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Pediatr Qual Saf
Pediatr Qual Saf
PQS
Pediatric Quality & Safety
2472-0054
Lippincott Williams & Wilkins Hagerstown, MD

PQS-D-24-00029
00005
10.1097/pq9.0000000000000757
3
Individual QI projects from single institutions
Sustainability of a PICU Situation Awareness Intervention: A Qualitative Study
Dewan Maya MD, MPH *†‡§
Prideaux Jonelle MA ¶‖
Loeb Daniel MD, MEd *†
Patel Ruchit V. **
Zackoff Matthew MD, MEd *†
Kudchadkar Sapna R. MD, PhD ††
Vaughn Lisa M. PhD *¶‖
Schondelmeyer Amanda C. MD *‖‡‡
From the * Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.
† Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
‡ Division of Biomedical Informatics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
§ James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
¶ Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
‖ Qualitative Methods & Analysis Collaborative (QMAC), Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
** Harvard Medical School, Boston, Mass.
†† Departments of Anesthesiology and Critical Care Medicine, Pediatrics and Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, Md.
‡‡ Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio.
*Corresponding author. Address: Maya Dewan, MD, MPH, Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave Cincinnati, OH 45229, PH: 215-756-7060, E-mail: maya.dewan@cchmc.org
Sep-Oct 2024
03 9 2024
9 5 e7577 3 2024
11 8 2024
Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

Introduction:

We aimed to investigate facilitators and barriers that impact the sustainability of an interprofessional situation awareness bundle.

Methods:

This is a single-center qualitative study at a tertiary care pediatric center examining the sustainability of an interprofessional situation awareness bundle to reduce in-hospital cardiac arrests. The bundle includes an automated clinical decision support tool, twice-daily safety huddles, and a bedside mitigation plan. A trained research staff member interviewed participants in October 2022. Interviews were audio recorded and transcribed verbatim, and recruitment continued until data saturation. Inductive and deductive analyses were used here.

Results:

The authors interviewed twelve staff members via individual semistructured interviews: registered nurses (RN, n = 2) and clinicians [(advanced practice providers, n = 2), pediatric critical care fellows, n = 4 and attendings, n = 4)]. Five main themes were identified: (1) the situation awareness bundle is ingrained into daily practice and culture, (2) the bundle has strengthened communication, decision-making, and improved outcomes, (3) standardized processes, stakeholder buy-in, and support of team members are key to adoption and sustainability, (4) variation in processes and fast-changing clinical context remains a challenge for reliable use, and (5) the situation awareness bundle excluded families.

Conclusions:

The situation awareness bundle has become ingrained, strengthened, and sustained over the last 5 years through integration into daily practice and culture and leveraging standardized processes, tools and technology. It is associated with improved communication and shared decision-making. Understanding the key components for implementation and sustainability is necessary for ongoing spread and improvement in the future.

Agency for Healthcare Research and Quality Safety Program for Telemedicine 10.13039/100024031 K08-HS026975 Maya DewanOPEN-ACCESSTRUE
SDCT
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pmcINTRODUCTION

Proactive surveillance or identification of patients before deterioration enhances situation awareness, which is crucial in reducing the frequency of in-hospital cardiac arrest (IHCA) events.1–3 In our previous work, we developed and used a paper-based prediction tool that accurately assessed the risk of IHCA within the pediatric intensive care unit (PICU).4 Due to its time-intensive nature, the first-generation tool had limited feasibility and practicality for real-time clinical use. To address this challenge and make IHCA risk assessment feasible, we transformed the tool into an automated electronic health record-based clinical decision support system called the PICU Warning Tool, implemented in a single-center setting as part of a quality improvement situation awareness bundle. The situation awareness bundle (Fig. 1) is an intervention within our PICU1 with three key components: (1) an automated clinical decision support tool, The PICU Warning Tool, that provides a noninterruptive interprofessional predictive alert,5,6 (2) twice daily safety huddles with unit leadership, and (3) assessment by the care team and completion of a bedside mitigation plan that is displayed outside the patient room and discussed with the family to prevent deterioration. Using this multifaceted situation awareness bundle, we achieved a significant 52% reduction in IHCA events at a single center.1

Fig. 1. PICU Situation Awareness Process and Demonstrated Impact.

