Radiation Safety Perceptions and Practices Among Pediatric Anesthesiologists: A Survey of the Physician Membership of the Society for Pediatric Anesthesia.

BACKGROUND: Pediatric anesthesiologists are exposed to ionizing radiation from x-rays on an almost daily basis. Our goal was to determine the culture of safety in which they work and how they adhere to preventative strategies that minimize exposure risk in their daily practice. METHODS: After Institutional Review Board waiver and approval of the Society for Pediatric Anesthesia's research and quality and safety committees, an electronic e-mail questionnaire was sent to the Society's physician, nontrainee members and consisted of questions specific to provider use of protective lead shielding, the routine use of dosimeters, and demographic information. Univariate analyses were performed using the Wilcoxon rank sum test for ordinal variables, the Fisher exact test for categorical variables, and the Spearman test to analyze correlation between 2 ordinal variables, while a proportional odds logistic regression was used for a multivariable ordinal outcome analysis. P values of <.05 were considered statistically significant. RESULTS: Twenty-one percent (674/3151) of the surveyed anesthesiologists completed the online questionnaire. Radiation exposure is ubiquitous (98.7%), and regardless of sex, most respondents were either concerned or very concerned about radiation exposure (76.8%); however, women were significantly more concerned than men (proportional odds ratio, 1.66 [95% confidence interval, 1.20-2.31]; P = .002). Despite this and independent of sex, level of concern was not associated with use of a radiation dosimeter (P = .85), lead glasses (odds ratio, 1.07 [95% confidence interval, 0.52-2.39]; P = 1.0), or a thyroid shield (P = .12). Dosimeters were rarely (13%) or never used (52%) and were mandated in only 28.5% of institutions. Virtually none of the respondents had ever taken a radiation safety course, received a personal radiation dose report, notification of their radiation exposure, or knew how many millirem/y was considered safe. Half of the respondents were female, and while pregnant, 73% (151/206) tried to avoid radiation exposure by requesting not to be assigned to cases requiring x-rays. These requests were honored 78% (160/206) of the time. DISCUSSION: Despite universal exposure to ionizing radiation from x-rays, pediatric anesthesiologists do not routinely adhere to strategies designed to limit the intensity of this exposure and rarely work in institutions in which a culture of radiation safety exists. Our study highlights the need to improve radiation safety education, the need to change the safety culture within the operating rooms and imaging suites, and the need to more fully investigate the utility of dosimeters, lead shielding, and eye safety measures in pediatric anesthesia practice.

Endotracheal Intubation in Neonates: A Prospective Study of Adverse Safety Events in 162 Infants.

OBJECTIVE: To determine the rate of adverse events associated with endotracheal intubation in newborns and modifiable factors contributing to these events. STUDY DESIGN: We conducted a prospective, observational study in a 100-bed, academic, level IV neonatal intensive care unit from September 2013 through June 2014. We collected data on intubations using standardized data collection instruments with validation by medical record review. Intubations in the delivery or operating rooms were excluded. The primary outcome was an intubation with any adverse event. Adverse events were defined and tracked prospectively as nonsevere or severe. We measured clinical variables including number of attempts to successful intubation and intubation urgency (elective, urgent, or emergent). We used logistic regression models to estimate the association of these variables with adverse events. RESULTS: During the study period, 304 intubations occurred in 178 infants. Data were available for 273 intubations (90%) in 162 patients. Adverse events occurred in 107 (39%) intubations with nonsevere and severe events in 96 (35%) and 24 (8.8%) intubations, respectively. Increasing number of intubation attempts (OR 2.1, 95% CI, 1.6-2.6) and emergent intubations (OR 4.7, 95% CI, 1.7-13) were predictors of adverse events. The primary cause of emergent intubations was unplanned extubation (62%). CONCLUSIONS: Adverse events are common in the neonatal intensive care unit, occurring in 4 of 10 intubations. The odds of an adverse event doubled with increasing number of attempts and quadrupled in the emergent setting. Quality improvement efforts to address these factors are needed to improve patient safety.

Reducing intraoperative red blood cell unit wastage in a large academic medical center.

