The Children s Hospital Neonatal Consortium: Optimizing Perioperative Care for Neonates Eugenia K. Pallotto MD MSCE Associate Professor of Pediatrics, Medical Director, Intensive Care Nursery Medical Director, Neonatal ECMO Children s Mercy Hospital University of Missouri-Kansas City School of Medicine Kansas City, MO Eugenia K. Pallotto MD, MSCE is an Associate Professor of Pediatrics in the Department of Pediatrics and the Division of Neonatology at Children s Mercy Kansas City and the University of Missouri Kansas City School of Medicine. She completed her medical training at the Northwestern University Medical School in Chicago, Illinois in 1990. She completed a Categorical Residency in Pediatrics at Children s Memorial Hospital, Northwestern University Medical Center in 1997 and a clinical research fellowship in Neonatology at the Children s Hospital of Philadelphia, University of Pennsylvania School of Medicine in 2001. The most recent project is focused on systems and processes to improve peri-operative care for the neonatal patient. As a neonatologist and medical director she has a broad clinical experience caring for this population of critically ill neonates and the systems needed to care for these patients. Beverly S. Brozanski MD Professor of Pediatrics Medical Director NICU Children s Hospital of Pittsburgh Pittsburgh, PA Beverly S. Brozanski MD is a board certified pediatric specialist (1978 Neonatal-Perinatal Medicine) and a 2012 graduate of the Institute for Healthcare Improvement Advisor Professor Development Program (IA). She coordinated multiple single center and multi-center clinical research studies both as an investigator and site IP. As the Medical Director of the NICU Children s Hospital of Pittsburg (CHP), she has been responsible for programmatic development which included integration of the neonates with both medical and surgical problems into one neonatal care team, development of a neonatal ECMO program, Neuro-NICU care and Outreach via Telemedicine. As a quality improvement advisor, she is directly involved in the design and implementation of improvement projects in the NICU and throughout CHP. Teresa Mingrone RN, MSN, CCRN Programmatic Nurse Specialist Children s Hospital of Pittsburg of UPMC Pittsburg, PA Teresa Mingrone RN, MSN, CCRN is a Programmatic Nurse Specialist with 29 years of NICU nursing experience, 15 at the bedside, 8 years as NICU educator and close to 5 years as a nurse specialist in the NICU. Obtained BSN from the University of Pittsburgh in 1986 and MSN from Waynesburg University in 2008. She is collaborating on quality improvement topics for several years and served as project team member, faculty advisor, and improvement advisor.
Anthony Piazza MD Associate Professor Emory University Atlanta, GA Attending Neonatologist Medical Director of Neonatal Services at Children s Healthcare Atlanta at Egleston Hospital Atlanta, GA Anthony Piazza MD is currently the medical director of neonatal services for Children s Healthcare of Atlanta at Egleston Hospital. He is an associate professor at Emory University in the division of Neonatal-Perinatal Medicine. His clinical interests are related to tertiary care of the surgical neonates and the ongoing education of care providers and the training of residents and fellows. He actively mentored several fellows and residents clinically throughout his 15 year tenure at Emory. He is an active member of several educational committees for the residency and fellowship programs. Academic research includes site PI for the SUPPORT Trial. As the Medical Director of Children s Healthcare of Atlanta at Egleston Neonatal Services, he continues to be involved in the application of new research projects in the unit. As CHNC/CHND has grown, he became a member of the extended executive board and one of the leaders in its quality improvement mission. The database s purpose is to gather information and best practices as well as outcome data on rare disease specifics from Children s Hospital Tertiary NICUs. The current project includes over 20 participating hospitals focusing on improvement of transfer of care and euthermia as related to peri-opertive care. Joan R. Smith PhD, RN, NNP-BC Advanced Practice Clinical Nurse Scientist St. Louis Children's Hospital Goldfarb School of Nursing Barnes-Jewish College St Louis, MO Dr. Smith received associate s and bachelor's degrees in nursing from Maryville University in St. Louis, MO in 1986 and 1992, respectively. Master's and PhD in nursing degrees from the University of Missouri in Kansas City, MO in 1994 and 2013, respectively. For 29 years she has cared for