1. Impact of Quality Improvement in the CICU Santiago Borasino MD, MPH Associate Professor of Pediatrics, Section of Cardiac Critical Care University of Alabama at Birmingham

3. Standardization in Oncology: Quality and Research Hand by Hand Most patients enrolled Meticulous Data collection Adjustment of treatments as new therapies become available Comparison with previous protocol

4. STANDARDIZATION Case for Standardization in the CVICU

5. Standardization: CVICU High complexity dynamic environment Multiple decisions per day Admission can be classified by their surgical procedure and required similar care most of the time Multiple processes are performed in all patients at some point (feeds, ventilator weaning, etc.)

6. Standardization: Pro Simplification of Complex Processes – Time to concentrate on more important decisions Allow expert opinion to the bedside efficiently Training and Retraining Anticipatory care: all members of the team understand the process and their role(s) Detect protocol deviations and allow for corrections Protocol adjustments and comparisons (QI) Reduction of practice variation (care should change for the patient, not the physician) Research

7. Standardization: Cons “Loss” of physician’s judgment and experience – All patients are different – Decrease practice variation to adapt to the patient (or is it to adapt to the physician?) Rigidity

9. How to approach QI in the CVICU? Have the Will Power Tools – LEAN, Six Sigma, etc. Include all the important stakeholders – Especially the frontline clinicians (Nurse and bedside doctors) Use Data to create your guidelines – Internal/External – Evidence Based Medicine Have a plan to measure the effects

10. Quality Improvement in our Unit

11. Admission Order Sets (CPOE) Feeding – Pre-op Neonatal Feeding guidelines – Feeding guidelines – Swallowing and Aspiration Evaluation Potassium Management Anticoagulation – General – ECMO Postoperative Hemorrhage Transport Check Off List

12. Quality Improvement in our Unit cont. Resuscitation – Debriefing – Resuscitation Committee evaluation – ASAP’s – RAP Respiratory – Intubation “kits” – Ventilator Weaning Protocol – 3 person ETT suction – Tracheostomy Care – Oxygen Management Guidelines Cardiac Echo – HLHS pre and postoperative imaging schedule

13. Quality Improvement in our Unit cont. Chylothorax Laboratory Studies CVL – Placement (All US) – Maintenance (Access, dressing changes) Sedation weaning HLHS ECMO Transport off Unit Check list

14. EXAMPLES Quality Improvement in our Unit

15. Potassium Replacement Protocol IV potassium is considered a high risk medication Appropriate threshold for K replacement is not clear in pediatrics Enteral potassium is a safe alternative

17. Protocol implementation

18. Total intravenous KCL doses, n33647 Total enteral KCL doses, n11431733 Intravenous KCL doses per 100 patient days, n17.62.5<0.01 Enteral KCL doses per 100 patient days, n59.892.0<0.01 Cost of KCL supplementation per patient admission, US dollar 36.2315.66<0.01 Total intravenous KCL fluid administration, ml62263451 Total enteral KCL fluid administration, ml10703181 Total KCL fluid supplementation per patient admission, ml 40.518.2<0.01 Abbreviations: KCL, potassium chloride; ml, milliliters; US, United States Outcomes: Doses, fluid and cost

19. Before Protocol After Protocolp value Episodes of serum potassium >6.0mEq/L per 100 patient days 1.60.6<0.01 Episodes of serum potassium <3.5mEq/L per 100 patient days 47.950.70.4 Average morning serum potassium level, mEq/L mean (SD) 3.5 (0.6)3.4 (0.6)0.49 Arrhythmias per 100 patient days, n1.51.70.34 Abbreviations: SD, standard deviation Outcomes: Clinical

20. Laboratory Use 2012 CPOE was introduced Standardization through Order Sets Recurrent Daily Lab orders entered on admission Increase use of laboratory studies drive cost up but does not necessarily increase quality of care QI project : Decrease laboratory use by changing Order Sets and asking Health Care Team to evaluate needs for labs each day

21. X=3.5 6 Pre-ProtocolPost- Protocol

22. X=1.5 64 Pre-ProtocolPost- Protocol

23. Blood Product Utilization and Bleeding Multidisciplinary Effort – Anesthesia – CV surgery – CVICU Data Collection Primary Drivers and secondary drivers identified Leading to Standardization

24. Blood Product Utilization and Bleeding

27. Ventilator Weaning Protocol

28. Total Intubation Times (Median)

31. Postoperative Feeding Protocol Improves Outcomes Following Arterial Switch Operation Moellinger, A., Torsch, S., Abernathy, S., Borasino, S., Alten, J. 1. Department of Pediatrics, Division of Critical Care, 2. Department of Surgery, Division of Cardiothoracic Surgery; University of Alabama at Birmingham

32. CURRENT QI PROJECTS DATA COLLECTION UNDERWAY, RESULTS PENDING

37. HLHS: Norwood/Sano Includes Daily Care plan – Standardization of Management and goals of Care Hemodynamic Data Collection- Trends Algorithms – Hypotension and Hypoxia Allows for: – Early recognition of deviation Team meeting: Cardiologist, Intensivist and Surgeon

41. Cardiac Arrest Debriefing- Standardized Tool Event Review – Team of Nurses and Physicians Resuscitation Committee – Systems Problems – Education: ASAP (Arrest Summary and Action Plan) RAP (Resuscitation Action Plan)

45. Multicenter Collaboration

46. PC4Quality.org Identify “Real” Variation Study High Performers Identify Practices Associated with Performance Disseminate best practices Improve quality

47. PC4: Other Benefits Risk adjustment Outcome Metrics Real Time Feedback Opportunities for Knowledge Sharing – Multicenter QI initiatives

48. Conclusions Quality improvement is here to stay Standardization as the base for QI is possible in the CVICU Measure, adjust and measure again Publish results to share knowledge Multicenter QI way of the future