Measuring evidence-based clinical guideline compliance in the paediatric intensive care unit.

BACKGROUND: Evidence-based clinical care guidelines improve medical treatment by reducing error, improving outcomes and possibly lowering healthcare costs. While some data exist on individual guideline compliance, no data exist on overall compliance to multiple nuanced guidelines in a paediatric intensive care setting. METHODS: Guideline compliance was observed and measured with a prospective cohort at a tertiary academic paediatric medical-surgical intensive care unit. Adherence to 19 evidence-based clinical care guidelines was evaluated in 814 patients, and reasons for non-compliance were noted along with other associated outcomes. MEASUREMENTS AND MAIN RESULTS: Overall facility compliance was unexpectedly high at 77.8% over 4512 compliance events, involving 826 admissions. Compliance varied widely between guidelines. Guidelines with the highest compliance were stress ulcer prophylaxis (97.1%) and transfusion administration such as fresh frozen plasma (97.4%) and platelets (94.8%); guidelines with the lowest compliance were ventilator-associated pneumonia prevention (28.7%) and vitamin K administration (34.8%). There was no significant change in compliance over time with observation. Guidelines with binary decision branch points or single-page decision flow diagrams had a higher average compliance of 90.6%. Poor compliance was more often observed with poor perception of guideline trustworthiness and time limitations. CONCLUSIONS: Measuring guideline compliance, though onerous, allowed for evaluation of current clinical practices and identified actionable areas for institutional improvement.

Pediatric Respiratory Support Technology and Practices: A Global Survey.

OBJECTIVE: This global survey aimed to assess the current respiratory support capabilities for children with hypoxemia and respiratory failure in different economic settings. METHODS: An online, anonymous survey of medical providers with experience in managing pediatric acute respiratory illness was distributed electronically to members of the World Federation of Pediatric Intensive and Critical Care Society, and other critical care websites for 3 months. RESULTS: The survey was completed by 295 participants from 64 countries, including 28 High-Income (HIC) and 36 Low- and Middle-Income Countries (LMIC). Most respondents (≥84%) worked in urban tertiary care centers. For managing acute respiratory failure, endotracheal intubation with mechanical ventilation was the most commonly reported form of respiratory support (≥94% in LMIC and HIC). Continuous Positive Airway Pressure (CPAP) was the most commonly reported form of non-invasive positive pressure support (≥86% in LMIC and HIC). Bubble-CPAP was used by 36% HIC and 39% LMIC participants. ECMO for acute respiratory failure was reported by 45% of HIC participants, compared to 34% of LMIC. Oxygen, air, gas humidifiers, breathing circuits, patient interfaces, and oxygen saturation monitoring appear widely available. Reported ICU patient to health care provider ratios were higher in LMIC compared to HIC. The frequency of respiratory assessments was hourly in HIC, compared to every 2-4 h in LMIC. CONCLUSIONS: This survey indicates many apparent similarities in the presence of respiratory support systems in urban care centers globally, but system quality, quantity, and functionality were not established by this survey. LMIC ICUs appear to have higher patient to medical staff ratios, with decreased patient monitoring frequencies, suggesting patient safety should be a focus during the introduction of new respiratory support devices and practices.

A Review of Pediatric Critical Care in Resource-Limited Settings: A Look at Past, Present, and Future Directions.

Fifteen years ago, United Nations world leaders defined millenium development goal 4 (MDG 4): to reduce under-5-year mortality rates by two-thirds by the year 2015. Unfortunately, only 27 of 138 developing countries are expected to achieve MDG 4. The majority of childhood deaths in these settings result from reversible causes, and developing effective pediatric emergency and critical care services could substantially reduce this mortality. The Ebola outbreak highlighted the fragility of health care systems in resource-limited settings and emphasized the urgent need for a paradigm shift in the global approach to healthcare delivery related to critical illness. This review provides an overview of pediatric critical care in resource-limited settings and outlines strategies to address challenges specific to these areas. Implementation of these tools has the potential to move us toward delivery of an adequate standard of critical care for all children globally, and ultimately decrease global child mortality in resource-limited settings.