sick and preterm infants and their families in the capacity of a neonatal nurse and neonatal nurse practitioner. In 2014 she received a joint appointment faculty position at Goldfarb School of Nursing at Barnes-Jewish College and St. Louis Children's Hospital as an Advanced Practice Clinical Nurse Scientist with a focus on implementation science. Dr. Smith spent the last 7 years partnering with national neonatal providers/experts in building the infrastructure for an interdisciplinary Children's Hospital Neonatal Consortium/Database (CHNC/D) Collaborative Initiatives for Quality Improvement (CIQI) for neonates with rare and complex medical conditions referred to tertiary care NICUs. Dr. Smith served as a faculty advisor and steering committee member for both the CHND SLUG Bug and STEPP-IN projects. As a principal investigator, she led multiple interdisciplinary teams with a focus on implementation science and patient quality and safety. Currently their neonatal investigative team is examining the effects of an electronic clinical decision support and simulation education aimed at standardizing care to reduce practice variation and inappropriate use of therapeutic hypothermia treatment in infants born with hypoxic ischemic encephalopathy (HIE). Dr. Smith is a principal investigator of an interdisciplinary research project aimed at defining appropriate timed sensory exposures to optimize neurodevelopmental outcomes in infants born very preterm in the NICU with a focus on development of a detailed implementation plan. Dr. Smith has recently been selected to participate in the 2015 Training Institute for Dissemination and Implementation Research in Health (TIDIRH) supported by the National Institutes of Health and the U.S. Department of Veterans Affairs. Annual Quality Congress Breakout Session, Saturday, October 3 and Sunday, October 4, 2015 The Children s Hospital Neonatal Consortium: Optimizing Perioperative Care for Neonates Objectives: Identify strategies to improve outcomes for infants requiring surgical intervention. Summarize the key steps needed for process improvement in neonatal perioperative care.
Disclosure Optimizing Perioperative Care for Neonates Vermont Oxford Network Faculty: Beverly Brozanski, MD Teresa Mingrone, MSN, RN Eugenia Pallotto, MD MSCE Anthony Piazza, MD Joan Smith, PhD, NNP-BC The faculty have no relevant financial or nonfinancial disclosures October 2015 Identify strategies to improve outcomes for infants requiring surgical intervention Understand key factors for optimizing team peri-operative handoff for the neonatal patient Summarize the key steps needed for process improvement in neonatal perioperative care Identify barriers in the participant s local culture Define specific steps in participant s local system The Children s Hospitals Neonatal Consortium (CHNC) Collaborative Initiative for Quality Improvement (CIQI) CHNC CIQI S MISSION Provide leadership to CHNC for prioritizing and completing QI projects important for children s hospital NICUs CHNC CIQI s Vision All neonates in children s hospital NICUs receive safe, high quality care. 4 Neonatal Surgery Scope of the Improvement Opportunity How often does it occur? What types of surgery? Are there measurable morbidities? What perioperative improvement opportunities exist at you center? 5 6 October 3-4, 2015 1
STEPP IN Project Development Established an inter-disciplinary team to develop project Anesthesia Neonatology Nursing Defined Drivers Pre-Operative Preparation Safe Perioperative Handoff Optimization of physiological parameters Defined Measures OVERALL PERIOP QI Periop morbidity by 50% by December 2014 sustain decrease over 12 months Pre-op preparation Safe periop handoff Optimize physiological parameters Preparation checklist NPO policy and orders Appropriate labs obtained Vascular Access Communication system Communication tools available Providers available Maintain Euthermia Maintain euglycemia Optimize ventilation & oxygenation 7 Optimize hemodynamics 8 Why are neonates at high risk for hypothermia? Increased body-surface to body-weight ratio and increase in trans-epidermal permeability Limited ability for heat production Why are neonates at high risk for hypothermia during anesthesia? Neonates are at greater risk for heat loss and have limited ability for heat production General and regional anesthetics inhibit tonic vasoconstriction and cause vasodilation resulting in a shift of heat from body core to periphery and thus a decrease core temperature 9 10 Why do we care about hypothermia? Associated with an increase in oxygen consumption that results in acidosis and hypoglycemia