Background: Unnecessarily long preprocedural fasting can cause suffering and distress for children and their families. Institutional fasting policies are designed to consistently achieve minimum fasting times, often without regard to the extent to which actual fasting times exceed these minimums. Children at our hospital frequently experienced clear liquid fasting times far in excess of required minimums. Aims:The aim of this study was to utilize quality improvement methodology to reduce excess fasting times, with a goal of achieving experienced clear liquid fasting times ≤4 hours for 60% of our patients. Methods: This quality improvement project was conducted between July 2017 and August 2018. A multidisciplinary team performed a series of Plan-Do-Study-Act cycles focused on children undergoing elective procedures at a large children's hospital. Key drivers for clear liquid fasting times and relevant balancing measures were identified. Data were analyzed using control charts and statistical process control methods.Results: Approximately 16 000 children were involved in this project. Over the course of the project, the percentage of children with goal clear liquid fasting times improved from the baseline of 20%-63%, with a change in the mean fasting time from 9 hours to 6 hours. There were no significant effects on balancing measures (case delays/cancellations and clinically significant aspiration events). Conclusion:Using quality improvement methodology, we safely improved the duration of preoperative fasting experienced by our patients. Our results provide additional data supporting the safety of more permissive 1-hour clear liquid fasting minimums. We suggest other institutions pursue similar efforts to improve patient and family experience. K E Y W O R D S patient safety, patient satisfaction, pediatric anesthesia, perioperative aspiration, perioperative fasting, perioperative guidelines | 699 ISSERMAN Et Al.

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OBJECTIVE: Patients with limited English proficiency (LEP) benefit from the appropriate use of medical interpreters. A multidisciplinary quality improvement team sought to improve communication with patients with LEP within a pediatric emergency department (ED). Specifically, the team aimed to improve the early identification of patients and caregivers with LEP, the utilization of interpreter services for those identified, and documentation of interpreter use in the patient chart. METHODS: Using clinical observations and data review, the project team identified key processes for improvement in the ED workflow and introduced interventions to increase identification of language needs and offer interpreter services. These include a new triage screening question, an icon on the ED track board that communicates language needs to staff, an electronic health record (EHR) alert with information on how to obtain interpreter services, and a new template to prompt correct documentation in the ED provider’s note. Outcomes were tracked using statistical process control charts. RESULTS: All study measures met special cause for improvement during the 6-month study period and have been sustained during surveillance data collection. Identification rates for patients with LEP during triage increased from 60% to 77%. Interpreter utilization increased from 77% to 86%. The documentation of interpreter use increased from 38% to 73%. CONCLUSION: Using improvement methods, a multidisciplinary team increased the identification of patients and caregivers with LEP in an ED. Integration of this information into the EHR allowed for the targeted prompting of providers to use interpreter services and to correctly document their use.

Objectives: There is limited evidence on the impact of protocolized ventilator weaning in pediatric acute respiratory distress syndrome, despite utilization in clinical trials and clinical care. We aimed to determine whether protocolized ventilator weaning shortens mechanical ventilation duration and PICU length of stay in pediatric acute respiratory distress syndrome survivors. Design: Secondary analysis of a prospective pediatric acute respiratory distress syndrome (Berlin definition) cohort from July 2011 to June 2019 analyzed using interrupted time series analysis pre- and postimplementations of a ventilator-weaning pathway. We compared duration of invasive ventilation and PICU length of stay in survivors before and after implementation of a ventilator-weaning pathway. We excluded PICU nonsurvivors and subjects with greater than 100 ventilator days. Setting: Large academic tertiary-care PICU. Patients: Children with acute respiratory distress syndrome who survived to PICU discharge with less than or equal to 100 days of invasive mechanical ventilation. Interventions: Implementation of a ventilator-weaning pathway on May 2016. Measurements and Main Results: Of 723 children with acute respiratory distress syndrome, 132 subjects died and six subjects with ventilation greater than 100 days were excluded. Of the remaining 585 subjects, 375 subjects had acute respiratory distress syndrome prior to pathway intervention and 210 after. Patients in the preintervention epoch were younger, more likely to have infectious acute respiratory distress syndrome, and had increased use of alternative ventilator modes. Pathway adoption was rapid and sustained. Controlling for temporality, pathway implementation was associated with a decrease of a median 3.6 ventilator days (95% CI, –5.4 to –1.7; p < 0.001). There was no change in the reintubation rates. Results were robust to multiple sensitivity analyses adjusting for confounders. Conclusions: Ventilator-weaning pathway implementation shortened invasive ventilation duration in pediatric acute respiratory distress syndrome survivors with no change in reintubation. The effect size of this intervention was comparable with those targeted in acute respiratory distress syndrome trials.