Inappropriate Use of Peripherally Inserted Central Catheters in Pediatrics: A Multisite Study.

OBJECTIVES: This study aimed to describe how the current practice of peripherally inserted central catheter (PICC) use in hospitalized children aligns with the Michigan Appropriateness Guide for Intravenous Catheters (miniMAGIC) in Children recommendations, explore variation across sites, and describe the population of children who do not receive appropriate PICCs. METHODS: A retrospective study was conducted at 4 children's hospitals in the United States. Children with PICCs placed January 2019 to December 2021 were included. Patients in the NICU were excluded. PICCs were categorized using the miniMAGIC in Children classification as inappropriate, uncertain appropriateness and appropriate. RESULTS: Of the 6051 PICCs identified, 9% (n = 550) were categorized as inappropriate, 9% (n = 550) as uncertain appropriateness, and 82% (n = 4951) as appropriate. The number of PICCs trended down over time, but up to 20% of PICCs each year were not appropriate, with significant variation between sites. Within inappropriate or uncertain appropriateness PICCs (n = 1100 PICC in 1079 children), median (interquartile range) patient age was 4 (0-11) years, 54% were male, and the main reason for PICC placement was prolonged antibiotic course (56%, n = 611). The most common admitting services requesting the inappropriate/uncertain appropriateness PICCs were critical care 24%, general pediatrics 22%, and pulmonary 20%. Complications resulting in PICC removal were identified in 6% (n = 70) of inappropriate/uncertain PICCs. The most common complications were dislodgement (3%) and occlusion (2%), with infection and thrombosis rates of 1% (n = 10 and n = 13, respectively). CONCLUSIONS: Although the majority of PICCs met appropriateness criteria, a substantial proportion of PICCs were deemed inappropriate or of uncertain appropriateness, illustrating an opportunity for quality improvement.

Creating an Organizational Culture and Climate of Meaningful Recognition for Nurse Managers.

OBJECTIVES: To examine the current nurse manager (NM) recognition culture and climate in organizations and to develop a theoretical foundation for meaningful recognition. BACKGROUND: Nurse managers call for wider recognition, but the theoretical conceptualization and underpinnings of meaningful recognition are sparse in the literature. METHODS: A qualitative descriptive design was used utilizing individual interviews. The study participants included 30 individuals consisting of NMs, chief nursing officers, and chief nursing executives. Content analysis was conducted. RESULTS: A theoretical model with super-categories and supportive quotes was created to operationalize a culture and climate of meaningful recognition in the organizations represented by the sample. CONCLUSION: This qualitative descriptive study highlights the importance of recognizing the value of NMs for their contributions to nursing leadership and patient care. Implications of recognizing NMs are counteracting the feeling of being invisible and mitigating issues within the work environment.

Impact of central venous catheter repair in pediatric intestinal failure.

OBJECTIVES: Patients with intestinal failure (IF) require long-term parenteral nutrition through central venous catheters (CVCs). When damaged, catheter replacement or repair is considered. Limited literature exists on repair outcomes in this population. We aimed to assess the impact of repair on durability of exiting CVCs and infection rates. METHODS: This was a retrospective cohort study of pediatric IF patients with tunneled silicone CVCs over 10 years. Outcomes were evaluated by assessing CVC longevity, repair success, replacement, and postrepair infection rates. RESULTS: One hundred thirty-eight repairs and 45 replacements were conducted in 37 patients with repair and replacement rates of 4.7 and 1.5 per 1000 catheter days, respectively. Twenty patients (54%) required ≥1 repair. For CVCs requiring repair, median CVC durability without and with repairs were at 123 and 391 days, respectively (P < .0001). Overall repair success rate was 96% with significantly lower success in the emergency department at 81% (P = .007). The 7-day postrepair infection rate was 2.2% without specific risk factors identified. Most repairs (76%) were performed by the Pediatric Gastroenterology division. Variability in practice was noted among services, including frequency of periprocedural antibiotic use and performance of temporary repairs before permanent repairs. A gradual increase in CVC repair rate was noted over time. CONCLUSIONS: Our study showed that CVC repair is effective in prolonging CVC durability in pediatric IF patients without increasing infection rates. Incorporating a temporary repair as a step before permanent repair may offer a route to address potential intraluminal thrombosis before permanent repair.