glucose is consumed, energy stores are depleted and lactic acid accumulates Cardiovascular including: arterial pressure, cardiac output and peripheral resistance Associated with an increase in complications Infections Mortality Increased length of hospitalization OVERALL PERIOP QI Periop morbidity by 50% by December 2014 sustain decrease over 12 months Pre-op preparation Safe periop handoff Optimize physiological parameters Preparation checklist NPO policy and orders Appropriate labs obtained Vascular Access Communication system Communication tools available Providers available Maintain Euthermia Maintain euglycemia Optimize ventilation & oxygenation 11 Optimize hemodynamics 12 October 3-4, 2015 2
Why are standardized handoffs important? Miscommunication during handoff is involved with 80% of serious medical errors In 2010, The Joint Commission s National Patient Safety Goal required a standard approach to handoff communications with specific guidelines for the process interactive communications up-to-date and accurate information limited interruptions a process for verification an opportunity to review any relevant historical data Frequency of information omissions observed before and after intervention, with 95% confidence intervals. Patterson 2010, Joint Commission Center for Transforming Healthcare 2013 13 Joy BF et al. Standardized multidisciplinary protocol improves handover of cardiac surgery patients to the intensive care 14 unit. Pediatr Crit Care Med. 2011;12:304 308 Table Work What are you trying to accomplish? STEPP IN Project Development 1. What needs changing at your local center? 2. What is working? What isn t working? 3. What barriers are present to change? 4. Who do you need to engage at your local site? 15 16 Defining SMART Aim Specific Measurable STEPP IN SMART Aim Decrease the incidence of hypothermia (<36 o C) by 50%, as measured on the first temperature within 30 minutes of return to the NICU, by December 2014 and sustain over 12 months Attainable Relevant Time Bound 17 18 October 3-4, 2015 3
STEPP IN SMART Aim Defining Drivers for Success Reduce care failures by 30% and implement a standardized communication process for postoperative handoff for over 90% of transfers of care for NICU patients undergoing surgery by December 2014 and sustain over 12 months Care Failures: missing information, at the time of handoff, that will directly affect the patient or the lack of knowledge transfer that will impact staff ability to care for the patient SMART Aim Desired Outcome List the Main drivers that influence your aim. Using a verb to describe the driver might help focus on the exact meaning of the driver Primary Driver 1 Primary Driver 2 List the actions, processes or interventions that, when performed correctly will lead to a positive effect on the driver Secondary Driver 1 Secondary Driver 2 Secondary Driver 3 Secondary Driver 1 Secondary Driver 2 Secondary Driver 3 19 20 Euthermia Driver Diagram Maintain Pre-op Euthermia 36.5-37.5 C Pre Warm OR Transport Protocol NICU to OR Target pt. temp prior to transfer 36.5-37.5 C Transport protocol: use heated, pre-warmed transport bed or chemical warming mattress, or other warming devices; ensure bed is plugged in and stays warm during OR. Send heat loss prevention devices to OR Sign off last temp to OR team, transfer of responsibility Smart Aim To decrease the incidence of hypothermia (<36 o C) by 50%, as measured on the first temperature within 30 minutes of return to NICU, by December 2014 and sustain over 12 months Maintain Intra-op Euthermia Pre-op Holding Adjust ambient OR temp Heat Loss Prevention Active warming during case OR fluids Maintain temp during recovery in NICU Maintain infant in heated environment Monitor & document pt. temps per hospital protocol Avoid or minimize preoperative time Monitor & document pt. temps at least every 15 min or per hospital protocol Hat & reflective blanket as appropriate Pre-warmed prep solutions Bair Hugger, warming lights, circulating water garment or chemical warming mattress Avoid use of cold operative IV and/or irrigation fluids Heat loss prevention and active warming as needed Monitor & document pt. temps per hospital protocol Avoid or minimize time in PACU Increase care provider awareness and attention to temperature during the perioperative period Pre-op Intra-op Post-op Maintain Post-op Euthermia Maintain temp during transfer from OR to NICU Sign off last temp to PACU/NICU team, transfer of responsibility Heat loss prevention and active warming as needed Transport protocol: use heated, pre-warmed transport bed or chemical warming mattress; ensure bed is