The PICU Chain of Survival is an innovative framework that unites quality improvement, implementation science, clinical informatics, human factors, and emerging technologies to systematically improve care for critically ill children.
It enables data-driven, team-based interventions that are scalable, sustainable, and deeply rooted in real-world clinical workflows.
Through our prediction research program we aim to identify those patients at the highest risk for clinical decompensation. These efforts center on using innovative digital technologies to support clinician situation awareness and diagnostic excellence.
The SAMURAI PICU bundle, developed at Cincinnati Children's, locally led to a significant reduction of in-hospital cardiac arrest through enhancement of PICU clinician situation awareness anchored by a core bundle that includes:
Our team is currently leading an AHRQ funded multi-site clinical trial assessing the implementation of the SAMURAI PICU bundle at several other children's hospitals. Centers are adapting and innovating to meet the needs of their local context. The team is actively seeking collaboration to expand and spread the SAMURAI PICU bundle to support the prediction and prevention of in-hospital cardiac arrest.
Our team has partnered with in house developers to develop a digital twin PICU environment, experienced through immersive virtual reality, that allows for simulated experiences to test and evaluate the impact of clinical decision support on diagnostic excellence through real-life clinical care and interactions.
Our team is currently leading an AHRQ funded patient safety learning laboratory to explore clinical team workflow during patient decompensation events and how to optimize clinical decision support tools to enhance clinican diagnostic excellence. The team is actively seeking collaboration to explore additional opportunities to leverage this digital twin environment to support care delivery design, testing, training, and implementation efforts.
Our Prevention research program has two main arms. Within the PICU our teams efforts with SAMURAI and DISCOVER support the prevention of clinical decompensation in critically ill children.
Recognizing that the best prevention of clinical decompensation and cardiac arrest in the PICU is to address the drivers of developing critical illness in the first place, a major aspect of our research program focuses on addressing several top threats to child health with interventions prior to presenting to the PICU.
Firearm injury is the leading cause of death among children and adolescents. Clinician counseling on secure firearm storage is a key preventive strategy. Our team developed and tested a virtual reality based firearm injury prevention curriculum in partnership with the Massachusetts General Hospital Center for Gun Violence Prevention to enable clinicians to practice screening for and counseling on secure firearm storage with virtual patients and caregivers with local positive impact on counseling behaviors.
Our team is currently implementing this training program at multiple medical schools across the country as a formal New England Journal of Medicine training program. The team is actively seeking collaboration to expand this training to additional sites and populations to continue to help to address the epidemic that is gun violence.
In order to prepare pediatric clinicians to introduce and address concerns related to childhood vaccinations, our team has developed, studied, and implemented virtual reality curricula informed by evidence-based motivational interviewing skills and community feedback to discuss the flu, HPV, and COVID-19 vaccines. Results from previous studies have demonstrated a decrease in flu vaccine refusal by 10% and an increase in rates of HPV vaccine initiation by 18% amongst clinicians who underwent the respective VR curricula.
Our team is currently implementing these training programs with various populations, and is seeking collaboration to expand these training curricula to additional sites and populations.
Addressing behavioral health concerns early in childhood has been linked with reduced rates of mental health disorders later in life. Our team has developed, studied, and implemented a virtual reality curriculum Promoting Resilience and Emotional health through Virtual Education iN Training (PREVENT) that trains clinicians on the use of evidence based behavioral health anticipatory guidance and motivational interviewing communication skills.
Our team is currently collaborating with industry to assess the impact of a 2D autonomous version of this curriculum. We are actively seeking collaboration to adapt and expand this curricula for additional sites and populations.
Effective training is foundational to every link in the chain of survival. In addition the leveraging of innovative educational strategies in our Prediction and Prevention efforts, there are additional areas where our team leverages thoughtful training approaches, grounded in educational theory, to prevent, recognize, and respond to critical illness. We focus on promoting experiential learning via computerized manikins, virtual reality, augmented reality, and artificial intelligence to prepare our clinical teams to provide the best care for patients.
The Cincinnati Children's PICU Simulation Program partners with the Center for Simulation and Research to deliver a comprehensive training portfolio that integrates predictive analytics and real-time clinical data to support multidisciplinary and interprofessional training to support the recognition and response to clinical decompensation. We additionally apply a data driven approach to developing and establishing procedural competency for critical care trainees.