Characteristics, Comorbidities, and Data Gaps for Coronavirus Disease Deaths, Tennessee, USA.

As of March 2021, coronavirus disease (COVID-19) had led to >500,000 deaths in the United States, and the state of Tennessee had the fifth highest number of cases per capita. We reviewed the Tennessee Department of Health COVID-19 surveillance and chart-abstraction data during March 15‒August 15, 2020. Patients who died from COVID-19 were more likely to be older, male, and Black and to have underlying conditions (hereafter comorbidities) than case-patients who survived. We found 30.4% of surviving case-patients and 20.3% of deceased patients had no comorbidity information recorded. Chart-abstraction captured a higher proportion of deceased case-patients with >1 comorbidity (96.3%) compared with standard surveillance deaths (79.0%). Chart-abstraction detected higher rates of each comorbidity except for diabetes, which had similar rates among standard surveillance and chart-abstraction. Investing in public health data collection infrastructure will be beneficial for the COVID-19 pandemic and future disease outbreaks.

An international survey of pediatric and neonatal clinicians' vascular access practice: PediSIG assessment of vascular access, education, and support (PAVES) catheter selection.

HIGHLIGHTS: There is a wide variance in neonatal and pediatric vascular access workforce models, training, and competency assessments. Pain control during procedures is critical for children, yet it is not consistently used. Procedural support has shown improved patient outcomes, yet is not standardly used for every distressful procedure. Core standards are needed to ensure proper training and support for the pediatric and neonatal vascular access clinicians. BACKGROUND: Despite evidence to support best practice in neonatal and pediatric venipuncture delivery and procedural support, there are inconsistencies in practice. To inform future research, education, and workforce innovation, the Association for Vascular Access Pediatric Special Interest Group (PediSIG) developed and undertook a survey to describe the current vascular access practice for clinicians caring for neonatal and pediatric patients. OBJECTIVE: Describe the current state of workforce models, training, and clinical practices surrounding pediatric and neonatal vascular access. DESIGN: Cross-sectional, electronic survey using convenience sampling. SETTINGS: International clinicians who provide vascular access (peripheral intravenous catheter insertion, venipuncture for blood sampling) for neonatal and pediatric patients. METHODS: An electronic survey was developed by the PediSIG. The survey covered workforce models, clinician training and competency, pain relief, procedural support, and device securement. The electronic survey was then distributed to the PediSIG membership and shared among several neonatal/pediatric email lists. Data were analyzed descriptively, with an exploration of association between clinical outcomes, workforce, and training. RESULTS: There were 242 responses from 5 countries showing a wide variance of practice. Workforce models showed many different team names and responsibilities along with a variance of personnel and staffing hours. Clinician training was described as 4 hours or less by 44% (n = 69) of respondents. Less than half of the responses (47%; n = 99) reported having a formal procedure to escalate a patient to an expert care and not having a set number of max attempts before escalation. Only two-thirds (n = 115) of respondents said they had a standardized protocol for pain control and procedural support, with only 13% (n = 23) and 15% (n = 27), respectively, self-reporting that they always followed the protocol. CONCLUSIONS: The respondents reported a wide variance in neonatal and pediatric vascular access procedures and the resources used to support this practice. Core standards need to be developed to help guide neonatal and pediatric clinicians and their institutions. The standards should encompass recommendations for workforce models, proper training, competency, insertion guidelines, pain control.

Risk of Patient Harm Related to Unnecessary Dilution of Ready-to-Administer Prefilled Syringes: A Literature Review.

Unnecessary dilution of ready-to-administer (RTA) syringes could increase the risk of patient harm attributed to errors related to incorrect dose, improper labeling, and the potential for microbial contamination. Although published guidelines endorse the use of commercially available RTA syringes, recent surveys indicate that best practices are not always implemented. The purpose of this article is to review the existing literature and to assess the incidence and nature of errors related to the unnecessary dilution of RTA intravenous (IV) push medications in the inpatient clinical setting. The PubMed database was searched to identify studies of errors related to the use of RTA syringes for IV push medications within the last 10 years. An additional search was conducted using other search engines to identify relevant articles in the grey literature. This literature review concludes that unnecessary dilution of IV push medication in RTA syringes is an unsafe practice that occurs routinely. This practice increases the risk of patient harm through errors related to incorrect dose, improper labeling of syringes, and the potential for microbial contamination of the product. Greater awareness of the risks associated with unnecessary dilution of RTA syringes is still needed to eliminate this unsafe IV push medication administration practice and to thereby further improve outcomes.

