Prevalence of Acute Rehabilitation for Kids in the PICU: A Canadian Multicenter Point Prevalence Study.

OBJECTIVES: To evaluate mobilization practices, barriers, and mobility-related adverse events in Canadian PICUs. DESIGN: National 2-day point prevalence study. SETTING: Thirteen PICUs across Canada. PATIENTS: Children with a minimum 72-hour PICU length of stay on the allocated study day. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Outcomes of interest were the prevalence and nature of mobilization activities, rehabilitation resources, adverse events, and factors associated with out-of-bed mobility and therapist-provided mobility. Two PICUs (15%) had early mobilization practice guidelines, and one PICU (8%) reported a formal process for engaging families in the mobilization of patients. The prevalence of mobilization was 110 of 137 patient-days (80%). The commonest activity was out-of-bed mobility (87/137; 64% patient-days); there was no active mobilization on 46 patient-days (34%). Therapists provided mobility on 33% of patient-days. Mobility was most commonly facilitated by nurses (74% events) and family (49% events). Family participation was strongly associated with out-of-bed mobility (odds ratio 6.4; p = 0.001). Intubated, mechanically ventilated patients were mobilized out-of-bed on 18 of 50 patient-days (36%). However, the presence of an endotracheal tube, vasoactive infusions, and age greater than or equal to 3 years were independently associated with not being mobilized out-of-bed. Barriers were reported on 58 of 137 patient-days (42%), and adverse events occurred in 22 of 387 mobility events (6%). CONCLUSIONS: Mobilization is common and safe, and the majority of children in Canadian PICUs are being mobilized out-of-bed, even when mechanically ventilated. Family engagement in PICU-based rehabilitation is increasing. This study provides encouraging evidence that common barriers can be overcome in order to safely mobilize children in PICUs.

Increased Mortality and Length of Stay Associated With Medical Emergency Team Review in Hospitalized Pediatric Patients: A Retrospective Cohort Study.

OBJECTIVE: Rapid response systems using medical emergency teams reduce hospital wide cardiorespiratory arrest and mortality. While rapid response systems improve hospital-wide outcomes, children receiving medical emergency team review may still be at increased risk for morbidity and mortality. The study purpose was to compare the length of stay and mortality rate in children receiving a medical emergency team review with those of other hospitalized children. DESIGN: Retrospective cohort study. SETTING: Tertiary Pediatric Hospital, Children's Hospital of Eastern Ontario, Ottawa, Canada. PATIENTS: Cohort of 42,308 pediatric admissions to the general inpatient ward. INTERVENTIONS: Data over 7 years were obtained from a prospectively maintained rapid response systems database. MEASUREMENTS AND MAIN RESULTS: From the cohort, 995 (2.35%) of the admissions had one and 276 (0.65%) had multiple medical emergency team activations. When compared with patients without, children having one or multiple medical emergency team reviews had 13.34 (95% CI, 5.33-33.2) and 50.10 (95% CI, 19.86-126.39) times the odds of death, respectively. Patients experiencing a medical emergency team review stayed in hospital 1.59 times (95% CI, 1.39-1.82) longer, whereas those with multiple medical emergency team reviews stayed 2.44 times (95% CI, 1.85-3.20) longer. The associations remained significant after controlling for important confounders and excluding elective admissions from the analyses. Most repeat medical emergency team reviews occurred within a day of the initial review or involved patients with multiple comorbidities. CONCLUSIONS: Our study suggests that pediatric patients reviewed by the medical emergency team are at significantly higher risk of mortality and longer length of stay than general ward inpatients. As well, patients with multiple medical emergency team reviews were at particularly high risk compared with patients with one medical emergency team review. Patients who experience medical emergency team reviews should be recognized as a high-risk group, and future studies should consider how to decrease morbidity and mortality. Based on our findings, we suggest that these patients be followed for 24-48 hours after any medical emergency team activation.

A PICU patient safety checklist: rate of utilization and impact on patient care.

