Registed Nurses' Association of Ontario

Learning to understand, design, implement, and evaluate an effective quality assurance mechanism targeted at improving care during cardiac arrest events in a Paediatric Critical Care Unit

Rose Gaiteiro
The Hospital for Sick Children (Sickkids)

In-hospital cardiac arrest (IHCA) events remain a major concern in health care. Approximately 209, 000 adults and more than 6000 children receiver CPR for IHCA in the United States annually. Yet despite advances in healthcare and some improvements overall in survival rates, outcomes remain poor and can vary greatly between institutions. The American Heart Association’s “Get With The Guidelines” program reported an increase in the unadjusted survival rates of IHCA of 14.3% in 2000 to 39.4% in 2009. It is also important to note that only 5% of pediatric in-hospital cardiac arrests occurred on general wards, compared to 74% in PICU, 10% in Emergency, and 11% in other locations.

Any mechanism that delivers healthcare requires structures and processes which, when integrated, produce a system that leads to specific outcomes such as patient safety and quality improvement. An effective system of care comprises of structure, process, system, and patient care outcomes, all in a framework of continuous quality improvement. However, any system is only as strong as its weakest link. If any variable, whether medical skill/knowledge or non-medical quality (communication, leadership etc.) is lacking, the effectiveness of a team’s response to resuscitation, and potentially patient outcomes, could be hindered. There are many types of quality improvement processes that can be used in a cardiac arrest continuous improvement mechanism, so it is very important to gain knowledge about which methods are best suited to help identify possible gaps in performance.

The overall goal for this fellowship was to increase knowledge and understanding of the design, implementation, and evaluation of an effective quality improvement mechanism targeted at improving care for cardiac arrest events in a PICU. Current literature and existing Best Practice Guidelines were reviewed to help inform learning. Specific learning objectives included gaining an understanding of different quality improvement models, and how they contribute to improving care, factors that impact the development and implementation of a successful quality improvement mechanism, assessing current team functioning and how it impacts critical events, and increasing knowledge about translating quality initiatives into sustainable practice changes that may impact care and patient outcomes.

The early steps of the fellowship involved conducting an extensive review of current literature into cardiac arrests, pediatric resuscitations, team work, and quality improvement mechanisms. This review revealed a tremendously large body of articles under the search terms. My mentoring team providing invaluable leadership and support in helping me to focus my attention to themes relevant to my identified learning plan. The fellowship also allowed me the opportunity to attend two extremely valuable educational courses: “Ideas 2: Improving and Driving Excellence Across Sectors. An Introduction to Quality Improvement” (University of Toronto), and “Knowledge Translation Training Course: Towards an Understanding of Knowledge Translation” (SickKids learning Institute). These workshops helped strengthen my budding knowledge of QI and the importance of having a solid KT plan incorporated into the early phases of planning any QI initiative. I was also able to take advantage of these sessions to network and make contact with experts in other organizations interested in this work, which will continue to prove invaluable as this initiative progresses.

Learning and development based on this fellowship experience also included:

  • Completing a review and summary of 3 Best Practice Guidelines that had some relevance to the overall learning goal
  • Developing a summary of QI frameworks that would be effective when setting up a QI process for reviewing cardiac arrest events. These were reviewed with the mentoring team for correctness, and will be presented the newly formed resuscitation committee in the Critical Care Department
  • Completing a summary if relevant knowledge translation practices that would lend themselves to this manner of event review and system implementation
  • Benchmarking resuscitation continuous quality improvement systems/activities at 3 other Pediatric Children’s Hospitals ( Boston, Philadelphia, and Chicago)
  • Preparing and delivering a presentation to my research Ethics Board and CCU interprofessional colleagues on the differences of QI and research as well as the specific nuances within the SickKids environment.

I have always had a keen interest in resuscitation and looking at factors, both clinical (simulation, quality of CPR) and non-clinical (team work, team structure, communication) which could potentially impact outcomes. This fellowship provided me with an invaluable opportunity to gain and refine knowledge on quality improvement and what factors need to be considered when setting up a continuous improvement mechanism. The structured approach and invaluable guidance of my mentor team ensured that I was able to focus my learning and not get overwhelmed by the preponderance of information available, some of which may not have had relevance to my topic of interest.

I would like to extend a sincere thank you to the Registered Nurses’ Association of Ontario (RNAO) for this opportunity to challenge myself professionally and to reflect on this new area of personal learning which I might not have had otherwise.