Introduction: Patient safety gaps were identified following an unanticipated serious adverse event (USAE) in the Children’s Mercy (CM) Exercise Physiology laboratory. While prevalence of USAEs during pediatric exercise stress testing (EST) is low, guidelines/practice recommendations have noted inter-institutional inconsistencies in high-risk EST protocols. The purpose of this QI project was to design and implement a standardized protocol for high-risk EST focused on enhanced preparedness and increased safety during an USAE.  

Methods: The project team (exercise physiologists, CM intensive care and resuscitation committees, and pharmacy) utilized driver diagrams and process mapping tools to design the high-risk EST protocol (9/2020).  The protocol included: criteria for identifying high-risk patients, standard processes for enhanced communication, scheduling specifications, and emergency medications. PDSA cycles were performed to refine education and communication, including time-out huddles, and specify pre-defined locations for patients to be transported following an USAE.  

Results: Fifty-four patients (10 inpatients, 44 outpatients) have followed the high-risk protocol since implementation (11/2020) with no USAEs. Although balancing measures demonstrated no change in appointment wait times or exercise physiologist workload following protocol implementation, EST using the high-risk protocol require longer appointment duration and increased workload for the attending physician. Feedback from patients/families revealed the need for additional communication with families prior to high-risk EST.  Overall hospital/staff feedback has been positive. 

Conclusions: Although there have been no USAEs since implementation of the high-risk EST protocol, its development has yielded increased communication and collaboration within and between CM hospital/staff. Future directions could include dissemination of this protocol to reduce inter-institutional inconsistencies.