Chapters Transcript Oral abstract presentations Back to Symposium Oral abstract presentations. Up next. We have Brandy Beal Smith, uh, from the symposium committee, um, who will be talking, uh, who will be introducing the next subject, I believe. Hello Thank you guys for sticking with us this afternoon. I recognize we're the only thing standing between you and 80 degree weather, so we're trying very hard to get this, uh, completed. We have just, um, one more hour session here. Uh, we have 3 speakers that will, um, uh, share their, uh, topics, uh, over a short presentation, and then we will hold questions until they're finished, and we will bring them up to the table, um, together for a panel, um, questions. So please um go ahead and put your questions in the um poll everywhere and we will get those once those are finished. One other thing to note is that uh the booklet had a mistake. It says that this um this section is not, um, CEU um authorized but it is so the this this section will have CEU so please um fill out your, um, survey at the end of this section as well. Alright, first up, so we have Doctor Abby Huddleston. She's a 2nd year resident at Saint Louis Children's Hospital. She is looking forward to applying for fellowship this coming summer and is interested in pediatric critical care medicine. She's currently involved in quality improvement and outcome research in the critical care setting, and she hopes to continue being involved in this work in her future career. Welcome. Like this or this? Yeah, yeah. Oh hi everyone. My name is Abby. I am a 2nd year resident at Saint Louis Children's. Thank you for having me. Um, today I'm gonna talk about a QI project that is, um, going on in our CICU regarding cardiac arrest prevention. I have no financial relationships to disclose. Here our objectives. So first we're gonna talk a little bit about in hospital cardiac arrest, um, in our pediatric patients, and then we'll discuss an an evidence-based method of reducing cardiac arrest in the CICU and how we've implemented it at ours. So as you might have guessed, cardiac arrest occurs more frequently in hospitalized kids with acquired or congenital cardiac disease compared to any other disease type, specifically at a rate of 2.6 to 6%, and that has significant morbidity and mortality consequences as well. Because of that, I feel like there's an echo from the microphone, but, um, because of that there's been a lot of time and effort put into, uh, investing in research and resources to decrease not just the morbidity and mortality risk but preventing cardiac arrest in the first place, which is where this project comes in. So the Pediatric Cardiac Critical Care Consortium, or PC4 is a group of more than 70 hospitals, um, whose aim is to reduce cardiac arrests in the CICU. And a few years ago they did a study where they implemented this cardiac arrest prevention or CAP bundle. Um, at 15 hospitals and then compared it to 616 control hospitals, um, and we emulated that cat bundle at our hospital, but what that involves is 5 elements. So first, uh, is a twice daily multidisciplinary team huddle to discuss, um, patients who are at a high risk for cardiac arrest at their bedside, and that involves providers, um, nurse practitioners, bedside nursing, charge nursing, uh, respiratory therapy. The pharmacy team, anyone who's involved in direct patient care. Next, during those huddles, they identify specific vital sign parameters, um, for nursing to watch out for. They discussed the need for pre-sedation for specific components of nursing or respiratory care that could be like suctioning or any sort of treatments that needs to happen. And then they um look at availability of emergency meds emergency medications um with patient specific dosing to be present at the bedside and we'll talk specifically about what those medications are here in just a second and then there's a formal code review of all cardiac arrests that occur. And then as you can see from this graph from their original study at the top is cardiac arrest rates at the hospitals where the cap bundle was implemented, and then on the bottom are control hospitals, um, and it found that there was quite a bit of, um, a decrease in, in, um, cardiac arrest rates at hospitals where the CAP bundle was implemented, specifically 30% relative reduction. So at our hospital, um, we split our patients up into surgical and non-surgical patients in the CICU first off, um, and then this is our, um, cardiac arrest rates over the last couple of years compared to the PC4 rate. So the PC4 group created a database that has a lot of patients specific data, especially regarding cardiac arrests, and allows us to compare our cardiac arrest rates to a more aggregate rate. So as you can see. Um, the Saint Louis Children's Rate is the blue line, whereas the PC4 rate is the green line, and we have, um, quite a bit of work to do in terms of bringing our rates down. Specifically for surgical patients, in 2023, the cardiac arrest rate was 4.9%, whereas in non-surgical patients, it was 2.4%. This is our key driver diagram, and here are some of our smart aims for our quality improvement projects. So, first, our initial aim was to decrease our cardiac arrest rates in surgical patients