Outcomes of Patients Receiving Temporary Circulatory Support Before Durable Ventricular Assist Device.

BACKGROUND: Temporary circulatory support (TCS) is used to stabilize patients in critical cardiogenic shock and bridge patients to a durable ventricular assist device (VAD). Whether TCS confers increased risk at the time of VAD implant is unknown. METHODS: Prospectively collected data from five institutions was retrospectively reviewed. All profile 1 through profile 3 patients implanted with a continuous-flow VAD (n = 804) were categorized into three groups: TCS (n = 68); non-TCS profile 1 (n = 70); and non-TCS profile 2-3 (n = 666). RESULTS: End-organ function and hemodynamics were worse before TCS than in non-TCS profile 1 patients: creatinine (1.7 ± 0.1 mg/dL versus 1.3 ± 0.06 mg/dL, p = 0.003); and right atrial pressure (16 ± 0.8 mm Hg versus 13 ± 1.1 mm Hg, p = 0.048). The TCS restored cardiac output before durable VAD (4.9 ± 0.2 L/min), and was comparable to profile 2-3 patients (4.3 ± 0.05 L/min) and better than profile 1 patients (4.0 ± 0.2 L/min, p = 0.002). Markers of hepatic function such as bilirubin were impaired before VAD in TCS and profile 1 patients (2.0 ± 0.2 mg/dL) compared with profile 2 and 3 patients (1.1 ± 0.03, p < 0.001). The incidence of postoperative right ventricular failure necessitating a right VAD was 21% for TCS patients and non-TCS profile 1 patients compared with 2% for profile 2-3 patients (p < 0.001). Profile 1 and TCS patients had similar 1-year survival (70% and 77%, p = 0.57), but inferior survival as compared with profile 2 and 3 patients (82%, p < 0.001). On multivariable analysis, TCS increased the hazard of death twofold. CONCLUSIONS: Temporary circulatory support restores hemodynamics and reverses end-organ dysfunction. Nevertheless, these patients have high residual risk with postoperative morbidity and mortality that parallels profile 1 patients without TCS. Caution is suggested in downgrading risk for TCS patients with improved hemodynamic stability.

Treatment of device thrombus in the HeartWare HVAD: Success and outcomes depend significantly on the initial treatment strategy.

BACKGROUND: Pump thrombosis is a major adverse event in patients supported with a left ventricular assist device (LVAD). Treatment approaches include device exchange, lytic therapy, or augmentation of anticoagulation or antiplatelet therapy. The optimal strategy in the HeartWare HVAD Ventricular Assist System (HeartWare, Framingham, MA) is uncertain, and because few large studies have examined differing treatment outcomes, we have reviewed findings from the Mechanical Circulatory Support Research Network registry. METHODS: Between March 2009 and August 2014, 175 patients (133 male) underwent implantation of the HeartWare HVAD at institutions that comprise the Mechanical Circulatory Support Research Network. Median age at implant was 59 years (range, 18-76 years). Follow-up was available in all patients for a median of 6 months (maximum, 61 months) and for a total of 163 patient-years of support. There were 36 pump thromboses (using Interagency Registry for Mechanically Assisted Circulatory Support criteria) in 21 patients for a total event rate of 0.22 events/patient-year of support; 13 patients had 1 event, 4 had 2, 2 had 3, 1 had 4, and 1 had 5. The median time to the first thrombosis was 6.4 months, and to each subsequent thrombosis was 4, 3, 2, and 2 months, respectively. Primary treatment success was defined as the patient remaining alive and within the first 30 days of the initial treatment be free from stroke, recurrence of pump thrombosis, device exchange, or urgent transplantation (United Network of Organ Sharing Status 1A). Medical treatment was defined as tissue plasminogen activator, heparin plus glycoprotein IIb/IIIa inhibitor, or heparin alone, not followed by surgical treatment within 72 hours. RESULTS: Initial medical treatment was used in 29 episodes (tissue plasminogen activator in 24, heparin alone in 4, and heparin plus glycoprotein IIb/IIIa in 1) and surgical (device exchange) in 7. Medical treatment was successful in 14 of 29 episodes (48%). Complications of medical treatment included hemorrhagic stroke in 6 patients (21%), need for urgent device exchange/transplant in 6 (21%), and death in 3 (10%). Surgical treatment was successful in all 7 patients (100%). No significant early complications or early deaths occurred after device exchange. CONCLUSIONS: In this large multicenter analysis, we observed that medical therapy, as the initial treatment strategy for HeartWare HVAD thrombosis, is associated with low success (48%) and a significant risk of hemorrhagic stroke (21%) and death (10%). However, initial treatment with device exchange was uniformly successful and not associated with significant early morbidity or death. Although the optimal treatment approach for HeartWare HVAD pump thrombosis remains undecided, these data do not support the routine use of medical therapy as an initial treatment strategy.