Despite a substantial body of evidence supporting the effectiveness of situation awareness-based interventions, similar to our bundle, in mitigating deterioration among pediatric patients,1,2,7–14 a common perception remains that these interventions are difficult to maintain, impeding broad implementation and sustainability. However, these perceived barriers have not materialized within our institution, allowing for prolonged sustainability. We have successfully implemented and sustained this situation awareness bundle within the PICU for over 5 years, spreading it to other care areas outside the PICU.1,11,13,15 Using a qualitative research approach, we aimed to investigate clinicians’ perceived facilitators and barriers that impact the success of sustaining the situation awareness bundle at our institution to help improve our local system and support additional spread outside our institution.

METHODS

We conducted a qualitative interview study using a hybrid (inductive/deductive) thematic analysis process. This study was determined to be exempt by the hospital’s institutional review board (2021-0678). We adhered to the Consolidated Criteria for Reporting Qualitative Research to ensure rigorous methodology and comprehensive reporting of our qualitative study.16

Setting and Participants

We conducted these single-center qualitative interviews at an urban tertiary care pediatric center, Cincinnati Children’s Hospital Medical Center (CCHMC). The CCHMC PICU is a closed 48-bed noncardiac medical-surgical unit with over 2750 admissions annually. An interprofessional situation awareness bundle aimed at reducing IHCA events was previously implemented (Fig. 1). We extended email invitations to all staff in the CCHMC PICU who engage with the situation awareness bundle, including nurses, physicians, and advanced practice practitioners. In our PICU, respiratory therapists do not commonly participate in bedside huddles for watchers following multiple Plan, Do, Study, Act (PDSA) cycles. Instead, they are updated on watchers at shift handoff and twice daily safety huddles. Based on their differential participation, they were not recruited for this study. To capture perspectives across disciplines, we used purposive sampling with an oversampling of physicians and advanced practice providers (APPs), collectively called clinicians. The situation awareness bundle is primarily a clinician-driven process. More specifically, the clinicians are responsible for supporting their team in identifying the patient, huddling at the bedside, completing the bedside mitigation plan, discussing the patient at twice-daily safety huddles, and reviewing the plan with the bedside nurse. Participants were interviewed from June to October 2022.

Interview Process

Participants shared demographic information via a structured email reply before the semistructured interviews. A single trained research staff member, independent of the PICU team, conducted the interviews using a written guide developed and reviewed by all team members (See document, Supplemental Digital Content 1, which shows the interview guide. http://links.lww.com/PQ9/A595). Before use, we piloted this tool with one bedside nurse and one attending physician. Pilot interviews were not included in the final analysis. The interviews were audio recorded via Microsoft Teams and transcribed verbatim by an independent transcriptionist. There were no repeat interviews, and recruitment continued until data saturation, or informational redundancy of major categories/themes, was reached in the analysis process by the coding team.17–19

Saturation occurs when subsequent data collection and/or analyses generate no substantive new information or theoretical insights.18–20 For this study, we defined saturation as the point at which three consecutive clinician interviews yielded no new substantive information.

Qualitative Data Analysis

We used a hybrid approach to thematic analysis,21–23 We first followed thematic analysis, an inductive, iterative process of coding and distilling codes into themes24 Thematic analysis follows six steps: (1) reading all of the transcripts to become familiar with the data; (2) generating codes (descriptive labels for meaningful segments of data); (3) sorting and relating the codes into themes (patterned responses in the data); (4) refining themes to ensure that key ideas are captured and sufficient data is available as evidence; (5) defining and naming the themes; and (6) describing the themes in a written report.24,25

An initial codebook (See document, Supplemental Digital Content 2, which shows the Code Book. http://links.lww.com/PQ9/A596) was created collaboratively by a team of three investigators (M.D., J.P., and a research coordinator trained in qualitative methodology) following a thorough review of the transcripts. These three investigators applied an inductive coding approach to analyze the transcripts using MAXQDA software (VERBI GmbH, Berlin, Germany). To ensure systematic application of the codebook and promote discussion and reflexivity among the coding team, all three investigators coded each transcript independently before meeting to agree on codes, adding additional codes as they were identified.26,27 The research team then sorted the codes, identifying patterns, or themes, across multiple types clinicians.