to less than 3%, and then in non-surgical patients to less than 2% in 1 year. And then about a year into the study, uh, we realized that there was a drop in some cap bundle compliance, specifically in our non-surgical patients. So we had a, uh, branch arm of the study looking at, um, cap bundle compliance with a smart aim to increase, uh, cap bundle compliance for cap bundle eligible patients to greater than 75% or at least 75% within an hour of admission. And what we measured was the change in the cardiac arrest rates collected from the PC4 database, and then the cap bundle compliance via chart review of all the eligible patients. So this is an example of the cardiac arrest prevention bundle tool that's present at the bedside of all of our cat bundle patients. So this first box has all of your patient identifiers, um, but it also highlights different groups that are, um, high risk for cardiac arrest in the CICU. And so each, um, during each huddle, it's discussed which bracket our patients fall into and who would, um, who the cat bundle would apply to. This next box highlights the expected modes of decompensation and then highlights whether or not the patient is an ECHO candidate just for awareness. Next, these are the vital sign parameters. So during each of these huddles, the team will talk about exactly what vital signs, um, what range of vital signs we should expect, and that comes into play, especially in this box here, which is for contingency planning, um. One of the big goals of the cap bundle is to empower nursing at the bedside to be able to follow these specific contingency plans and respond to an emergency without having to take the time to call the provider to the bedside, wait until they Get there, obtain all of the medications. So during the huddle, specific contingency plans specifically related to like the vital sign parameters are laid out so that nursing can use the medications down here to respond as the provider is coming to the bedside. Um, specifically, those medications are code dose, epi, rescue dose Epi, and then fluid boluss. Um, and all of these are based on the patient's weight. They're kept at the bedside in a little lockbox. Um, and then calcium, gluconate, and sodium bicarb are available in the nearby Pixis. So here you can see our results from our current project. So on top we have again, our surgical patients, and then on the bottom we have our non-surgical patients. The blue line is, um, children's cardiac arrest rate, and then, um, the green line is for the PC4. Aggregate rate. So in the first year for surgical patients, you can see that it decreased from 4.9% to 1.8%, which is below the aggregate rate. And then in non-surgical patients, it decreased from 2.4% to 1.26%, which is below the aggregate rate. And then, um, in year two, In surgical patients, this was sustained at 2.1%. And then, interestingly enough, in non-surgical patients, this increased back to 2.67%. And we'll talk about why we think that is in just a second. As for the compliance arm, as you can see from our graph here, so our dots are daily compliance, uh, with the cap bundle in our cap bundle eligible patients. Our green line is our goal set by our, um, smart aim, and then our red line is the median cap bundle compliance. So about a year in, we had sent out these cap bundle refreshers and, um, sent out a cap bundle order set. And reviewed compliance with cap bundle. And you can see that our compliance, um, went quite a bit up. The blue dots are reaching the 100% mark now. So in conclusion, um, our cap bundle implementation reduced cardiac arrest among all the groups in year one, which is great. Um, and it was sustained in surgical patients in year two. Likely because, um, in handoff from the OR to the CICU team, the CA bundle has become a really standardized part of that interaction and that admission handoff. But that's not the same for surg non-surgical patients. There's not really a standardized process just yet for implementing the CA bundle in these patients as they can. You know, admissions can happen at any time. They can be, um, after a cardiac arrest or an acute decompensation on the floor and so it's not as intuitive to think about the CA bundle as you're admitting a new and very sick patient, um, but that's an opportunity for future QI work and what we're working on now is trying to find a way to standardize that process to, um, increase our compliance with the cat bundle. These are my references. Thank you guys so much. Thank you, Doctor Huddleston. OK, next up, Doctor Elizabeth Lanham. She's a 3rd year pediatric resident at Saint Louis Children's Hospital who will begin neonatology fellowship at Saint Louis Children's Hospital in July of this year. Her research experience includes longitudinal studies investigating long term outcomes and neurodevelopmental progress of neonates and various quality improvement projects. She looks forward to expanding upon these interests during fellowship in her future career. OK, um, hi everyone, my name's Elizabeth Lanham. Um, like she said, I'm a 3rd year pediatrics resident, and I've been working on this QI project with some of my NICU colleagues, and we've been aiming to decrease our time to antibiotic administration for our patients