Assessment of a Situation Awareness Quality Improvement Intervention to Reduce Cardiac Arrests in the PICU

Dewan, Maya; Soberano, Blaise; Sosa, Tina; Zackoff, Matthew; Hagedorn, Philip; Brady, Patrick; Chima, Ranjit S.; Stalets, Erika; Moore, Lindsey; Britto, Maria T.; Sutton, Robert M.; Tegtmeyer, Ken; Wolfe, Heather

doi:10.1097/pcc.0000000000002816

Cited by 17 publications

(24 citation statements)

References 25 publications

(39 reference statements)

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“…11 , 12 Although their bundle elements are ICU-specific, they offer a model by which multidisciplinary huddles demonstrate improved outcomes, specifically decreased CA rate, for high-risk patients. 11 , 12 Dewan et al 13 described the implementation of a bundle to increase situational awareness of patients at risk for CA within the pediatric ICU. Their bundle included daily safety huddles and was associated with a significant reduction in CA events following implementation, similar to our findings with HeartWatch.…”

Section: Discussionmentioning

confidence: 99%

HeartWatch: Implementing a Pediatric Heart Center Program to Prevent Cardiac Arrests Outside the ICU

Birely

Avula

Butts

et al. 2022

Pediatric Quality &Amp; Safety

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Introduction: Pediatric patients with cardiovascular disease are at increased risk of cardiopulmonary arrest. Despite utilization of Cardiac Pediatric Early Warning Scores to identify patients at risk of decompensation, our institution had a twofold increase in cardiac arrests (CAs) in the acute care cardiology unit (ACCU) over 2 years. Through a quality improvement initiative, we developed a watcher program, HeartWatch, to reduce the CA arrest rate in the ACCU by 50% over the first year of implementation. Methods: HeartWatch aims to identify patients not adequately captured by Cardiac Pediatric Early Warning Scores who are at high risk for sudden decompensation. Inclusion criteria were developed and evaluated during pilot and implemented phases (April 2020–April 2021) and then monitored in a sustained phase through June 2022. Our primary outcome was the reduction in the out-of-ICU CA rate. Results: During the 13 months, we enrolled 169 patients, and the CA rate decreased from 0.7 to 0.33 per 1,000 patient days, a 53% reduction. The CA rate further decreased to 0.28 events per 1,000 patient days, a 60% reduction, by June 2022. The most common indications for HeartWatch inclusion were high-risk single-ventricle patients (31%) and patients with diminished ventricular function (20%). Conclusions: Implementation of HeartWatch was associated with a meaningful reduction in CA in the ACCU. Creating shared mental models for high-risk patients is essential for patient safety. Future work will optimize local processes that focus on the sustainability of our gains. We will also evaluate opportunities to adapt and implement a similar framework in other institutions to assess reproducibility.

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Section: Discussionmentioning

confidence: 99%

HeartWatch: Implementing a Pediatric Heart Center Program to Prevent Cardiac Arrests Outside the ICU

Birely

Avula

Butts

et al. 2022

Pediatric Quality &Amp; Safety

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“…As our field continues to improve patient outcomes, we must preserve our capacity to adapt quickly while maintaining processes that keep patients safe. The study by Dewan et al (7) provides critical insight on how to accomplish this. Daily or twice daily rounds that are common in ICUs may in fact not be enough for the dynamic nature of our patients and the rate at which their disease and clinical status change.…”

Section: Balancing Adaptive Capacity and Patient Safetymentioning

confidence: 99%

“…It focuses attention on how we as humans operate amidst an increasingly technological world where the abundance of data can quickly become a threat more than an asset (6). In this issue of Pediatric Critical Care Medicine, Dewan et al (7) aimed to reduce cardiopulmonary resuscitation (CPR) events by 25% from February 2017 to December 2020 with interventions over 18 months to increase situation awareness. They implemented twice daily safety huddles, designated "WATCHER" status with bedside signs, initiated smaller pod-based huddles called "puddles, " and integrated data from an automated clinical support system used to identify high-risk patients.…”