Next, the study team took a deductive approach, grouping the codes into the facilitators, barriers, and opportunities for improvement and mapping them to the Systems Engineering Initiative for Patient Safety 3.0. The Systems Engineering Initiative for Patient Safety model accounts for the complex system issues that contribute to patient safety, the collaborative nature of patient safety work, and the ability of the patient to be placed at the center (Fig. 2).28–30

Fig. 2. SEIPS 3.0 Figure Adapted for PICU Situation Awareness Work.

RESULTS

We conducted individual semistructured interviews with 12 staff members (Table 1). The following disciplines were represented: registered nurses (RN, n = 2) and clinicians [(advanced practice providers (APPs, n = 2), and physicians (pediatric critical care fellows, n = 4, and attendings, n = 4)]. The median interview duration was 34 minutes, ranging from 18 to 50 minutes.

Table 1. Description of Participants

PICU Role (N)	Median Years in Pediatric Critical Care (Range)	Median Years at CCHMC PICU (Range)	
RN (2)	6 (3–9)	6 (3–9)	
APP (2)	12.5 (12–13)	12.5 (12–13)	
PICU Fellows (4)	2 (1–3)	2 (1–3)	
PICU Attendings (4)	14.5 (5–16)	9.5 (5–16)	

Themes

We identified five main themes (Table 2): (1) Ingrained: Five years after implementation, the PICU situation awareness bundle to reduce IHCA is ingrained into daily practice and culture; (2) Strengthened: Situation awareness bundle has strengthened communication, decision-making, and improved outcomes; (3) Sustained: Standardized processes, tools and technology, stakeholder buy-in, and support of inexperienced team members are key to adoption and sustainability, (4) Challenged: Variation in processes and fast-changing clinical context remains a challenge for reliable use, (5) Excluded: Current use of the situation awareness bundle excluded families.

Table 2. Themes and Additional or Full Representative Quotes

	Theme	Representative Quotes	
Clinician Interview	Nurse Interview	
Facilitators	Situation awareness work is INGRAINED in daily practice and culture	It’s been so well structured since my first year that like now, it’s just part of my workflow, and I don’t think about it. (MD, Fellow)
I mean, I think the first thing is buy-in from everybody that’s participating, so making sure that people understand its value and are committed to performing the process because they feel like it actually improves the care of patients and the functioning of the team and awareness of the team. So I think that’s probably the most important thing, and maybe at times, the biggest barrier, to successful implementation (MD, Attending)	So it’s just like, it’s part of our practice now. And I feel like every day is an engagement of it because it’s, it used to be kind of like, oh, nobody filled out your thing or like your sign, or I was never told my patient was a watcher. That’s how it kind of began. And now it kind of has evolved to where it’s the expectation, and it’s ingrained in our practice now, I feel. (RN)	
Situation awareness work has STRENGTHENED communication, decision making, and outcomes	It allows you to kind of plan ahead and just be able to maybe, I don’t know, like preemptively manage issues. Yeah, I think overall, our patients do benefit from us creating these mitigation plans and then being able to quickly act with the use of the mitigation plan that we’ve created. (APP)
I think overall, it helps improve outcomes, making especially some of our newer staff aware of things that you should look out for, potential interventions that we’ll quickly ask for in the event that X happens. (APP)		
Standardized tools and processes are key to adoption and SUSTAINABILITY	I think year by year, we’ve implemented a more structured process to identify them, review their plans, and to identify them at the bedside, from, you know, a simple little sheet that we hung on the door to now in the new building, the signs, digital signs outside with color indications. (APP)
I, personally, like the column in Epic, so that I can quickly, especially when I’m coming in to a new day of work, see who are the patients that I should look at first because they are a watcher for some reason or another. So I think all that is really great and really useful and improves the care of our patients (MD, Attending)	If you’re just coming up to help, you can look at their watcher plan and immediately know what is going on, kind of what they’re a watcher for, what we would be intervening with, things like that. I think those are really the two most beneficial, like identifying them as watchers at the bedside and then having that plan up in place physically for people to look at. And then also doing the safety like huddles in the evenings is really helpful, just having an in-depth plan in place, and then having every participating person aware of that plan. (RN)	
Barriers	Variation in processes and fast-changing clinical context remains a CHALLENGE	it’s just dependent upon kind of who you’re working with as an attending (MD, Fellow)
But with evolving patients, it’s just sometimes challenging to stay on top of things, as a patient evolves. But I think the important thing is everyone is one the same page. So maybe the plan isn’t exactly typed up to where, you know, the next step would be. It was the second step, because we’ve already done the first step. I think that’s okay because it gets everyone on the same page of knowing what we’re watching for, so. (APP)		
Situation awareness work EXCLUDES families	That’s hard to say, because it’s not something that I routinely talk to families about. If they are newly identified on rounds or during the course of the day, or if I’m on call, and we decide at that time to make a patient a watcher, and families are there, we’ll discuss what that means, especially if we’re using that terminology for the first time with families that are new. So I would say that that’s sort of, it depends, type of answer (MD, Attending)	Honestly, I’ve never heard a family, really talked to one. Our old ones used to be like right on the door, so they probably saw it every time they walked in. With it being down further, I don’t even know if they actually notice it, to be completely honest. I’ve never had a family ask me about it so, and I think it’s because it’s kind of like out of sight now a little bit more than it used to be. (RN)	