with suspected late onset sepsis. I have no financial disclosures and our project was approved by the QI review committee and sanctioned by WasU's IRB. So briefly my objectives, I'm gonna talk about what neonatal late onset sepsis is and the importance of timely recognition and treatment, then go through our, uh, key driver diagram highlighting our SMAR aim, discuss our PDSA cycles, and then share our results and sustained improvement as well as talk about where we'd like to go in the future. So as a little bit of background, um, neonatal late onset sepsis is characterized as sepsis that occurs after 72 hours of life. As we are all well aware, sepsis is a significant source of morbidity and mortality in all patients, and infants are at high risk as compared to other pediatric populations, and sepsis risk increases with lower birth weight and earlier gestational age. So, uh, it's a big thing we see in our NICU patients. Um, the clinical manifestations of sepsis though, in neonates can be very non-specific and highly variable. And they can overlap with a lot of other common conditions we see in our NICU patients. This graphic up here is from a study that looked at the clinical manifestations, um, prompting septic workups and neonates, and you can see there's a lot of overlap between the darker columns where patients were found to have sepsis and the lighter columns where patients were found to have no infectious source. So diagnosis can be challenging as, um, these symptoms have a lot of overlap. Even though diagnosis can be challenging, we know that timely recognition and treatment is really key to our patient outcomes. There was a 2020 study published out of CHOPP that showed that delayed antibiotic administration was associated with increased mortality and prolonged cardiovascular dysfunction. And our study in particular looked at late onset sepsis, um, as sepsis evaluations that occur right at the time of admission to the NICU typically have a lot of, um, additional resources readily available at the bedside, um, whereas if we're doing a workup kind of later in a patient's course we don't have all of those resources right at the bedside. So this is our key driver diagram. I won't, um, go through all the details, but, um, over circled on the right or the left, um, you can see our smart aim. So specifically we set out to decrease the time to antibiotic administration from a median of 84 minutes to less than 60 minutes by December of 2025. So I'll briefly go over our uh PDSA cycles. All of these were implemented with the intention and overall goal of creating a shared mental model for working up a neonate with suspected sepsis to make sure we're doing a timely coordination of the many number of tasks that need to happen in that one hour period. So first, um, we identified our most experienced nurses to get our IV access and obtain our blood cultures. As we've shown sustained improvement over the last several months, um, this is opening up a little bit more and so we're having more opportunities for our less less experienced, um, nurses to get those cultures, um, and increase the overall capabilities of our unit. The second cycle we implemented was dedicated provider check-in times at 30 minutes and 55 minutes. Thirdly, we had some of our, um, specialized central line nurses who helped design the sepsis supply checklist to make it easier and more efficient for our bedside team to get all the necessary supplies, uh, to the bedside in a timely manner. And then our fourth cycle was, um, formal, um, education sessions for our bedside nurses and roving demonstrations for urine catheterization. Throughout our QI project, our sepsis note, um, huddle template was updated to reflect these interventions, um, to streamline our work up altogether. So in the next few slides we'll go through what the sepsis huddle template looks like. So this is the note template, um, that we use for any patient we're working up for sepsis in the NICU. Um, our first step is to gather our team at the bedside that includes our bedside nurse, our providers, and then a resource or charge nurse as well. And we state our concerns about a new infection in our patient and then um go through our timeline. So state our goal of getting our antibiotics in in less than 60 minutes and we write that time on our patient's door and then we also note the times for when our provider check-ins will be at 30 and 55 minutes and um who will be responsible for doing those check-ins and again all of this is kind of to create that shared mental model for everyone on the team. After we talk about our timeline, we go through our workup. Um, every patient we have concerns about sepsis in the NICU gets a blood culture, um, which leads us into talking about our vascular access that we have for our patients if we need additional access, if we need central access, if we don't have it, all of those sorts of things, those discussions are had right then and who will be obtaining, um, the cultures and getting that access if we need it. And then we talk about the rest of our workup. Typically we'll get a urine culture, um, a respiratory panel, you know, a tracheal aspirate if we have an artificial airway, and then if there's any concerns for CNS involvement, we'll