ABSTRACT Background Latent safety threats (LSTs) have been defined as system based issues that threaten patient safety that can materialize at any time and were previously unrecognized by healthcare providers, unit directors, or hospital administration. While LSTs such as system deficiencies, equipment failures, training, or conditions predisposing medical errors are frequently reported in the literature, a paucity was noted in the management and mitigation of these threats. The purpose of the translational simulation quality improvement project study was to utilize translational simulations to identify, manage, and mitigate future latent safety threats in our EDs. METHODS In 2017, 18 in-situ inter-professional simulation sessions were conducted at 11 EDs. Following each session, a survey assessment tool, created by the research team, was completed by participants to identify latent safety threats. Findings were shared with site clinical nurse educators and managers to help facilitate institutional follow up. For reporting, latent safety threats were categorized thematically and coded as either (i) resolved, (ii) ongoing, or (iii) not managed. Follow-up with sites was completed 1 year following the simulation. RESULTS A total n=158 LSTs were identified. The number and percentage by theme was: staff 48 (30.4%), equipment 41 (25.9%), medications 33 (20.9%), resuscitation resources 24 (15.2%), and information technology (IT) issues 12 (7.6%).Site follow-up identified that 149 LSTs were resolved and ten required ongoing work to manage. No occurrences of a LST ‘not managed’ were identified. CONCLUSIONS Translation simulation effectively identified latent safety threats and assisted interdisciplinary teams in the creation of a structured plan and systematic follow-up to enhance the health system and patient care. Through use of a threat mitigation strategy all identified threats were addressed while some require ongoing management.

Background Between 10 and 25 percent of pediatric patients present to the emergency department (ED) with difficult to cannulate veins. Recent RCT evidence suggests that in pediatric patients assessed at being a predicted difficult IV start (by DIVA score of 3 or more), ultrasound guided catheter placement decreased the number of IV attempts, decreased time to successful IV placement, and improved first pass success, patient satisfaction, and catheter dwell time. Our QI project examines the specific learnings around ultrasound guided peripheral IV in pediatric patients and suggests opportunity for non-pediatric specialist hospitals to consider with the overall aim of minimizing IV attempts on all pediatric patients within our EDs. Building on a RCT led by Dr Curtis in pediatrics patients conducted at the Stollery from 2012-2014, a standardized ultrasound guided nurse performed procedure was implemented in 2016 at the University of Alberta and Stollery EDs, and expanded to the Royal Alexandra ED in 2017 and the Misericordia ED in 2019. Using the same education package and QI study methodology as previously reported in adult patients this study focused specifically on pediatric patients. Methods A quality improvement (QI) registry was utilized to track complications and success of pediatric patients at all sites. The aim was to assess for program success, and improve education, training, and procedural success as required. Staff who had achieved independent practice voluntarily completed a tracking form whenever an ultrasound procedure occurred. Completed forms were assessed on a continual basis for any opportunities for improvement. Qualitative feedback was also obtained from informal interviews, a focus group, and a survey of the trained nurses. Feedback was thematically analyzed and grouped into themes for reporting. Results There were no reported pediatric UGIV placed at the MCH and RAH during the study period. At the Stollery 126 cases were reported. Immediate insertion complications were noted in three cases as ‘pain or swelling at site’, and ‘unable to advance catheter’. In the first and second years of data collection the average number of traditional IV attempts prior to UGIV attempt decreased from 3.9 to 2.8; first ultrasound pass success increased from 65% to 86%; overall ultrasound success improved from 85% to 97.6% respectively. Increasing nurse skill was significant with a linear increase of first pass and overall success seen with increasing number of ultrasound starts: From 6-20 starts (54% first pass 64% overall success) through to >150 starts (97% first pass and 100% overall). QI staff feedback included ensure adequate pediatric specific supplies such as longer length small gauge catheters, and a procedural focus of patient, provider, and assistant set up. Location of IV placement was noted to change in a number of cases from hand and A/C to forearm. Advice and Lessons Learned The key for staff to transition to procedural competance was to ensure initial and ongoing oportunities to place many ultrasound guided IVs (i.e. when time allows in all patients with non-optimal IV placement locations or with non-easy predicted tradititional IV starts) Further work is required at non specilaist hospitals with trained staff to increase ultrasound guided use in pedatric patients At all particapting sites work continues on unit level QI to minimize the number of IV attempts on all pedatric patients as well as work towards a cohort of available staff that are comforable and competent with ultrasound that can provide 24/7 unit coverage. (with limited numbers of trained staff there is increase burden on these staff to assist others while also completing their own nursing assignment.

