Background: Implementation of a Watcher program to improve early recognition and response to patient deterioration outside the ICU is known to improve outcomes and reduce Emergency Transfers (ETs). The unique physiology of cardiac patients and differences in care models have limited generalizability of general pediatrics Watcher criteria to this population.   
 
Objectives: To demonstrate a significant decrease in ETs and codes for cardiac patients outside the CICU as evidenced by a centerline shift.   
 
Methods: Using the CHOP improvement framework, we implemented a Watcher program with cardiac-specific criteria developed through expert consensus. Utilizing a project dashboard, we established baseline metrics, including adapting the literature definition of ETs to the cardiac population through retrospective data review.  

A Cardiac Watcher order set was created, to obtain Q2 patient vitals for 8 hours, reduce patient:nurse ratio, and heighten awareness and communication. Watcher status was re-assessed every 8 hours. 

A multidisciplinary group assessed and implemented the tiered review process in “Implementation of a Multidisciplinary Debriefing Process for Pediatric Ward Deterioration Events”1, adapting minor elements of data collection and expanding the venues for Tier 2 reviews to include monthly cross-unit reviews. 

Results: We have not yet achieved a centerline shift in our Days Between ETs/Codes; however, we have seen an increase in our median Days Between events from 26 days to 48 days, an 84% increase. 

May 2021 to February 2022 included 94 unplanned CICU transfers with 9% ET and 15% ICU bouncebacks. 37% of those had a Tier 1 huddle recorded. Nursing was represented at 100% of the huddles, with FLOC participation at 76%.  

Of the 34 Tier 1s, 54% were identified as Watchers at the time of their escalation, and 58% of those Watchers were in a 2-patient RN assignment. Of the 46% not identified as Watchers, 24% were deemed as missed opportunities for Watcher designation. 28% could have benefited from earlier CICU input, and 26% were described as having been affected by bed availability. Increase in respiratory support and clinician concern were the most common early signs of deterioration. 53% of patients were described as having inadequate vascular access in the setting of escalation.  

44% of unplanned CICU Transfers were identified as requiring Tier 2 review, with 15% of those resulting in action items.  
 
Conclusions/Implications: Implementation of the Watcher process alone did not result in an improvement of days between ETs or codes. The tiered review process has identified actionable insight, such as the need for more standardized inclusion of respiratory therapy, additional vascular access support at the time of escalation, and a clinician concern measure. The Cardiac Center continues to assess established systems for escalation of care to identify opportunities for appropriate implementation with the cardiac population.