BACKGROUND: The wastage of red blood cell (RBC) units within the operative setting results in significant direct costs to health care organizations. Previous education-based efforts to reduce wastage were unsuccessful at our institution. We hypothesized that a quality and process improvement approach would result in sustained reductions in intraoperative RBC wastage in a large academic medical center. STUDY DESIGN AND METHODS: Utilizing a failure mode and effects analysis supplemented with time and temperature data, key drivers of perioperative RBC wastage were identified and targeted for process improvement. RESULTS: Multiple contributing factors, including improper storage and transport and lack of accurate, locally relevant RBC wastage event data were identified as significant contributors to ongoing intraoperative RBC unit wastage. Testing and implementation of improvements to the process of transport and storage of RBC units occurred in liver transplant and adult cardiac surgical areas due to their history of disproportionately high RBC wastage rates. Process interventions targeting local drivers of RBC wastage resulted in a significant reduction in RBC wastage (p < 0.0001; adjusted odds ratio, 0.24; 95% confidence interval, 0.15-0.39), despite an increase in operative case volume over the period of the study. Studied process interventions were then introduced incrementally in the remainder of the perioperative areas. CONCLUSIONS: These results show that a multidisciplinary team focused on the process of blood product ordering, transport, and storage was able to significantly reduce operative RBC wastage and its associated costs using quality and process improvement methods.

Quality and safety in pediatric anesthesia.

Health care quality and value are leading issues in medicine today for patients, health care professionals, and policy makers. Outcome, safety, and service-the components of quality-have been used to define value when placed in the context of cost. Health care organizations and professionals are faced with the challenge of improving quality while reducing health care related costs to improve value. Measurement of quality is essential for assessing what is effective and what is not when working toward improving quality and value. However, there are few tools currently for assessing quality of care, and clinicians often lack the resources and skills required to conduct quality improvement work. In this article, we provide a brief review of quality improvement as a discipline and describe these efforts within pediatric anesthesiology.

Interventions to Improve Patient Safety During Intubation in the Neonatal Intensive Care Unit.

OBJECTIVE: To improve patient safety in our NICU by decreasing the incidence of intubation-associated adverse events (AEs). METHODS: We sequentially implemented and tested 3 interventions: standardized checklist for intubation, premedication algorithm, and computerized provider order entry set for intubation. We compared baseline data collected over 10 months (period 1) with data collected over a 10-month intervention and sustainment period (period 2). Outcomes were the percentage of intubations containing any prospectively defined AE and intubations with bradycardia or hypoxemia. We followed process measures for each intervention. We used risk ratios (RRs) and statistical process control methods in a times series design to assess differences between the 2 periods. RESULTS: AEs occurred in 126/273 (46%) intubations during period 1 and 85/236 (36%) intubations during period 2 (RR = 0.78; 95% confidence interval [CI], 0.63-0.97). Significantly fewer intubations with bradycardia (24.2% vs 9.3%, RR = 0.39; 95% CI, 0.25-0.61) and hypoxemia (44.3% vs 33.1%, RR = 0.75, 95% CI 0.6-0.93) occurred during period 2. Using statistical process control methods, we identified 2 cases of special cause variation with a sustained decrease in AEs and bradycardia after implementation of our checklist. All process measures increased reflecting sustained improvement throughout data collection. CONCLUSIONS: Our interventions resulted in a 10% absolute reduction in AEs that was sustained. Implementation of a standardized checklist for intubation made the greatest impact, with reductions in both AEs and bradycardia.

Use of blood-sparing surgical techniques and transfusion algorithms: association with decreased blood administration in children undergoing primary open craniosynostosis repair.

OBJECT Craniofacial reconstruction surgery (CFR) is often associated with significant blood loss, coagulopathy, and perioperative blood transfusion. Due to transfusion risks, many different approaches have been used to decrease allogeneic blood transfusion for these patients during the perioperative period. Protocols have decreased blood administration during the perioperative period for many types of surgeries. The object of this study was to determine if a protocol involving blood-sparing surgical techniques and a transfusion algorithm decreased intraoperative blood transfusion and blood loss. METHODS A protocol using transfusion algorithms and implementation of blood-sparing surgical techniques for CFR was implemented at Vanderbilt University on January 1, 2013. Following Institutional Review Board approval, blood loss and transfusion data were gathered retrospectively on all children undergoing primary open CFR, using the protocol, for the calendar year 2013. This postprotocol cohort was compared with a preprotocol cohort, which consisted of all children undergoing primary open CFR during the previous calendar year, 2012. RESULTS There were 41 patients in the preprotocol and 39 in the postprotocol cohort. There was no statistical difference between the demographics of the 2 groups. When compared with the preprotocol cohort, intraoperative packed red blood cell transfusion volume decreased from 36.9 ± 21.2 ml/kg to 19.2 ± 10.9 ml/kg (p = 0.0001), whereas fresh-frozen plasma transfusion decreased from 26.8 ± 25.4 ml/kg to 1.5 ± 5.7 ml/kg (p < 0.0001) following implementation of the protocol. Furthermore, estimated blood loss decreased from 64.2 ± 32.4 ml/kg to 52.3 ± 33.3 ml/kg (p = 0.015). Use of fresh-frozen plasma in the postoperative period also decreased when compared with the period before implementation of the protocol. There was no significant difference in morbidity and mortality between the 2 groups. CONCLUSIONS The results of this study suggested that using a multidisciplinary protocol consisting of transfusion algorithms and implementation of blood-sparing surgical techniques during major CFR in pediatric patients is associated with reduced intraoperative administration of blood product, without shifting the transfusion burden to the postoperative period.