plugged in and stays warm during OR. 22 Pre-operative Considerations Establish euthermia prior to transport Should we pre warm? If so how warm? Do not transport a cold baby to OR (temp should be >36.5ºC) Each center should establish a standard protocol for transport to and from the Operating Room. Processes to consider may include: Warm hat and / or warm blanket Prewarm bed, transport in isolette or battery operated heated bed. Chemical heat mattress, thermal blanket, plastic wrap Monitor patient temperature during transport Communicate patient temperature in handoff to OR Intra-operative Considerations Prewarm OR to preset temperature for all neonates (optional) Recommend OR temp of 23 o C (73.4 o F) Use devices to maintain temperature which may include Forced air device Chemical mattress (this can be used during prep) Warming lights Warmed Intravenous fluids Warmed irrigation fluids Keep bed plugged in for post op transport Include patient temperature during handoffs during the surgical procedure 23 24 October 3-4, 2015 4
Intra-operative Considerations Post-operative Considerations Prewarm OR to preset temperature for all neonates The Perioperative Standards and Recommended Practices (2012) recommends OR temp > 26 o C (78.8 o F) OR temp< 23 o C (73.4 o F) increased the risk of hypothermia by 1.96 times (Tander et al., 2005) Whenever possible, NICU ambient temp to 23 o C (73.4 o F) for surgeries performed in the NICU. Establish standard equipment recommendations to prevent heat loss. Processes to consider may include: Warm hat and / or warm blanket Prewarm bed, transport in isolette or battery operated heated bed. Chemical heat mattress, thermal blanket, plastic wrap Report patient temp in handoff to NICU to include first OR temp, last OR temp and lowest OR temp during case 25 26 HAND OFF PROJECT Team Members participatep Reduce care failures by 30% and implement a standardized communication Standardized process for communication postoperative method handoff for over 90% of transfers of care for NICU patients undergoing Providers surgery by received December 2014 accurate and and sustain over 12 months complete information Identify participants Define Roles pre-op checklist post-op checklist Develop Monitoring Tool Data collection method Establish notification system for patient transfers Educate team members on checklist use Collect and collate monitors Need to change our culture Increase the importance of care provider handoff during the peri-operative period Pre-op Intra-op Post-op 28 Characteristics of the Ideal Handoff A. TEAM MEMBER a. Define Team Members b. Develop Team Member Notification Process B. STANDARDIZED/STRUCTURED COMMUNICATION a. Develop a Communication Plan b. Develop Handoff Content c. Team Members need training C. HANDOFF EFFECTIVENESS a. Clinical Outcomes/Care Failures b. Provider Satisfaction Training Team Members Training should: occur prior to implementation include what constitutes a successful handoff should be standardized can occur in departmental meetings, educational setting, by viewing training videos, and/or simulations Petrovic 2012 29 30 October 3-4, 2015 5
Table Work Tackling the Problem 1. Create a Smart Aim 2. Identify Key Drivers 3. Identify Measures 4. How will you engage team members? 5. How will you monitor? 31 STEPP IN Success Review collaborative results 32 STEPP IN Participating Centers STEPP IN Project Development Team A.I. dupont Hospital for Children All Children s Hospital-St. Petersburg Ann & Robert Lurie Children s Hospital of Chicago Boston Children s Hospital Children s Healthcare of Atlanta Children s Hospital of Omaha Children's Hospital of Colorado Children s Hospital of Michigan Children s Hospital of Philadelphia Children s Hospital of Pittsburgh Children s Medical Center Dallas Children s Mercy Hospital-Kansas City Cook Children s Health Care System Florida Hospital for Children- Orlando LeBonheur Hospital-Memphis Nationwide Children s Hospital Primary Children s Hospital-Salt Lake Rady Children s Hospital- San Diego Project Development Team Hospitals: Children's Healthcare of Atlanta - Egleston Nationwide Children's - Columbus Children's Medical Center - Dallas Children's Hospital Colorado Denver Children's Hospital of Michigan - Detroit Texas Children's Hospital - Houston Children's Mercy Hospital - Kansas City Arkansas children's Hospital - Little Rock Children's Hospital of Los Angeles Le Bonheur Children's Hospital - Memphis Children's Hospital of Pittsburgh of UPMC Children's Hospital of Philadelphia St. Louis Children's Hospital Alfred I. DuPont Hospital for Children - Wilmington 33 34 October 3-4, 2015 6