.

OBJECTIVE: The desire for evidence-based clinical guidelines for nutritional support of the preterm infant has been identified. Published evidence has not yielded clear guidelines about the best method of delivery, substrate use, or appropriate outcome measure to evaluate nutrition support. In addition, reports on research of nutrition support often fail to give the most rudimentary process necessary to improve quality in various unit settings. METHODS: The Vermont Oxford Network "Got Milk" focus group developed eight potentially better practices for nutrition support, implementation strategies for these practices, and a comprehensive appraisal process to measure nutrition outcome in preterm infants. RESULTS: After implementation of the potentially better practices, all participating institutions showed earlier initiation of nutrition support, earlier attainment of adequate energy intakes, reduced delay in reaching full enteral feeds, more consistent nutrition support practice, decreased length of stay, cost savings, and improved growth at time of discharge. CONCLUSIONS: Development and implementation of evidence-based better nutrition support practices in neonates led to improved nutrient intake and growth with reduced length of stay and related costs. Consistent, comprehensive, multidisciplinary appraisal of practice is an integral component of improving nutrition outcomes in the neonatal population.