talk about, um, the whether or not we need a lumbar puncture and if so, who will be performing that. Then we get into discussion about our treatment. Um, this chart populates in our sepsis huddle note, um, to help serve as a guide for which antibiotics we'll order for our patients. Obviously every patient is different and the clinical scenarios change, so it's not, um, hard and fast for every scenario, but, um, it's a good starting off point and then you'll see high. Highlighted at the bottom is a very important line from our sepsis huddle script to remind our providers to make our orders stat, um, that really is imperative for getting our antibiotics verified by pharmacy quickly and then, um, made and sent up to the bedside in a timely manner because if we don't have our antibiotics at the bedside within 60 minutes we certainly can't give them to our patient that quickly, um, so there are lots of steps that go into this and. Creating a timely and coordinated approach to these workups has been really important. Over the last year we did monthly data collection and review. We looked at 50% of sepsis huddles each month, uh, taking down the time of the huddle, the time where our cultures were ordered, collected, and arrived in the lab, and then what time our antibiotics were ordered, verified by a pharmacists, and then what time they were administered. In total we looked at 227 sepsis huddles from 200 different patients over the course of the year. Um, of these workups, 11% were found to show sepsis, whether that was culture positive or clinical sepsis, and then an additional 25% found some source of focal infection with a negative blood culture, so things like a pneumonia, tracheitis, UTI, something like that, and the remaining 64% were shown to have no infection. So this is a run chart of our primary outcome measure, so our median time from our sepsis huddle to our antibiotic administration. Our goal was to get this to less than 60 minutes, and, um, we were successful in that. We reduced our median from 84 minutes to 45 minutes and showed sustained improvement for the last several months, um, enough to have our that center line shift. And I think this really highlights the benefits of making adjustments to our current system practices and having increased collaboration in our shared mental model amongst everyone on the team. These graphs are, um, some of our process measures, so the time of our blood culture order to reception and lab is up on top and then our median time from urine culture order to reception and lab is um down below. Both of those we showed a reduction in our. Uh, median time for these as well and then our balancing measure, um, didn't graph that because it only happened a couple of times but that was the number of times that our pharmacy had to adjust our antibiotic regimens after, um, but that was pretty rare. Looking ahead, um, we'd like to create an antibiotic decision algorithm for, um, more optimized, uh, antibiotic choices for our patients and then, um, in a kind of similar but but different vein you may have noticed that many of our patients get worked up for sepsis who are found to have no infection and so. We are working on, um, a retrospective study using the data from these huddles to, uh, analyze a computerized sepsis risk score to stra risk stratify patients, um, on their, on their risk of sepsis, um, to hopefully give real-time ideas on escalation of care. That's all I had. Um, these are my references. Thank you. Thank you, Doctor Lanham. Our final presenter is Emily Wambold. She's the senior manager for quality, safety and Practice excellence at Saint Louis Children's Hospital. She serves as the co-chair of the Housewide resuscitation Committee, and she has over 20 years of experience. She has a special interest in fostering an environment of continuous improvement, promoting a culture of safety, and improving patient outcomes, particularly as it relates to the early recognition and treatment of clinical deterioration. Thank you. And thank you all for sticking in there. We'll get you out of here in just a little while and closer to these attendance prizes and this 80 degrees that we have outside. OK. Um, the Institute of Healthcare Improvement introduced rapid response systems to the United States in 2001 during their 100,000 lives campaign. This campaign aimed to eliminate 100,000 preventable patient deaths and address gaps in care. Some of these preventable patient deaths are from unrecognized clinical deterioration. So critical to any rapid response system is its ability to detect subtle changes in patients' clinical status, to respond and treat, and also to measure their success in achieving those goals, and also to identify opportunities for continuous improvement. Um, so, In this, um, project that we did, our measure that we wanted to look at was emergency transfers. An emergency transfer is defined as a patient needing intubation, inotropic support, or 3 or more fluid boluss in the hour leading up to ICU transfer or the hour after. And this emergency transfer represents a very acutely ill and very very vulnerable population of children. And so we wanted to make sure that we were able to quickly identify, um, that clinical deterioration so we could