Abstract
Evidence-Based Practice, Quality Improvement, & Practice Innovation Poster presented at NAPNAP's 44th National Conference on Pediatric Health Care, Posters on the Move, March 16th, 2023
Transfers to the ICU from the acute care setting have been shown to have higher severity-adjusted mortality compared to other ICU admissions. A lack of structured debriefing following an emergent event can impact a healthcare provider's emotional well-being. Benefits of clinical debriefing identified in the literature include improved patient outcomes, improved emotional processing, improved individual and team performance, and identification of systems issues and areas for quality improvement.
This quality improvement project aimed to evaluate a newly implemented clinical debriefing process for emergent events outside the ICU setting in a pediatric, urban academic hospital. Identify and address the barriers that inhibit the ability of staff to complete a post-emergency event debrief survey. As well as evaluate the clinical assessment triggers for pediatric patients who experienced an emergency event and staff perceptions of debrief survey. In addition, assess current pediatric patient deterioration tools, including Pediatric Early Warning Score (PEWS) and Watcher status, and clinical correlation to emergent events.
The survey debrief occurred directly after the emergent event, defined as a Code or concern for an acute decline in clinical status requiring a higher level of care, defined as initiating a Critical Assessment Team (CAT). The debriefing survey was implemented on four acute care units totaling 180 beds specializing in pediatric subspecialty care, including hematology-oncology, neurology, endocrinology, pediatric surgery, gastroenterology, pulmonary and general medicine. The data analysis occurred over 14 weeks from September through December 2022. The unit charge RN initiated the electronic survey and accessed it via QR codes on the unit. The survey debrief occurred directly following the event, outside the bedside area, with the primary patient care team present. Quantitative and qualitative survey data were analyzed for trends in statistical analysis for patient-specific and systems characteristics surrounding the emergent, acute care event. In addition, a feedback survey evaluation was sent to all nursing staff on each acute care floor unit to evaluate barriers, perceptions, and long-term goals of the survey debrief.
174 surveys were completed (170 CATs, 4, Codes), with overall survey compliance with recorded events in the electronic medical record of 74%. Compliance increased 59% from baseline at week 2 to week 14. The most frequent clinical reason for a CAT/Code to be called included changes in worsening respiratory status (n=126, 72%). Barriers to completing the survey were identified as staffing (34%), time to complete (24%), charge RN not available (18%), and not all team members present (34%). In addition, 47% of respondents agreed that the debrief survey helped identify and close individual and team performance gaps. However, respondents did not perceive the debrief survey improved team morale or emotional processing. PEWS score >6 was documented in 5% (n=8) of all patients who had a CAT/Code event and in 10% (n=4) of patients who were also documented as a Watcher. The monthly number of patients with Watcher status initiated at this hospital institution increased from baseline n=12 to n=17 following the debrief survey initiation.
Patients identified as high acuity and at risk for decompensation, Watcher, only had documented PEWS scores >6 in 10% of patients. PEWS may not be an effective method to evaluate and predict changes in patient clinical status. An acute decline in respiratory failure is the predominant reason for initiating a CAT or Code, which is consistent with the current pediatric literature. Facilitated debriefs that occur hours to days following the event may have a more significant potential to improve the emotional processing of emergency events as opposed to immediate post-event debriefing, which may better identify and close team performance gaps surrounding the event. Watcher status initiation may be a valuable tool to proactively monitor and assess patients at higher risk for acute decompensation.