Background   AHS suggests a limit of four attempts at traditional peripheral vascular access, however there are limited current options at many sites for these patients. Between 10 and 25 percent of patients present to the emergency department (ED) with difficult to cannulate veins. In these patients ultrasound guided catheter placement decreases the number of IV attempts, decreases time to successful IV placement, improves patient satisfaction, and in adult patients decreases central line use. Emergency nurses have been shown to successfully employ ultrasound-guided peripheral vascular access. Physician and Nursing clinical practice guidelines place a high recommendation for this practice. Despite the evidence and recommendations, in Canadian EDs, with notable exceptions there remains minimal standard procedural uptake or ED research.   Implementation For difficult peripheral intravenous access a standardized ultrasound guided nurse performed procedure was implemented in 2016 at the University of Alberta (UAH) ED, in 2017 to the Royal Alexandra Hospital (RAH) ED, and in 2018 the Misericordia Community Hospital (MCH) ED. An education module was created that included didactic learning and an exam, approximately one hour of in-person training which included vessel and structure identification and cannulation practice on a gel model until competence was achieved, and finally three successful mentored starts prior to independent practice. Mentorship ensured good technique was followed, provided additional tips to improve practice, and most importantly ensured an IV attempt was on a patient with veins amenable to a novice ultrasound provider attempt (e.g. if a patient was assessed to be a challenging ultrasound start with limited vein options the mentor would place the IV in much the same way as traditional IV placement mentoring). The ultrasound technique taught was a single operator, short access or traverse approach with dynamic tip tracking where the catheter needle tip is continually visualized as the target vessel is cannulated. Catheter placement is confirmed with the catheter tip visualized intraluminal and with an ultrasound visualized saline flush. This study reports on the first 30 nurses trained at the UAH, 12 at the RAH and 6 at the MCH.   Evaluation Methods A quality improvement (QI) registry documented complications and was used to improve education, training, and procedural success. The two QI study objectives were 1) to determine ultrasound program success for all sites by comparing QI results to historic results from other programs 2) to determine if an abbreviated training regimen (shorter than previously documented for adult patients in Canada) can be used to train nurses in EDs with minimal support or pre-existing experience with UGIVC. Staff who had achieved independent practice voluntarily completed a tracking form whenever an ultrasound procedure occurred. Completed forms were assessed on a continual basis for any opportunities for improvement. Qualitative feedback was also obtained from informal interviews, a focus group, and a survey of the newly trained nurses. Feedback was thematically analyzed and grouped into themes for reporting. Data and trends from the registry were used to reinforce education to promote greater procedural success. Also identified were questions to add to the tracking form to improve the usefulness of the registry. Ongoing review will identify if these efforts improve practice. Opportunities for system improvements were managed through consultation with all stake holders including nursing management, CNEs, physicians, and bedside nurses. Program evaluation will shape all aspects of the program development.   Results At the UAH, RAH, and MCH respectively; the mean number of failed IV attempts [SD] before UGIV was: 4.2 [2.5]; 3.4 [2.1]; 4.77 [2.9]; while first pass success by novice provider (1-10 UGIV starts) was 76%; 66%; and 62%. Success increased rapidly with the number of starts and plateaued after 100. Complications occurred in 4/374 (1%) starts. Qualitative feedback suggests that provider and patient positioning, and equipment preparation improve individual success; engaged staff and a QI registry improve program success; even in cases with more reported pain, patients prefer UGIV to traditional placement.  Advice and Lessons Learned  Creating an ultrasound guided peripheral IV program and quality registry that supports emergency nurse use of this procedure is possible. First pass and overall catheter success rates and low reported compilications are reassuring. The quality registry has provided useful data to support practice and suggest modifications to the education and site specific system level supports provided. An example of system feedback is that newly trained staff need to have a clinical assignment that allows the opportnuity to utilize the procedure. Also enough mentors are required to support new staff. A third interesting system issue identifed is the possible effects of the training on traditional difficult IV placement skill and how to best support this. Emergency physicians and nurse champions can play a key supportive role to ensure the success of the program.

Introduction & Aims Some palliative patients have one or multiple ED visits near their end of life. People who stay home are more likely to die at home or in hospice compared to those admitted to acute care. This study was to describe decisions and outcomes of palliative home care patients who go to Emergency (ED) within the last 6 weeks of life in one metropolitan zone of Alberta Health Services. Description In the 2017-2018 fiscal year, there were 1874 palliative home care patients in the Edmonton Zone, of whom 646 (34.4 %) patients went to ED in the last 6 weeks of life. Of these, home care and emergency charts were reviewed for 194 deceased patients, selected by CTAS score, urban and suburban/rural, and unusual events: died in the ED, left the ED, admitted to critical care. Key Findings Patients who went to ED were more likely to be male (59%) and older than 65 years (65 %). Most had cancer as a primary diagnosis (82.6%). More than 50 % went to ED more than once. For the majority (74.3%), the final ED visit was within 2 weeks of death; almost half were within 7 days (49.2%). Primary presenting concerns were pain (24.9%) and dyspnea (21.5%). There was no known goal of care reported or documented in either chart for 28.2%. In ED 85% had documentation that their goals or wishes for care were reviewed or discussed, of whom 9% had their first order written and 47.8% had their order changed to align care with their wishes and illness. 44.6% spent 8 hours or less in ED; 21 patients died in the ED. Most patients (73.8%) identified a preference to die at home or hospice; some wishes were unknown (7.2 %), others had not been discussed (17%); 77.5% died in hospital. Conclusions and Implications This study highlights the ongoing opportunity to meet palliative care needs, including communication and collaboration between ED and home care. Some patients presented urgently to home care near end of life; others were diagnosed in ED and then referred. Additional anticipatory guidance may benefit those who present to the ED near end of life but prefer to die at home or hospice.