intervene early and potentially avoid invasive interventions, um, rush transfers to the ICU and potentially patient death. Emergency transfers is a widely used, uh, metric across pediatric hospitals and is the only validated metric that's been shown to be associated with increased morbidity and mortality, prolonged hospital length of stay, and increased healthcare costs. Um, of course, impacting emergency transfers really relies heavily on our ability to detect that clinical deterioration early. So early warning scores are commonly used tools across both pediatric and adult populations. Most of these tools combine physiological data, such as, um, neurobehavioral status, respiratory status, and cardiovascular status, along with the patient's vital signs to come up with a predictive score on their, um, likelihood to deteriorate in the next several hours. So during a review of a patient event, we recognized defects in the resources that we had available to detect that deterioration early. So we had an early warning score that was already in use, but it was clunky. It was sometimes difficult to find in the electronical medical record. It was difficult for people to interpret, and we had very little guidance on what to do with that score. So we started out by evaluating the literature and talking with the experts at other pediatric institutions, discovering that many other hospitals were experiencing the same challenges that we were. Through this process, we found a different early warning score called CHOS that was developed and validated by Boston Children's Hospital, and we tested that score against the one that we were using. We recognized that the CHO score was, um, finding and, um, really. Able to predict that early decline better than the tool that we were using. However, we still felt that within that tool, there was more opportunity to provide better guidance and clarity within the physiological criteria, especially because we have a relatively novice nursing staff and our patient mix is heavy with medically complex patients. Historically, early warning scores have not been developed to consider patients with medical complexities, and we wanted to make sure that we were able to capture that population. So using the Choose tool as a guide, we worked with our nursing and physician staff to adapt and tweak that physiological criteria to our patient population, paying attention to the nuances that we see when our medically complex patients decline. So we began testing and using this tool that we call SHIELD, St. Louis Children's Hospital indicator for early likelihood of deterioration, first evaluating its performance using retrospective rapid response events. In our next PDSA, our shield nurses began testing it in real time, um, at the time of rapid response. And the Shield Nurse was a sister project that we implemented around the same time. This is an ICU trained nurse who serves as an invaluable resource, proactively rounding on all of our watcher patients, attending rapid response events, and facilitating interprofessional communication and transfers to the ICU. As we saw success with our shield nurse scoring at the time of rapid response, we decided to implement a paper process with the shield nurse and the floor nurse scoring, um, together, but intermittently at the time of rapid response, and then comparing their scores. So as we became more comfortable with the function of the tool, as well as inner innerator reliability, we decided then to allow testing once per shift to see if we could really still gain that, um, predictability. During that time, we also began working with our CIS partners to begin building an electronic version and also worked with our nursing and physician partners from all of our departments and specialties to start building education and a communication plan for that electronic rollout. With the electronic rollout, we would also require to move scoring from once per shift to every 4 hours. And this is a graphic of the scoring tool that we were using before. I want to point out how subjective the criteria. How subjective the criteria are in each of the physiological categories. And you'll be able to see in comparison to the next slide, next slide, the guidance for scoring, the physiological parameters, and the additions and deletions we made. Um, specifically, removed these bottom two categories because they rarely ever applied to our patient population and added some things that we felt would be more pertinent. So this is a graphic. I know it's busy on this slide of our shield tool. In the red text are parameters that pull directly from the vital signs flow sheet and Epic. And because this is a snapshot in time, we wanted this, this to be as accurate as possible. And so we limited this to pulling vital signs only if they've been documented within the prior 30 minutes. If it's been greater than 30 minutes, the nurse will be required to get an additional set of vital signs and document that at the time they complete this in the flow sheet. Um, we also looked at the oxygen saturation and calculate that from the patient's baseline. This is set to default at 100%, but it can be changed at any time, um, after a conversation with the care team and a provider order. And