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INTRODUCTION: Specific criteria for de-escalation from the PICU are often not included in viral bronchiolitis institutional pathways. Variability of transfer preferences can prolong PICU length of stay. We aimed to decrease the time from reaching floor-appropriate heated high flow nasal cannula (HHF) settings to the transfer decision by 20% through standardizing PICU-to-floor transfer assessment in a PICU bronchiolitis cohort. METHODS: We included PICU bronchiolitis admissions from October 2019 to April 2020, who were 6-months to 2-years-old with no comorbidities nor intubation during their encounter. Our intervention bundle included introduction of transfer criteria and standardization of transfer-readiness assessment. The primary outcome was time from reaching floor-appropriate HHF settings [8 L per minutes (Lpm)] to placement of the transfer order ("time-to-transfer decision"). The secondary outcome was PICU length of stay. The main process measure was the proportion of patients transferred on ≥6 Lpm HHF. Balancing measures included Rapid Response Team activation and unplanned PICU readmission. We assessed admissions meeting inclusion criteria from December, 2018-March, 2019 for the preintervention baseline. RESULTS: Special cause variation indicated improvement in our primary outcome and process measures. Comparison of baseline to postintervention revealed a reduction in median time-to-transfer decision (14.4-7.8 hours; P < 0.001) and increase in children transferred on ≥6 Lpm (51%-72%; P < 0.001). We observed no change in PICU length of stay or balancing measures. CONCLUSION: Standardizing de-escalation criteria and transfer-readiness assessment reduced the time-to-transfer decision out of the PICU and increased the proportion transferred on ≥6 Lpm HHF for children with viral bronchiolitis without increasing PICU readmissions.
RESUMO
Although foodborne outbreaks of illness are relatively common, they are rarely caused by chemical agents. An outbreak of gastrointestinal illness occurred among students at two schools shortly after lunch was served. A cohort study, an environmental investigation, and microbiological and toxicological laboratory testing of food samples were performed. A case was defined as a student or teacher who ate food prepared in the kitchen at school A on 25 November 2002 (and served at schools A and B) and who later developed headache or symptoms of gastrointestinal tract irritation, with onset within 180 min of eating lunch. Among 312 persons interviewed, 157 persons became ill (attack rate = 49%; attack rate 41% for school A, 11% for school B). Onset of illness occurred within 60 min for 81% of cases; 91% of students reported that their chicken tenders smelled unusual. Eating chicken tenders that smelled unusual was associated with being a case (relative risk 9.2, 95% confidence interval 1.4 to 62.6, P < 0.05). Ammonia was detected in uncooked chicken tenders at levels as high as 2,468 ppm. The chicken had been contaminated during a warehouse leak of ammonia refrigerant. This outbreak of ammonia poisoning is only the second reported in food, and the first in a solid food. Heated chicken tenders contaminated with ammonia can cause acute illness within a short period of time.
