Mobile Rounds, Consultation, and Critical Event Review in the Pediatric CICU

Author: Hayden Zaccagni

Background: Critically ill pediatric patients with congenital heart disease or cardiomyopathy are at increased risk for deterioration culminating in a cardiac arrest (CA), which leads to significant morbidity and mortality in the cardiac intensive care unit (CICU). Most CA are preceded by a period of time where vital sign (VS) trends reveal an ongoing deterioration, which if recognized, could be intervened upon. Medical data has been brought to mobile devices (MD) allowing physicians to digitally monitor live VS as well as VS trends of critically ill patients in their ICUs. We describe our institution’s collaborative efforts to utilize MD to trend VS, obtain consultation from senior intensivists as they review VS, as well as the use of these MD to review critical events such as CA to disperse education regarding the etiology and course of the events. Methods: Team structure: One intensivist from a remote location with a MD. Two other intensivists with a multidisciplinary team form two medical teams, which perform medical rounds in a 20 bed CICU. Daily Rounding Process: Intensivist with MD from remote location, reviews live VS and then trends heart rate (HR), peripheral oxygen saturation (SpO2), blood pressure (BP), respiratory rate (RR), end-tidal CO2 (ETCO2), and ST segment changes in a cohort of critically ill patients. After review, the 3 intensivists combine knowledge of patient data over phone consultation. Patient care is adjusted according to information provided by all three physicians. Consultation: Example 1: Intensivist in the ICU consults electrophysiologist (EP) regarding a patient with an arrhythmia. EP reviews data from previous 24 hours. Allows him to pinpoint etiology of arrhythmia and leads to specific treatment recommendations all from remote location. Example 2: CA occurs in patient. One intensivist in CICU is code leader while another intensivist from remote location utilizes a MD to analyze real-time important VS including ETCO2, Pulse-oximeter waveform, and rhythm; all of which have been described as important metrics in delivering quality cardiopulmonary resuscitation (CPR). The remote intensivist is then able to communicate with the code leader and contribute additional perspective with feedback on quality of CPR. CA Review Process: “Screen shots” from a MD capturing VS trends revealing clinical deterioration are used to uncover the etiology of CA. “Screen shots” of reviewed VS are also utilized to determine the quality of CPR delivered by showing the BP, pulse-oximeter waveform, and ETCO2. This data is reviewed bi-weekly by the CICU Code Committee. Formal discussion highlights potential missed opportunities for CA prevention. Key drivers are identified and specific projects and activities are assigned to address/prevent the factors that led to CA. Additionally, an Arrest Summary and Action Plan (ASAP) form is completed which includes the “Screen shots” of reviewed VS and is mandatorily signed off on by all CVICU RN, RT, APN, MD– with code summary, key leaning points and upcoming policy changes. Conclusion: Medical data delivered to mobile devices allows our CICU the ability to have multiple experts reviewing VS and trends to deliver high quality patient care from remote locations.