then in the behavioral neuro, cardiovascular, and respiratory categories, um, we provided much more guidance here to make that a little bit less subjective, and also included changes from the patient's baseline. We added the bottom three categories, staff concern, family concern, and fragility diagnosis. The staff concern honors the value that we placed on nursing intuition and their ability to recognize when something is wrong. The same goes for family concern. We know that our caregivers know their patients or their child best, and they can often pick up on those subtle signs of deterioration before our care teams. And so a point can be added here for family concern, and also for family absence because those kids without a caregiver at the bedside are more vulnerable to undetected deterioration. And this fragility diagnosis also gives an additional point, um, to patients with those medically complex conditions. We developed these criteria with physicians from all of our subspecialty teams, but also allow some flexibility there for, um, clinical judgment. So if a nurse feels like a patient has a condition that's not on the list that places them at increased risk, they are able to add an additional point there as well. And the tool does not mean much of anything without the ability to interpret it and escalate concerns. So this is a graphic that our clinicians can use to help guide that escalation. So patients in, um, the category of 1 to 2 are at low risk for clinical deterioration. However, they are still able to escalate concerns or activate a rapid response regardless of the patients score. A patient with a score of 3 to 4 is escalated to the frontline provider, and an assessment is done at the patient's bedside. Additionally, a patient of a 3 or 4 of a 3 or higher will be added to our watcher list. Along with this, um, new tool, we had a new definition for watchers, which is any patient with a score of 3 or higher, and that shield nurse will proactively round on all of those patients. And then a score of 5 or higher is moderate to severe risk for impending decline. So these patients receive that same interventions as the prior category, but this is also required to be escalated to the attending. And these are the results that we've had so far. This graph demonstrates percentages of our emergency transfers with the denominator being all rapid response events in code blues. And again, emergency transfers are those patients requiring intubation, vasopressor support, or 3 or more boluss in that hour before or 1 hour after transfer. So we're tremendously proud to have seen a downshift in our average percent of emergency transfers, which really demonstrates that intervening early can protect patients from avoidable invasive interventions, rush transfers to the ICU, and even potentially death. And I know I'm over time, um, but learning and sustaining is really important to us, so we know the work is not done, um, so we're continuing to look at what our opportunities are for learning, um, specifically around improved communication in that escalation pathway from the nurse to the frontline provider and then to the attending and also, um. Really looking at how we manage patients who have higher scores at their baseline. So how can we huddle with those patients, look at what their scores are at their baseline, and determine when we're concerned for those patients and really have that patient-specific contingency plan. And that's all I have. These are my references. Thanks Emily. I'm gonna invite all three of our presenters back up to the table here and we'll do a brief Q&A session. And your mics are probably off, so just FYI. Um, so first question, Emily, do you track if someone is a green but a rapid response or code is called? There we go. I think that's working now. Um, yes, we do track what the shield score is for all patients at time of rapid response or code blue. Um, typically, if someone is in that green category, um, with a score of 1 to 2, and they have an event, it's usually pretty acute. So sometimes I would say probably most commonly we see those on our, um, neuro unit where a patient may be having a seizure and has an acute respiratory, um, Issue that needs some bagging or something like that for a short period of time. Does the Shield RN have their own team as well as functioning in the role? That's a great question, but this is a dedicated FTE, so these critical care trained nurses are also charge nurses, but in the shift that they're functioning as a shield nurse, they cannot be pulled to staffing or to charge. Doctor Lanham, who calls the huddle or is it a set time? Um, the sepsis huddle can be kind of initiated by anyone, but if the bedside nurse has a concern, brings it up to the provider team, and then, um, we would all discuss if there's a concern high enough to warrant a workup for, um, an infectious process, a new infectious process, then we would have the huddle, but there's no like set time it would just be whenever the concern arises. Doctor Huddleson, I'm impressed with the use of driver diagram. Who or where did you learn how to use it to set your goals? Thank you. Um, I, I'll be honest with you, I wasn't a part of the project when the initial like smart aims were