Elevation of plasma milrinone concentrations in stage D heart failure associated with renal dysfunction.

PURPOSE: To determine steady state milrinone concentrations in patients with stage D heart failure (HF) with and without renal dysfunction METHODS: We retrospectively identified patients with stage D HF at a single medical center on continuous milrinonein fusion at the time of plasma collection for entry into a research registry database. Milrinone was prescribed and titrated to improve hemodynamic and clinical status by a cardiologist. Plasma samples were obtained at steady state milrinone concentrations. Patients were stratified by creatinine clearance (CrCl) into 4 groups: group 1 (CrCl >60 mL/min), group 2 (CrCl 60-30 mL/min), group 3 (CrCl <30 mL/min), and group 4 (intermittent hemodialysis). Retrospective chart review was performed to quantify the post milrinone hemodynamic changes by cardiac catheterization and electrophysiologic changes by implantable cardiac defibrillator (ICD) interrogation. RESULTS: A total of 29 patients were identified: group 1 (n=14), group 2 (n=10), group 3(n=3), and group 4 (n = 2). The mean infusion rate (0.391+0.08 mg/kg/min) did not differ between groups (P=0.14). The mean milrinone concentration was 451+243 ng/mL in group 1, 591+293 ng/mL in group 2, 1575+962 ng/mL in group 3, and 6252+4409 ng/mL in group 4 (P<0.05 compared to groups 1). There was no difference in post milrinone hemodynamic improvements between the groups (P=0.41). The ICD interrogation revealed limited comparisons, but 6 of the 8 post milrinone ventricular tachycardia episodes requiring defibrillation occurred in group 4 patients. CONCLUSION: Patients with stage D HF having severe renal dysfunction have elevated milrinone concentrations. Future studies of milrinone concentrations are warranted to investigate the potential risk of life-threatening arrhythmias and potential dosing regimens in renal dysfunction.

Lineage-specific expression of polypyrimidine tract binding protein (PTB) in Drosophila embryos.

Polypyrimidine tract binding protein (PTB) is a member of the hnRNP family of RNA binding proteins (Nucleic Acids Res., 20 (1992) 3671) that functions in a number of processes important for the regulation of mRNA metabolism and gene expression (reviewed in Curr. Biol., 7 (1997) R705). Specifically, PTB binds polypyrimidine-rich intronic elements upstream of alternatively spliced exons to antagonize the binding of the essential U2AF splicing factor and repress the use of the regulated exons in specific tissues (RNA, 1 (1995) 234). Additionally, PTB interacts with elements that mediate 3-prime end processing of nascent transcripts (Mol. Cell. Biol., 19 (1999) 78) and is required for the expression of viral mRNAs that contain an internal ribosome binding site (RNA, 5 (1999) 344; RNA, 1 (1995) 924). Tissue-specific or alternatively spliced isoforms of PTB are thought to have different gene regulatory properties (Proc. Natl Acad. Sci. USA, 97 (2000) 6350; RNA, 7 (2001) 819), but little is known about the function and activity of PTB isoforms during development. Here, we investigate the expression of PTB during Drosophila embryogenesis using in situ hybridization assays. We show that PTB expression is patterned in the early embryo and occurs in specific mesodermal and neuronal lineages as well as in the imaginal discs and adult germline. These data indicate that PTB regulates gene expression in specific tissue lineages during development.