Theme 1: Situation awareness is INGRAINED in daily practice and culture (FACILITATOR)

Participants highlighted the cultural shift over the last few years in situation awareness, discussing it as a part of their everyday care of patients within the PICU. One RN noted that “now it [situation awareness] kind of has evolved to where it’s the expectation, and it’s ingrained in our practice now” (RN). An overall sense of collective buy-in for situation awareness processes in the PICU was also highlighted and mentioned as a necessary tool for success, “I think the first thing is buy-in from everybody that’s participating, so making sure that people understand its value and are committed to performing the process because they feel like it improves the care of patients and the functioning of the team and awareness of the team” (MD, Attending). All participants positively described the situation awareness work, including RN, APP, and MD fellows and attendings.

Theme 2: Situation awareness work has STRENGTHENED communication, decision-making, and improved outcomes (FACILITATOR)

All participants emphasized how the situation awareness bundle in the PICU facilitates improved communication by sharing a mental model and mitigation planning for deteriorating patients. For example, one MD attending remarked, “I think it does help in communication and getting everybody on the same page with what we think the biggest problems are and what we would do to address them.” Several participants highlighted that the system facilitates shared decision-making, enabling any care team member to “speak up, voice concerns, voice their incomplete understandings of what’s going on” (MD, Fellow) regarding the risk of deterioration and subsequently integrating those concerns into future planning. Crucially, a few participants highlighted that the departure of more experienced staff has left a significant gap in the team’s ability to recognize clinical deterioration. They underscored the role of the situation awareness bundle in assisting new and less-experienced staff in recognizing clinical deterioration, “particularly given the number of newer nurses and respiratory therapists that we have on our team, I think it’s a benefit for them to hear that group plan and have opportunities to ask the questions and things like that” (MD, attending). Lastly, most participants touched on the positive impact of situation awareness efforts on patient outcomes, specifically citing improved patient safety in the PICU, “I think it’s made us a safer culture. I think it’s only been like beneficial for our patients and our staff and our families” (RN).

Theme 3: Standardized tools and processes are key to adoption and SUSTAINABILITY (FACILITATOR)

Participants highlighted the various standardized processes incorporated in the situational awareness work as key components leading to adoption and sustainability. Such tools include the automatic electronic health record identification of high-risk patients, the twice-daily safety huddles, and the bedside mitigation signs, “we’ve implemented a more structured process to identify them [high-risk patients], review their plans, and to identify them at the bedside, from, you know, a simple little sheet that we hung on the door to now in the new building, the signs, digital signs outside with color indications” (APP). Key suggestions to improve these tools and processes included improved accuracy of automated identification, direct electronic notifications, and more structured education and training for staff on situation awareness processes.

Theme 4: Variation in processes and fast-changing clinical context remains a CHALLENGE for reliable use (BARRIER)

Participants stated that the inconsistency in identifying high-risk patients and compliance with the situation awareness processes can be frustrating and challenging. Many participants pointed to the clinician-dependent subjective nature of some inclusion criteria, including the choices of “provider intuition” and “other” within the PICU Warning Tool. RNs, APPs, and MDs also note that this lack of consistency worsens in a fast-changing clinical context in which a patient or multiple patients are rapidly changing, and staff are routinely challenged to keep up with changing patient status, “I will say sometimes it can be hard or frustrating to keep the signs updated as the plans change so rapidly” (MD, fellow).