OBJECTIVE: In healthcare, checklists help to ensure patients receive evidence-based, safe care. Since 2007, we have used a bedside checklist in our PICU to facilitate daily discussion of care-related questions at each bedside. The primary objective of this study was to assess compliance with checklist use and to assess how often individual checklist elements affected patient management. A secondary objective was to determine whether patient and unit factors (severity of illness, unit census, weekday vs. weekend, admitting diagnosis group) influenced checklist use. DESIGN: This was a prospective observational study. A research assistant attended daily bedside rounds to collect data at each eligible patient encounter. SETTING: The study was conducted in the Children's Hospital of Eastern Ontario (CHEO) PICU, a 12-bed cardiac and medical-surgical unit. PARTICIPANTS: Included all patients admitted to the PICU prior to 6 am and who were not being discharged that day. INTERVENTION: A bedside rounds checklist. MAIN OUTCOME MEASURES: Included compliance and whether the checklist affected the patient's management plan. RESULTS: A total of 148 encounters were collected on 28 days between September 2013 and February 2014. Compliance with the checklist was 89.2% (132/148; 95% CI 83.2-93.2%) and was not influenced by admitting diagnosis group, patient census, severity of patient's conditions or weekday/weekend status. The checklist affected the patient management plan 52.6% of the time (69/132; 95% CI 44.2-61%). CONCLUSIONS: Our study found high rates of compliance with an established checklist that has been in use in the PICU since 2007. Checklist use frequently resulted in a change in the patient management plan.

Fatal pneumococcal meningitis in a 7-year-old girl with interleukin-1 receptor activated kinase deficiency (IRAK-4) despite prophylactic antibiotic and IgG responses to Streptococcus pneumoniae vaccines.

UNLABELLED: IRAK-4 deficiency causes IL-1R and TLR signaling failure, resulting in minimal clinical features despite invasive bacterial infection. We report the course of a 7-year-old IRAK-4-deficient girl presenting in the first year with multiple occult Staphylococcus aureus lymphadenitis. She was managed with antibiotic prophylaxis (sulfa/trimethoprim/PenV, then - due to neutropenia - Cefprozil), pneumococcal vaccination (PCV-7, Pneumovax23, PCV-13) and vigilance. Pneumococcal-specific IgG levels were monitored. No bacterial infections occurred on prophylaxis for 6 years after initial presentation. IgG response to pneumococcal polysaccharide was satisfactory but short-lived, requiring frequent boosting. At age 7, patient developed a morning headache and vomited once. Cefprozil was administered and re-dosed. Over 12 h, she was fatigued without other symptoms. Low fever accompanied another emesis. A few hours later she was confused, and purpuric rash appeared. Emergency physicians diagnosed sepsis/meningitis and started vancomycin-ceftriaxone. Respiratory failure and cerebellar herniation occurred <24 h after first symptoms. Blood and CSF grew Streptococcus pneumoniae type 6C resistant to second-generation cephalosporins. The patient's latest PCV-13 vaccination was 6 weeks before death, which included serotype 6A. Immunoglobulins were normal except IgG4 was increased (3.4 g/L). IgG response to vaccine antigens was satisfactory. IgG to 6A is reported to cross-react with 6C, but this was not the case here. CONCLUSION: Despite antibiotic prophylaxis and repeated vaccination, even older IRAK-4-deficient patients are at high risk of rapidly fatal infection due to emergence of antibiotic resistance. These patients need early assessment at any age, bacterial culturing, alternative empiric antibiotic therapy and close observation when even vaguely unwell. Based on increasingly recognized immunological and/or clinical impairments in B cell function, and possibly other defects, long-term IgG prophylaxis in addition to antibiotics is recommended.

Identification of adverse events in pediatric severe traumatic brain injury patients to target evidence-based prevention for increased performance improvement and patient safety.