In addition to our robust baseline training curricula, our team is actively engaged in studies assessing the impact of an experiential CPR Coach Course on CPR performance during both simulated and real-life code events. We are also actively assessing the impact of real-time ventilation feedback on respiratory therapist performance during simulated CPR events to inform future clinical trails addressing much needed guidance on ventilation best practices during CPR. The team is actively seeking collaboration for additional sites for our novel simulation training programs.
While our team has led in the development, testing, and implemetation of novel training modalities including augmented reality, virtual reality, and artificial intelligence, it is vital that we understand how these new training approaches (as well as the established ones) influence particiant attention and behavior based upon the modality itself.
Our team continues to innovate with novel simulation modalities and is looking for collaboration to continue to best understand how these modalities inform and influence participant behaviors to support educators in better aligning goal learning objectives with the ideal training modalities.
Our team has successfully implemented institution wide virtual reality (VR) trainings for individual and team learning focused on building individual and team situation awareness for clinical deterioration. Efforts have extended to nurses, residents, advanced practiced providers, and physicians in practice to enhance the care provided by our interprofessional teams.
A safe and effective care enviroment also extends to our interactions with patients and staff. Our team has developed virtual reality training curriculum to encourage and promote upstander behaviors in the workplace as well as train clinicians on how to manage conflict at the bedside.
When a child experiences deterioration, a coordinated team with established roles responds to provide life-saving care. In addition to our extensive portfolio within our Training efforts that focus on preparing teams to respond to clinical deterioration, we have leveraged improvement science and international collaboration to further optimize the care we provide.
Our team has leveraged human factors and lean principles to optimize the efficiency and intuitiveness of pediatric code carts. Our efforts to ensuring that the new design was acceptable and usable to staff while investing time and effort to integrate the new care into interprofessional training led to a decrease in the time required to access lifesaving supplies.
Our team has taken similar apporaches to optimizing access to key supplied for chest tube and central venous catheter placement with similar outcomes. The team is actively seeking collaboration to enhance processes and optimize resources to support the effient care of critically ill children.
Our team serves as the site lead for participation in Pediatric Resuscitation Quality (pediRES-Q), an international collaborative of pediatric hospitals of diverse size, geographic locations, and academic support passionate about pediatric resuscitation. This clinical learning laboratory network aims to discover, measure, analyze, publish, implement, and disseminate improved evidence-based CPR data to inform current and future evidence-based resuscitation guidelines that saves more lives and improves quality of life for children.
Several of our active studies, including the SAMURAI PICU study, are conducted in collaboration with pediRES-Q.
Learning all we can following a resusication event is vital to ensure that we continued to optimize the care we provide. Our team gathers this crucial data through two main vehicles:
The learnings from hot and cold debriefs feed back to inform the interventions across the entire chain of survival and support a focus on continuous growth, improvement, and innovation. The team is actively seeking collaboration to extend our Hot/Cold Debriefing model to additional sites of care.
Through tracking Post Cardiac Arrest Care for patients in PICU our team takes a data driven approach to developing processes or systems to enhance this crucial care for patients to optimize their clinical outcomes. Our team developed actionable report cards to help inform the clinical team of needed areas for improvement and to highlight successes.
Through tracking adherence to evidence based goals of care for patients in the PICU who have experienced a traumatic brain injury (TBI) our team takes a data driven approach to developing processes or systems to enhance this crucial care for patients to optimize their clinical outcomes.
Through tracking adherence to evidence based care for patients in PICU who experienced a traumatic brain injury (TBI) our team takes a data driven approch to developing processes or systems to enhance this crucial care for patients to optimize their clinical outcomes. Our team developed actionable report cards to help inform the clinical team of needed areas for improvement and to highlight successes.
Through tracking adherence to institutional and evidence based standards for the care of patients in the PICU on extracorporeal membrane oxygenation (ECMO) our team takes a data driven approach to developing processes or systems to enhance this crucial care for patients to optimize their clinical outcomes. Our team developed actionable report cards to help inform the clinical team of needed areas for improvement and to highlight successes.
Immobility in PICU patients is known to contribute to prolonged mechanical ventilation, potentially prolonged length of stay and increased delirium. Cincinnati Children's has adapted the PICU Up! Program, first created at Johns Hopkins. Currently, efforts include implementing a rounds checklist that is inclusive of early mobility as well as other harm prevention, and introducing PICU Up! level animal signs that designate a mobility goal for each patient each day.
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