Theme 5: Situation awareness work EXCLUDES families (BARRIER)

Consistently, participants revealed a lack of standardized inclusion of patients and their families in the situation awareness processes within the PICU, “Honestly, I’ve never heard a family talked to” (RN). Communication regarding high-risk status and plan lacked intentionality and was either only briefly included as part of another update or if families joined for rounds if discussed at all.

Mapping to SEIPS 3.0 Framework

The SEIPS 3.0 model offers a robust framework to improve healthcare systems and patient safety. It comprises several key components: the work system, which includes people, tools, and the environment; communication, care delivery, and decision-making; and outcomes that impact patients, employees, and the organization. Additionally, it incorporates feedback loops for continuous system refinement and emphasizes dynamic adaptation to address evolving healthcare challenges. This model is particularly effective for designing and evaluating interventions to enhance patient safety.30 We mapped codes for facilitators, barriers, and opportunities for improvement identified in the coding/analysis process to SEIPS 3.0 via deductive analysis (Table 3). The task domain included standardized communication and processes as a facilitator, whereas the time required to complete these processes and process variation were barriers. Suggested task domain improvements included the development of a formal de-implementation or de-activation approach—a structured way to “turn off” a patient’s high-risk status.

Table 3. Themes Mapped to SEIPS 3.0 Via Deductive Analysis

SEIPS 3.0	Mapped Facilitator Codes	Mapped Barrier Codes	Mapped Improvement Codes	
Tasks	Standardized Communication & Processes	Time Required to Complete Situation Awareness Processes
Variations in Process	Formal De-Implementation	
Organizational Conditions	Intrinsic Culture, Cultural Change, & Impact
Education & Training
Accountability
Buy-In	Working Outside the System
High Clinical Workload & Acuity
Fast Changing Clinical Context
Lack of Resources
Poor Education & Training	Simulation & Just In Time Training/Education	
Tools & Technology	Well Designed Mitigation Plans
Defined or Objective Situation Awareness Criteria
Visualizations	Inaccurate Identification	Pre-Identification
Improved Visualizations & Identification
Adding Expert Opinion
Physiological Prediction
Electronic/Epic Base Communication
Changes to Mitigation Plan	
Physical Environment	Physical Layout & Space	None	None	
Care Team	Resource & Coach RN
SA Champion
Shared Decision Making	Missed Communication
Lack of Family Inclusion
Turnover
Situation Awareness Burnout	Feedback & Debriefing
Explaining the Why
Engagement of Support Staff
Respiratory Therapy Inclusion
Clinician Expectations & Communication
Structured Family Engagement	
External Environment	None	None	None	

The themes frequently emphasized the care team, organizational conditions, and tools and technology from the SEIPS 3.0 framework, demonstrating their integral role in the success of the situation awareness bundle. Important organizational condition facilitators included the culture and impact of this work, education and training, and buy-in/accountability. Barriers included high clinical workload, understanding, and the fast-changing clinical context within the organizational structure, with suggested improvements anchored within education and training. Mitigation plans, defined inclusion criteria, and bedside and EHR visualizations were situation awareness tools identified as facilitators of this work. We regarded patient identification accuracy as a barrier and potential target for improvement.

As the central hub, the care team had the highest number of themes mapped, including facilitators around specific roles and communication and shared decision-making among team members. The lack of family inclusion and missed communication opportunities were barriers, with the engagement of staff and families noted as a key area for improvement. Participants noted that the physical layout and space of the physical environment of our PICU facilitated their work, highlighting the ease of visibility of the bedside signage. Lastly, no themes arose around the external environment’s impact on this work.

DISCUSSION

Five years after implementation, the PICU Situation Awareness bundle, including the PICU Warning Tool, is ingrained into daily practice and culture—improving communication, shared decision-making, and, most importantly, impacting patient outcomes with a sustained reduction in IHCA.1 Our PICU staff acknowledges the sustained success of this situation awareness bundle, attributing it to the adoption of standardized processes, advanced tools and technology, enthusiastic stakeholder buy-in, and ongoing support of inexperienced team members. Nevertheless, barriers threaten this work’s ongoing sustainability and success, including process variability, a fast-changing clinical context, and inadequate family inclusion.

