255 - Developing and Creating Efficient and Safe High-risk Bedside Procedures in a Pediatric Cardiac Intensive Care Unit
Description: Description of team: Involved in the process improvement of extrocorporeal cardiopulmonary resuscitation (ECPR) at the bedside in cardiac intensive care unit (CICU) involves a wide variety of people. ECPR is Children Healthcare of Atlanta’s Heart Center emergent ECMO process. Included in ECPR are the cardiovascular operating room (CVOR) team (scrub tech and circulator) with various levels of pediatric cardiac experience, the surgeon, intensivists, CICU team (RN’s, MD’s), main OR team (scrub techs and circulators) with limited cardiac experience, and the extracorporeal membrane oxygenation (ECMO) team. Every person involves bring a unique skill to an emergency situation and are vital in streamlining a standardization process for bedside ECPR procedures. Preparation and planning: In order to restructure an emergent ECPR bedside procedure in the CICU there needed to be a plan to step back and look at every angle of the current process. In order to do this there were committee meetings with every stakeholder involved in the procedure and discussed were the current processes in place and what an ideal future state would look like. Various simulations of emergent ECPR procedure were scheduled to see what processes worked best under high stress and full debriefing took place. A supplies list was created by staff to know what equipment and materials were vital to start and finish the emergent ECPR. Most importantly, a failure mode and effect (FMEA) analysis and root cause analysis (RCA) were performed to identify knowledge gaps in CVOR, CICU, and the main OR team.
Assessment: After a full analysis of what the current state of emergent ECPR’s were, what was concluded was that there was no standardized process in place for an ECPR at the bedside. There was found to be low confidence levels in CICU and main OR staff in starting an emergent procedure without the cardiac team present and no standardization in equipment or surgical trays causing more confusion to the process. In the trays there were too many instruments present and difficult to disassemble in an emergency. There was also not a seamless transition of supplies from the OR to CICU causing an unknown knowledge of what was available for supplies verse not. The supplies were also not stored in the most efficient location, also causing delays in a true ECPR. Communication problems were also found; the team not using closed loop communication, activation processes, and knowing who the actual team was performing the procedure. The expectation of the main OR is to cover an ECPR procedure while the cardiac team is called in as the cardiac team is not staffed 24/7 in house. This thus caused a safety concern with cardiac surgeons, staff, and patient. A plan needed to be implemented in order to streamline the ECPR process from the beginning stages to the end with all staff involved.