20 SECTION I Pediatirc Critical Care The Discipline the combination of elements performed consistently and in aggregate that drive improvement The ABCDEF ICU liberation bundle is a recent example of l[.]
20 S E C T I O N I Pediatirc Critical Care: The Discipline TABLE Key PICU Processes 2.3 Rounding Process Transitions of Care Medication reconciliation Daily multidisciplinary rounds (including medical and surgical subspecialists) Daily goals sheet Operating room to ICU hand-offs Daily shift huddles Other hand-offs Primary nursing assignments Discharge planning PICU leadership walk rounds Bundles Protocols Central line insertion bundle Clinical pathways Standard care protocols (e.g., extubation readiness testing, sedation/analgesia protocols) VARI bundle Condition-specific protocols (e.g., status asthmaticus, sepsis, diabetic ketoacidosis, traumatic brain injury) Urinary catheter care bundle Pressure ulcer prevention bundle Peripheral IV care bundle IV, Intravenous; PICU, pediatric intensive care unit; VARI, ventilator-associated respiratory infection Modified from Riley C, Poss WB, Wheeler DS The evolving model of pediatric critical care delivery in North America Pediatr Clin North Am 2013;60:545–562 the combination of elements performed consistently and in aggregate that drive improvement The ABCDEF ICU liberation bundle is a recent example of large-scale bundle use in adult ICUs that, when used reliably, is linked to improved survival, reduced delirium, and decreased ICU readmissions.60 Large collaborations between children’s hospitals, such as the Children’s Hospitals’ Solutions for Patient Safety, have contributed to the development of pediatric specific best practices and HAC prevention clinical care bundles, including those aimed at surgical site infection, catheter-associated urinary tract infection, and pressure injury reductions The use of these bundles leads to HAC rate reduction.61–64 Finally, sepsis recognition and treatment bundles are increasingly common Work published by Evans et al assessing the use of the New York sepsis guidelines demonstrated improved outcomes when a sepsis bundle (antibiotics, cultures, and fluid) was completed within hour.65 Balamuth et al demonstrated improved outcomes with use of a sepsis identification bundle in the emergency department in combination with the electronic medical record to generate automatic alerts to identify patients at risk of sepsis.66,67 Checklists have also been used to improve care of critically ill children admitted to the PICU The NEAR4KIDS group developed an Airway Bundle Checklist to identify tracheal intubation risk factors, improve team situation awareness, improve the use of time-outs, and mitigation plan generation.68 Clinical pathways are flowcharts or algorithms to guide provider decision-making and offer education to learners about evidence behind clinical care recommendations.69 Consistent use of pathways decreases hospital LOS, increases adherence to evidence-based practices, and improves flow through emergency departments when applied to care for common pediatric conditions such as asthma and acute gastroenteritis.69–71 Finally, structured communication during multidisciplinary rounds and hand-offs are additional key processes driving quality and improved outcomes in the PICU.72–74 An example of the efficacy of structured hand-off communication is I-PASS (illness severity, patient summary, action list, situational awareness, and synthesis by receiver) Reliable use of this nursing hand-off bundle demonstrated improvements in hand-off completeness and quality However, there was no evidence that clinical outcomes improved.75 When elements of structure and process come together successfully, a unit begins to function as an HRO Several PICUs are adopting characteristics of HROs to drive improvements in safety and quality.11,76 To the extent that these principles (see Table 2.1) are operational, errors and adverse events should dramatically decrease, thus improving outcomes Safety II is another important concept in the pursuit of improved outcomes and error reduction that is receiving increased attention in healthcare, in particular in high-functioning organizations and systems Safety I involves a retrospective investigation of adverse events (find and fix) while Safety II focuses on what is going right (proactive anticipation of harm to come) in high-functioning systems.77 Erik Hollnagel, an early Safety II pioneer, identified four components of the concept: monitoring, anticipating, responding, and learning.78 Merandi et al analyzed staff behaviors related to safety in a complex quaternary PICU environment, which already had good safety outcomes.8,77 Four Safety II behavior themes emerged: (1) relying on teamwork when novel therapies or approaches are considered, (2) using teams to respond to challenging circumstances, (3) maintaining healthy skepticism, and (4) bringing atypical approaches from other environments.77 As organizations become more reliable and adverse events are less common, Safety II is likely to become an increasingly important field of study with an opportunity to significantly improve outcomes Outcomes It is a challenge to compare outcomes between PICUs given the marked heterogeneity in case mix and illness severity No single measure is sufficient to adequately summarize the overall quality of care that a critically ill child receives in a particular PICU We believe that a panel of metrics, including both process and outcome