Mapping to the SEIPS 3.0 framework30 revealed that the core of success resides with the care team, emphasizing the significance of targeting communication and collaboration among teams, including families. For healthcare institutions looking to implement, improve, or sustain situation awareness systems, our findings highlight the importance of developing tools and technology that are both accurate and user-friendly. Moreover, the organizational conditions, fostering accountability and securing buy-in, are pivotal for long-term success. Importantly, inaccurate identification of high-risk patients—either false positive alerting or false negative identification failures—was mentioned numerous times and is a clear concern for ongoing success. Education and training, simulation, feedback and debriefing, and standardized communication and processes were all important implementation supporters in our interviews.

Comparatively, a study examining the perspectives of hospital staff involved with a non-ICU-based pediatric situation awareness initiative found similar facilitators and barriers.31 Factors like understanding the benefits of shared situation awareness, team commitment, and senior leadership buy-in were important for sustainability and spread. However, our research highlighted the need for improved family engagement, an aspect not addressed in the other study. Other research on the implementation and sustainability of nonsituation awareness-based quality improvement programs in the PICU, including one around rehabilitation and mobilization,32 has highlighted that structured family engagement is necessary for success and sustainability. We know that empowering families within the critical care environment can decrease caregiver stress and anxiety.33,34 A satisfactory PICU experience for families employs a caregiver-provider relationship of mutual trust established through clear communication and respectful collaboration.35 Despite our intention to regularly include families in completing the bedside mitigation plan, comments highlighted that engagement with patients and families around situation awareness occurs ad hoc in our PICU and is inequitable for families who cannot be at the bedside. We know families can have a structured role in situation awareness-based interventions outside the PICU.11,13 A vital next step for our work is to strengthen family engagement in an empowering and equitable way.

Our qualitative study has limitations. First, this small sample size may fail to account for all perspectives, and we had a limited number of nurse participants. However, despite the small sample size, these clinician interviews are dense with information and comments about the interactions of different roles and the experience of the multidisciplinary care team. Furthermore, we did not identify substantially different information related to the sustainability of our tool between roles. As this was a narrow topic area with a focused question guide, the information power within this small group was high; therefore, a small sample size is expected.36 Numerous other studies have demonstrated data saturation at similar numbers, and “Corpus size (ie, size of qual data set) is not necessarily a true indication of theoretical saturation.”37 Second, the results are based on data from a single PICU at an institution where the culture highly supports situation awareness and quality improvement interventions, limiting generalizability. Third, the purposive sampling approach to soliciting participants for interviews may have led to participant response bias as those most interested in situation awareness and the success of such interventions may have been those first to volunteer. Those with more negative opinions of the situation awareness work may have felt less comfortable contributing. Nevertheless, this qualitative study on facilitators and barriers to a complex situation awareness bundle’s sustainability provides important insights to improve our local system and impact spread outside our institution.

CONCLUSIONS

Over the past 5 years, the situation awareness bundle in our PICU has been ingrained, strengthened, and sustained through integration into daily practice via standardized processes, tools and technology, improved communication, and shared decision-making. Ongoing challenges remain around process variations and the fast-changing clinical context within the PICU. As we continue to develop and refine this work, it is imperative that our situation awareness bundle systematically includes families. Understanding the key components for implementation and sustainability is necessary for ongoing spread and improvement in the future.

ACKNOWLEDGMENTS

We wish to acknowledge the Pediatric Intensive Care Unit staff at CCHMC, who make this work possible.

Supplementary Material

Published online September 3, 2024.

Supplemental digital content is available for this article. Clickable URL citations appear in the text.

Disclosure: The authors have no financial interest to declare in relation to the content of this article.

Supported by the Agency for Healthcare Research and Quality (grant no.: K08-HS026975) and the Center for Clinical & Translational Science and Training at the University of Cincinnati.

To cite: Sustainability of a PICU Situation Awareness Intervention: A Qualitative Study. Pediatr Qual Saf 2024;9:e757.
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