Preventability of early readmissions at a children's hospital.

OBJECTIVE: To determine whether pediatric readmissions within 15 days of discharge were considered preventable. METHODS: Retrospective chart review of 200 randomly selected readmissions (8% of all readmissions) occurring within 15 days of discharge from a freestanding children's hospital between January 1, 2007, and December 31, 2008. The degree of preventability was assessed independently for each case by 4 pediatricians using a 5-point Likert scale and was correlated with chronic conditions and reason for index admission with 3M's Clinical Risk Groups and All Patient-Refined Diagnostic-Related Groups, respectively. RESULTS: The rate of 15-day readmissions considered more likely preventable by the discharging hospital was 20.0% (1.7% of total admissions, 95% confidence interval 14.8%-26.4%). Reviewers failed to reach initial consensus in 62.5% of cases, although final consensus was achieved after the panel reviewed cases together. Consensus ratings served as the standard for the remainder of the study. Readmissions in children with malignancies were considered less preventable than those in children with other chronic illnesses (5.8% vs 25.8%, P = .003). Readmissions following surgical admissions were considered more likely preventable than those following medical admissions (38.9% vs 15.9%, P = .002). Central venous catheter infections and ventricular shunt malfunctions accounted for 8.5% of all readmissions reviewed. CONCLUSIONS: Although initial consensus about which readmissions were more likely preventable was difficult to achieve, the overall rate of preventable pediatric 15-day readmissions was low. Pediatric readmissions are unlikely to serve as a highly productive focus for cost savings or quality measurement.

Family-member presence during interventions in the intensive care unit: perceptions of pediatric cardiac intensive care providers.

OBJECTIVE: Should family members be present during interventions in an ICU? This question is a source of debate among health care providers. We propose to define perceptions and practice regarding family-member presence during ICU interventions from a multidisciplinary group of pediatric cardiac intensive care providers. METHODS: A 20-question survey was created and distributed to attendees of the 2004 Pediatric Cardiac Intensive Care Symposium, 1 year after the meeting. Interventions were defined as noninvasive (team rounds), invasive (tracheal intubation, central/arterial line placement, chest tube placement, or pericardiocentesis), or extremely invasive (cardiopulmonary resuscitation). RESULTS: A total of 211 surveys (145 physicians and 66 nonphysicians) were completed. Of all responders, the majority believe family members have a right to be present during cardiopulmonary resuscitation (75%), team rounds (77%), and invasive procedures (57%). Sixty-five percent of respondents encounter families that frequently request to be present for team rounds. However, the majority of respondents encounter families that rarely request to be present during invasive procedures (69%) and cardiopulmonary resuscitation (73%). Many providers practice in ICUs where family-member presence is allowed; 64% allow family members to attend team rounds. Some of the concerns providers have regarding family-member presence in the ICU include family-member presence causing stress to the provider during invasive procedures along with distractions and nervousness among the team during cardiopulmonary resuscitation. The majority of providers predict family-member presence during cardiopulmonary resuscitation would not increase medicolegal concerns. CONCLUSIONS: Most respondents, nonphysicians more than physicians, believe that family members have a right to be present during all ICU interventions. The majority of respondents encounter families that frequently request to be present for team rounds. However, the majority of respondents encounter families that rarely request to be present during invasive procedures and cardiopulmonary resuscitation. Most respondents believe family-member presence during cardiopulmonary resuscitation would not increase medicolegal concerns.