Section: Optimizing Situation Awareness In the Icumentioning

confidence: 99%

“…If a technology existed that achieved such astonishing clinical results, it would receive extraordinary attention. Dewan et al (7) are to be congratulated for demonstrating real clinical benefit by increasing situation awareness at several different levels in an ICU, including individual, team, pod, and unit levels. This is a critically important concept because ICUs deliver care at all those levels, and efficient care at all levels requires situation awareness.…”

Section: Optimizing Situation Awareness In the Icumentioning

confidence: 99%

“…It is important to note that studies like that by Dewan et al (7) may have unintended consequences, and we must anticipate and understand them. Did the system fail to identify some patients, who consequently received slower care because the teams were in fact "distracted" by those whom the system did identify?…”

Section: Does Increasing Situation Awareness Have Unintended Conseque...mentioning

confidence: 99%

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Optimizing Human Performance in ICUs*

Kudchadkar²

2022

Pediatric Critical Care Medicine

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The origin of the term "situation awareness" is attributed to the military dating as far back as World War I (1). Colonel John Boyd of the U.S. Air Force defined the "observe-orient-decide-act loop, " also known as "the OODA loop or the Boyd cycle. " The main emphasis in OODA is the understanding of actionable information and subsequent change in action as a direct result of that information. In other words, the right people must get the right information, must be capable of analyzing it, and must do something useful with it that affects outcome (2). After gaining traction in military aviation, the concept of situation awareness became integrated into crisis resource management and team training, later finding its way into medicine, with one of its earliest appearances in an anesthesiology journal (3).

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Use of design thinking and human factors approach to improve situation awareness in the pediatric intensive care unit

Gifford,

Butcher,

Chima

et al. 2023

Journal of Hospital Medicine

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BackgroundOptimal design of healthcare spaces can enhance patient care. We applied design thinking and human factors principles to optimize communication and signage on high risk patients to improve situation awareness in a new clinical space for the pediatric ICU.ObjectiveTo assess the impact of these tools in mitigating situation awareness concerns within the new clinical space. We hypothesized that implementing these design‐informed tools would either maintain or improve situation awareness.Design, Settings, and ParticipantsA 15‐week design thinking process was employed, involving research, ideation, and refinement to develop and implement new situation awareness tools. The process included engagement with interprofessional clinical teams, scenario planning, workflow mapping, iterative feedback collection, and collaboration with an industry partner for signage development and implementation.InterventionImproved and updated communication devices and bedside mitigation plans.Main Outcome and MeasuresProcess metrics included individual and shared situation awareness of PICU care teams and our patient outcome metric was the rate of cardiopulmonary resuscitation (CPR) events pre‐ and post‐transition.ResultsWhen evaluating all patients, shared situation awareness for accurate high‐risk status improved from 81% pre‐transition to 92% post‐transition (p = .006). When assessing individual care team roles, accuracy of patient high‐risk status improved from 88% to 95% (p = .05) for RNs, 85% to 96% (p = .003) for residents, and 88% to 95% (p = .03) for RTs. There was no change in the rate of CPR events following the transition.

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Assessment of a Situation Awareness Quality Improvement Intervention to Reduce Cardiac Arrests in the PICU

Abstract: To use improved situation awareness to decrease cardiopulmonary resuscitation events by 25% over 18 months and demonstrate process and outcome sustainability.

Cited by 17 publications

References 25 publications

HeartWatch: Implementing a Pediatric Heart Center Program to Prevent Cardiac Arrests Outside the ICU

HeartWatch: Implementing a Pediatric Heart Center Program to Prevent Cardiac Arrests Outside the ICU

Optimizing Human Performance in ICUs*

Use of design thinking and human factors approach to improve situation awareness in the pediatric intensive care unit

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