Transforming PICU Patient Safety: A Decade of Quality Rounds

1. Keeping a pulse on the bedside: Ten years of Quality and safety rounds in the Pediatric Intensive Care unit Karla Abela, MSN, RN, CCRN-K Angela Stutts, MS, RN, CCRN-K Darlene Acorda, MSN, RN, CNE, CPNP Anne Lam, MSN, RN, CPNP

2. objectives • Discuss the history of patient rounding in healthcare. • Describe the challenges of PICU patient rounding efforts pre-2008. • Discuss the evolution of PICU rounding over the past 10 years. • Describe the future direction of patient rounding in the PICU.

3. History of patient safety rounds • To Err is Human (1999) report increased awareness of U.S. medical errors • Focus on patient safety culture • Walk rounds became a strategy to engage leaders directly with front-line providers • Aim was to show leader commitment to safety, foster trust and psychological safety, and provide support • Proactively address threats to patient safety (Weaver et al., 2016).

4. Ahrq recommendations for patient safety rounds • Developed by Allan Frankel, MD • Objectives: • Increase awareness of safety issues by all clinicians • Make safety a high priority for leadership • Educate staff about patient safety concepts such as a “just culture” • Obtain information collected from staff about barriers to safety • Act, after analysis, on information collected from staff • Consistently give feedback to frontline providers and leadership on processes

5. Picu rounds prior to 2008 • Medical rounds separate • Multidisciplinary rounds – lacked physicians, child life, respiratory, nursing • 3 days per week • No focus • Non-quality related • Addressing patient needs rather than assessing patients • No accountability piece

6. PICU Clabsi Rates pre-2008 • FY 06: 2.78/1000 central-line days • FY 07: 2.05/1000 central-line days • FY 08: 12 CLABSIs in PICU

7. Challenges and barriers pre-2008 • Lack of interest, not viewed as important • Getting providers on board • Dissemination of rounds to other units • Lack of data behind the value of rounds not established • Manual data collection

8. The impact of nachri and ohio collaborative • Became part of NACHRI in 2008 • Attended conference related to CLABSI • Learned about bundles and checklists • Learned about 15/15 scrub and dry • Data related to interventions • Had an increased in CLABSI (12) • Officially tracked CLABSI rates in 2008 • Beginning of care bundles • Beginning of RCAs for CLABSI • Shifted to Ohio Collaborative in 2015

11. Evolution over time Rounds focused on hospital acquired conditions and overall quality of care

12. Current Quality and safety rounds • Occurs weekly • Covers PICU/TICU 9-12th floors • Involves a multidisciplinary group of nurse leaders, critical care providers, infection control, infectious disease providers • Targets patients at risk for hospital acquired conditions • Focuses on current gaps in practice and organizational initiatives (e.g. PPID, etc)

14. Data collection and reporting • Reports generated daily for CLABSI and Hygiene • Review of patient lists by the clinical specialists to identify other risk factors • Findings on rounds recorded in RedCAPsoftware • Findings shared to staff at quarterly state of the unit (SOU) meetings

15. CLABSI 2016-2019

16. CLABSI Bundle Compliance

17. Cauti 2016-2019

18. Hand hygiene

19. Gaps found through rounding • Barriers to proper PPID • Practice deviations from standards • Gaps in parent education • Practice-related misinformation • Gaps in provider education related to hospital standards

20. Initiatives • Respiratory rounding • Skin/Surface rounds • Night Shift rounding • CLRN pilot • PPID • Pump audits

21. Challenges • Number of beds • Increased acuity of patients • Physical geography • Parent/family involvement • Attendance • Staff awareness of rounding goals

22. Lessons learned • Best way to find out what is actually happening at the bedside • Entire team focused on the same goal • Automation of reports saves time • Tracking outcomes is essential to value • Night shift rounds are critical • Culture change starts with leadership visibility and engagement at the bedside

23. Future direction • Full automation of reports using the EMR • Inclusion of staff nurses in rounds • Rounding as part of every major initiative