Handoff improvement and adverse event reduction programme implementation in paediatric intensive care units in Argentina: a stepped-wedge trial.

BACKGROUND: There are only a few studies on handoff quality and adverse events (AEs) rigorously evaluating handoff improvement programmes' effectiveness. None of them have been conducted in low and middle-income countries. We aimed to evaluate the effect of a handoff programme implementation in reducing AE frequency in paediatric intensive care units (PICUs). METHODS: Facility-based, cluster-randomised, stepped-wedge trial in six Argentine PICUs in five hospitals, with >20 admissions per month. The study was conducted from July 2018 to May 2019, and all units at least were involved for 3 months in the control period and 4 months in the intervention period. The intervention comprised a Spanish version of the I-PASS handoff bundle consisting of a written and verbal handoff using mnemonics, an introductory workshop with teamwork training, an advertising campaign, simulation exercises, observation and standardised feedback of handoffs. Medical records (MR) were reviewed using trigger tool methodology to identify AEs (primary outcome). Handoff compliance and duration were evaluated by direct observation. RESULTS: We reviewed 1465 MRs: 767 in the control period and 698 in the intervention period. We did not observe differences in the rates of preventable AE per 1000 days of hospitalisation (control 60.4 (37.5-97.4) vs intervention 60.4 (33.2-109.9), p=0.99, risk ratio: 1.0 (0.74-1.34)), and no changes in the categories or AE types. We evaluated 841 handoffs: 396 in the control period and 445 in the intervention period. Compliance with all items in the verbal and written handoffs was significantly higher in the intervention group. We observed no difference in the handoff time in both periods (control 35.7 min (29.6-41.8) vs intervention 34.7 min (26.5-42.1); difference 1.43 min (95% CI -2.63 to 5.49, p=0.49)). The providers' perception of improved communication did not change. CONCLUSIONS: After the implementation of the I-PASS bundle, compliance with handoff items improved. Nevertheless, no differences were observed in the AEs' frequency or the perception of enhanced communication. TRIAL REGISTRATION NUMBER: NCT03924570.

Prevalencia y características clínicas de episodios paroxísticos no epilépticos y epilepsias en el Servicio de Pediatría del Hospital Británico en el período junio 2013 a junio 2015 / PREVALENCE AND CLINICAL CHARACTERISTICS OF PAROXYSMAL EPISODES NONEPILEPTIC EVENTS AND EPILEPSIES IN THE PEDIATRIC SERVICE OF THE BRITISH HOSPITAL FROM BUENOS AIRES, BETWEEN THE PERIOD JUNE 2013 THROUGH JUNE 2015

Introducción: El diagnóstico temprano de los Episodios Paroxísticos No Epilépticos (EPNE) y la clara diferenciación con crisis epilépticas es esencial para su manejo y evitar tratamientos innecesarios. Conocer la frecuencia y características clínicas permite mejorar las estrategias diagnósticas, disminuyendo la cantidad de estudios complementarios solicitados y los días de internación, mejorando la calidad de atención. Materiales y Métodos: estudio descriptivo y retrospectivo de revisión de historias clínicas de pacientes de un mes a 16 años de edad internados por convulsión en el Hospital Británico durante el periodo de junio 2013 a junio 2015. Resultados: Se obtuvo una muestra de 71 pacientes: 25.4% tuvieron como diagnóstico EPNE, 74.6% tuvieron otros diagnósticos. Se compararon ambos grupos. La edad de presentación de los EPNE fue en la mayoría de los casos antes de los 2 años de edad con hipotonía como presentación clínica más frecuente. En el resto de la población analizada, la edad de presentación fue a los 3.5 años y prevalecieron los movimientos tónicos clónicos generalizado. Los EEG realizados fueron normales en el 100% de los EPNE mientras que en los trastornos convulsivos resultó patológico en el 56.5% Conclusiones: Se observaron diferencias significativas entre los pacientes con EPNE en comparación con el resto de la población analizada. Los EPNE presentan crisis de menos de 1 minuto de duración, suelen no tener episodio post-ictal, presentan una mayor incidencia de hipotonía y el EEG es normal. Los pacientes con EPNE no requirieron medidas de cuidados intensivos lo que habla de la benignidad de estos eventos.

Introduction: Paroxysmal nonepileptic disorders can cause diagnostic confusion,and it is important to differentiate them from epileptic disorders, so that a correct management and treatment can be established. In order to settle a correct diagnostic strategy it is essential to know the incidence and the clinical presentation of this pathology. With an accurate diagnosis, the number of complementary studies and the length of the hospital stay will diminish. Methodology: A retrospective descriptive study of clinical histories from pediatric patients, aged 1 month to 16 years, admitted at the British Hospital of Buenos Aires with seizure diagnosis during the lapse of time between June 2013 and June 2015, was undertaken. Results: A total of 71 patients were analyzed. 25.4% had non-epileptic paroxysmal events, 74.5% had other diagnosis. Both groups were compared. Patients with non-epileptic paroxysmal events presented symptoms before the 2 years of age, hypotonia was the most common clinical presentation and these patients had a normal electroencephalogram (EEG). The other group presented symptoms at 3.5 years of age, tonic-clonic movement was the most frequent symptom and 56, 5% had abnormal EEG. Conclusion: Significant differences were found between patients with nonepileptic paroxysmal events and the rest of the patients analyzed. Patients with non- epileptic paroxysmal disorder present events of less than one minute of duration with no postictal state, hypotinia is the most frequent symptom seen and the EEG results normal. Patients with nonepileptic paroxysmal disorder did not require admission to intensive care unit; this reflects the benign condition of the pathology