Department of Paediatrics, Division of Critical Care, University of Louisville School of Medicine, Louisville, KY, USA.
Speed School of Engineering, University of Louisville, Louisville, KY, USA.
Cardiol Young. 2020 Jun;30(6):860-865. doi: 10.1017/S1047951120001201. Epub 2020 Jun 1.
Neonates undergoing surgery for congenital heart disease are vulnerable to adverse events. Conventional quality improvement processes centring on mortality and significant morbidity leave a gap in the identification of systematic processes that, though not directly linked to an error, may still contribute to adverse outcomes. Implementation of a multidisciplinary "flight path" process for surgical patients may be used to identify modifiable threats and errors and generate action items, which may lead to quality improvement.
A retrospective review of our neonatal "flight path" initiative was performed. Within 72 hours of a cardiac surgery, a meeting of the multidisciplinary patient care team occurs. A "flight path" is generated, graphically illustrating the patient's hospital course. Threats, errors, or unintended consequences are identified. Action items are generated, and a working group is formed to address the items. A patient's flight path is updated weekly until discharge. The errors and action items are logged into a database, which is analysed quarterly to identify trends.
Thirty one patients underwent flight path review over a 1-year period; 22.5% (N = 7) of patients had an error-free "flight." Eleven action items were generated - four from identified errors and seven from identified threats. Nine action items were completed.
Flight path reviews of congenital cardiac patients can be generated with few resources and aid in the detection of quality improvement opportunities. The regular multidisciplinary meetings that occur as a part of the flight path review process can promote inter-professional teamwork.
接受先天性心脏病手术的新生儿易发生不良事件。以死亡率和重大发病率为中心的传统质量改进流程在识别系统过程方面存在差距，尽管这些系统过程与错误没有直接关联，但仍可能导致不良后果。为手术患者实施多学科“飞行路径”流程可能有助于识别可修改的威胁和错误，并生成行动项，从而实现质量改进。
对我们的新生儿“飞行路径”计划进行了回顾性研究。在心脏手术后 72 小时内，多学科患者护理团队会召开会议。生成“飞行路径”，以图形方式说明患者的住院过程。识别威胁、错误或意外后果。生成行动项，并成立一个工作组来处理这些项目。每周更新患者的飞行路径，直到出院。将错误和行动项记录到数据库中，每季度进行分析以识别趋势。
在一年的时间里，有 31 名患者进行了飞行路径审查；7 名患者（22.5%）的“飞行”没有错误。生成了 11 个行动项——其中 4 个来自已识别的错误，7 个来自已识别的威胁。完成了 9 个行动项。
通过很少的资源就可以生成先天性心脏患者的飞行路径审查，并有助于发现质量改进机会。作为飞行路径审查过程的一部分，定期的多学科会议可以促进专业间的团队合作。