Rhabdomyolysis associated with hydroxymethylglutaryl-coenzyme A reductase inhibitors.

BACKGROUND: The recent withdrawal of cerivastatin by the manufacturer has led to an interest in hydroxymethylglutaryl-coenzyme A (HMG-CoA) inhibitors and the incidence of myopathy. We review the epidemiology, pharmacology, and presumed mechanisms of statin-induced myopathy, with a particular focus on cerivastatin. METHODS: A MEDLINE search of English-language articles published between 1985 and 2003 was performed. Key words included HMG-CoA inhibitors, statins, myopathy, myotoxicity, rhabdomyolysis, adverse events, drug interactions, and cerivastatin. RESULTS: The initial trials, which assessed the efficacy of first-generation HMG-CoA inhibitors, did not show a clinically significant increase in the incidence of myopathy. However, on the basis of Food and Drug Administration post-marketing surveys, the rate of cerivastatin-induced rhabdomyolysis appeared to be 10-fold greater than that of the other statins, despite safe pre-clinical profiles. However, no clinical trials have been performed directly comparing the rates of myotoxicity of all commercially available statins. The mechanism of statin-induced myopathy remains unclear. The prevailing theory is that lipophilic statins lead to depletion of intermediates normally formed after cholesterol synthesis within myocytes. Risk factors for the development of myopathy include drug interactions (especially with fibrates) and the coexistence of conditions known to predispose patients to rhabdomyolysis. CONCLUSION: The cerivastatin experience emphasizes the need for large safety trials before drug approval and for vigilant post-marketing surveillance. Further research and sound clinical judgment may lead to the identification of high-risk individuals in whom statins should be avoided.

In-hospital outcomes after percutaneous coronary intervention in Canada: 1992/93 to 2000/01.

BACKGROUND: Despite existing research on outcomes of cardiac care in Canada, little is known about Canada-wide trends and interprovincial differences in outcomes after percutaneous coronary intervention (PCI). OBJECTIVES: To examine Canadian trends in rates of in-hospital mortality and same-admission coronary artery bypass grafting (CABG) after PCI and to compare provincial risk-adjusted in-hospital death and same-admission CABG rates. METHODS: Hospital discharge abstract data were obtained from the Canadian Institute for Health Information and were used to identify cohorts of patients who underwent PCI in eight provinces in fiscal years 1992/93 through 2000/01. Crude data from Quebec hospitals were available for calendar years 1998 and 1999. Logistic regression modelling was used to calculate risk-adjusted in-hospital death and same-admission CABG rates by year and province. RESULTS: A total of 127,103 PCI cases performed in 23 hospitals across eight provinces were examined, with an overall unadjusted death rate of 1.4% and an overall unadjusted CABG rate of 1.6%. A national trend of stable in-hospital mortality rates was observed with a risk-adjusted death rate of 1.4% in 1992/93 versus 1.4% in 2000/01. An overall decline was seen in rates of same-admission CABG with a risk-adjusted rate of 2.7% in 1992/93 versus 0.9% in 2000/01 (relative decrease 67%, P<0.01). New Brunswick, Manitoba and British Columbia achieved overall declines in risk-adjusted death rates over the study period, while the other provinces experienced a slight increase (Newfoundland, Nova Scotia, Ontario, Alberta and Saskatchewan). All provinces displayed a similar decline in risk-adjusted same-admission CABG rates post-PCI. INTERPRETATION: Risk-adjusted rates of in-hospital death after PCI in Canada have remained stable over nine years, while risk-adjusted rates of same-admission CABG have decreased. The presence of interprovincial differences in risk-adjusted outcomes raises the possibility of variable quality of care for patients undergoing PCI across the Canadian provinces.