set, um, but I imagine they used the PC4 database to look at that, um, aggregate cardiac arrest rate and then chose, uh, a number that was more, more that they found more acceptable for our hospital. Thank you. This question is for each of you. What has been the biggest barrier to get people interested or on board and how was it addressed? Um, for our project, I think as far as the biggest barrier, um, I think people are, you know, easily on board with a project like that, especially as it relates to like cardiac arrest, which is a really significant issue in the CICU, but I think the biggest barrier from what I understand was getting having the ability to have medications at the bedside, um, for nursing to be able to use and. Um, to be able to, you know, empower nursing to do things before the provider comes to the bedside, um, and I can't really speak to exactly how they accomplish, how the pharmacy team accomplished those things, but I know they had to jump through a lot of hoops to be able to have those meds present at the bedside in their, um, the lock box, so present in a safe way. Um, I think most people in the NICU were on board with, um, getting our antibiotics into our patients who were concerned about infection, um, quickly, um, so I don't think that took a lot of buy-in, um, but the kind of logistics of creating a new kind of culture around doing the sepsis huddle, the note templates. The script I think any change takes effort and there was a lot of um effort put forth by um my colleagues in the NICU to make sure that that was a very regular and routine part of everyone's um clinical work up so. I think that's it. Yeah, um, so we started our project after a patient safety event and so we had some pretty immediate buy-in, but also involved our stakeholders very early, so they were involved throughout the entire project. So I think when we rolled out to frontline nursing staff, of course, there's always some hesitation with change, but we were also moving from a very clunky, difficult to use process to something that would be easier for them. Um, it was. Really not highly liked that we started out with a paper process, but that made the electronic implementation that much easier because we were getting rid of all the paper that people were really tired of using. Thank you. Whoever asked this question, help me out. What are you asking? Come on, don't be shy. You've been here all day. OK. OK. OK, I'm skipping it. Sorry, um, so I do have a couple questions. So Doctor Huddleston, what component of the cap bundle bundle was most successful in lowering the cardiac arrest rate? Um, I actually, that's a great question. I don't really know the answer to that one. I think that. A lot of it was I for my personal opinion, I think that the having the multidisciplinary team huddle and getting everyone on the same page at the same time I think is really beneficial, um, as well as having those specifically defined contingency plans during each huddle, um, so that everyone is on the same page. I think that can be a big challenge, especially in an acute like critical care situation, um, so I think that that would be a really beneficial part of the cap bundle. Thank you. Uh, Doctor Lanham, does a patient's comorbidities affect timely recognition of sepsis with this sepsis huddle model? Um, can you repeat that? Sorry, yeah, sorry, um, so a patient's comorbidities, um, other comorbidities related to maybe other, um, uh, medical conditions, does that affect timely recognition of sepsis with the sepsis, um, huddle model? Um, I don't think so necessarily. I think, um, especially our, our bedside staff has a great. Great insight into our NICU patients and when they start having signs or symptoms that are concerning, um, they bring it to the provider team really quite quickly so I think kind of regardless of if it's a small baby 25 weeks or um you know a more closer to term 34 week infant that's now misbehaving I think um our our teams are alerted pretty quickly of any changes. Uh, Emily, uh, what was the span of time for this S SHIELD PDSAs, um, different PDSAs? Uh, so we started, um, literature review and talking with other institutions at the end of March, um, implemented the first iteration with the Shield nurse, probably about the 3rd week of April. Um, and then we did a six-week week pilot with the shield nurse and the bedside nurse scoring at the time of rapid response before we moved to the bedside nurse doing once per shift. And then also we tweaked the time of that once per shift a couple of times based on feedback from our frontline nurses on what was, um, easiest for their workflow. And are the shield RNs, uh, you mentioned they are charge nurses in their role, are they 24 hour coverage? Are they covering both shifts or just day shifts? No, that's 24 hour coverage, OK. Any other questions? Anything else our speakers would like to share? OK, thank you so much. Created by Presenters Abbigail Huddleston, DO Pediatrics Resident, WashU Medicine, St. Louis Children's Hospital View full profile Elizabeth Lanham, MD Pediatrics Resident, WashU Medicine, St. Louis Children's Hospital View full profile Emily Wambold, MSN, RN, CPNP, APN Quality, Safety & Practice Excellence,St. Louis Children’s Hospital