measures, is necessary Some panels, albeit without process measures, are already in use The Center for Medicare and Medicaid Service’s Agency for Healthcare Research and Quality has three PICUspecific outcomes in their Pediatric Quality Measure Program.79 These include risk assessment for pressure ulcers, appropriateness of red blood cell transfusion, and baseline screening of nutritional status within 24 hours of PICU admission Other outcome measures, such as HAC rates, should also be included The Preventable Harm Index is currently used to aggregate total events of harm over a given time for hospitals or groups of hospitals and can be customized to specific units, such as a PICU.2,3,9 Virtual Pediatric Systems is a data collecting network of over 135 PICUs across the country used for numerous research endeavors, including recalibration of commonly used mortality and length-of-stay prediction models.80 Variations on these models have existed for many years The two most commonly used today (PIM and PRISM III) represent several iterations and recalibrations of their original forms (see Chapter 12) PIM focuses on the first hour of intensivist CHAPTER 2 High-Reliability Pediatric Intensive Care Unit: Role of Intensivist and Team in Obtaining Optimal Outcomes contact; PRISM III focuses on the first 12 to 24 hours to predict risk of mortality These models are physiologically based severityof-illness scoring systems They are used to identify observed-topredicted outcomes, in particular for mortality and LOS These observed-to-predicted ratios can be used to compare outcomes between ICUs with similar severity of illnesses.81 The Virtual PICU, using recurrent neural networks, has developed a severityof-illness model that continually updates as new data are added from participating PICUs.82 An outcome in Donebedian’s construct that deserves further mention is value Today, this is an increasingly important consideration when evaluating any process, particularly in healthcare Schleien documented many financial aspects related to PICU care delivery and discusses ways to enhance revenue and decrease cost in a system, which in the United States is largely based on fee for service.83 He anticipates that, over time, the overall payment system will shift to capitation and many incentives currently in place for overutilization of various diagnostic and therapeutic resources may shift If this results in limitations on use of expensive unproven technologies and medications, when these services and products would have been available previously, it may present challenges for pediatric intensivists to provide high-quality care with optimal value-based outcomes 21 Further impacting the cost of care is the previously described shortage in pediatric intensivists This factor, in addition to higher staffing demands on intensivists, growth of specialized ICUs—such as cardiac intensive care units (CICUs) and neuro-ICUs—and changes in duty hour requirements for trainees, will impact the professional cost of providing pediatric intensive care Summary A modern PICU is a complex system interacting with multiple other complex systems To attain, or even approach, HRO-level performance, the pediatric intensivist will need more than just clinical expertise As leader of a multidisciplinary PICU team, the pediatric intensivist must consistently reinforce and model HRO principles while understanding and managing delivery of optimal clinical care, including addressing the realities of personnel shortages, rapidly changing reimbursement mechanisms, and the everincreasing expectations of patients and their families Intensivists have 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2015 79 Agency for Healthcare Research and Quality Pediatric Quality Measures Program 2019 www.ahrq.gov/pqmp/index.html 80 LLC VPS Virtual Pediatric Systems 2019 www.myvps.org 81 Visser IH, Hazelzet JA, Albers MJ, et al Mortality prediction models for pediatric intensive care: comparison of overall and subgroup specific performance Intensive Care Med 2013;39:942-950 82 Laura P and, Leland K Whittier Virtual PICU www.vpicu.net 83 Schleien CL The pediatric intensive care unit business model Pediatr Clin North Am 2013;60:593-604 e3 Abstract: Pediatric intensivists, as leaders of multidisciplinary pediatric intensive care unit (PICU) teams, require an enhanced understanding of the PICU as a system within the greater hospital system, including management and evaluation of PICU operations and outcomes Integrated into this chapter’s discussion are specific challenges to attaining high-reliability care delivery We examine three key dimensions: structure (the setting in which care is delivered, including ICU staffing and physical design), process (how care is provided), and outcomes (end points of care) Key Words: High reliability, intensivist-led ICU, safety culture, quality outcomes, multidisciplinary teams ... understanding of the PICU as a system within the greater hospital system, including management and evaluation of PICU operations and outcomes Integrated into this chapter’s discussion are specific... currently in place for overutilization of various diagnostic and therapeutic resources may shift If this results in limitations on use of expensive unproven technologies and medications, when these... Further impacting the cost of care is the previously described shortage in pediatric intensivists This factor, in addition to higher staffing demands on intensivists, growth of specialized ICUs—such