INTRODUCTION: Trauma centres are required to continuously measure, evaluate and improve care. Severe traumatic brain injury (sTBI) patients are highly susceptible to adverse events (AE; unintended, potentially harmful events resulting from health care) due to their unstable condition requiring high risk interventions, multiple medications and invasive monitoring. Objectives were to describe: (1) a process for identifying AE in pediatric sTBI patients to identify safety risks, target and implement evidence-based prevention strategies; and (2) a tertiary care PICU's sTBI AE experience. METHODS: Merging databases, Trauma Registry with Adverse Events Management System, identified AE in patients. Details on the event location, type and severity of harm were combined with patient demographics, injury data, costs and outcomes in a cohort of 193 PICU sTBI patients (2000-15). Descriptive statistics and multivariate logistic regression were undertaken to describe AE, and their association with risk factors and outcomes. RESULTS: 103/193 sTBI patients (53%) suffered at least one AE. 238 AE occurred (1.23 AE/patient), with 30% of patients having 2+ AE. Most resulted in no harm (54%) with decubitus ulcers (15%) the most common AE. AE patients were more likely to be monitored for elevated ICP (p<0.001), with fewer ventilator-free days (p=0.015), longer LOS for PICU (11 vs. 3.5 days; p<0.001) and in-hospital (31 vs. 11 days; p<0.001) with higher median costs ($121,234 vs. $53,341; p=0.031). AE patients required a higher level of care on discharge (p=0.035). CONCLUSIONS: Merging databases is an effective practice to identify AE and safety risks in trauma populations. Utilizing this method, a PICU AE rate of 1.23 events per patient was found with TBI severity the most important factor to increase the odds of AE. AE represent performance improvement events, opportunities to optimize care, decrease costs, as well as improve outcomes, to ultimately improve patient safety in this vulnerable population.

High Rate of Medical Emergency Team Activation in Children with Tracheostomy.

Pediatric in-patients with tracheostomy (PIT) are at high risk for clinical deterioration. Medical emergency teams (MET) have been developed to identify high-risk patients. This study compared MET activation rates between PITs and the general ward population. This was a retrospective cohort study conducted at a tertiary pediatric hospital. The primary outcome (MET activation) was obtained from a database. Between 2008 and 2014, the MET activation rate was significantly higher in the PIT group than the general ward population (14 vs. 2.9 per 100 admissions, p < 0.001). PITs are at significantly higher risk for MET activation. Strategies should be developed to reduce their risk on the wards.

Saline-Lock Versus Continuous Infusion: Maintaining Peripheral Intravenous Catheter Access in Children.

OBJECTIVES: In children, peripheral intravenous catheters (PIVs) are maintained by either a continuous infusion of fluid "to keep vein open" (TKO) or a saline lock (SL). There is a widespread perception that TKO prolongs PIV patency, but there is a lack of evidence for this. We hypothesized that there would be no significant difference in duration of PIV patency between TKO and SL. PATIENTS AND METHODS: This prospective, time-allocated study included patients from newborn to 17 years of age admitted to our pediatric ward. Patients enrolled in the first 3 months were assigned to TKO, and patients in the latter 3 months were assigned to SL. Primary outcome was duration of functional patency of the first PIV during the time of TKO or SL. Secondary outcomes included PIV-related complications and patient and caregiver satisfaction. RESULTS: Complete PIV data were available on 172 (n = 85 TKO, n = 87 SL) of 194 enrolled patients. The mean (SD) duration of PIV patency was 41.68 (41.71) hours in the TKO group and 44.05 (41.46) hours in the SL group, which was not significantly different (P = .71). There were no significant differences in complication rates or overall patient and caregiver satisfaction. One patient in the TKO group had their PIV removed because of risk of strangulation from tubing. CONCLUSION: There were no significant differences between TKO and SL in the duration of PIV patency, complication rates, and overall patient and caregiver satisfaction in our pediatric population. Overall, SL is a safe and reasonable alternative to TKO in maintaining PIV patency in children.

Development and validation of an algorithm of diagnostic and procedural codes for the identification of children hospitalized with a tracheostomy in Ontario, Canada.

BACKGROUND: The requirement for a tracheostomy in children is associated with significant morbidity, mortality, and healthcare utilization. Easy identification of children with tracheostomies would facilitate important research on this population and provide quality improvement initiatives. AIM: The purpose of this study is to determine whether an algorithm of diagnostic and procedural codes can accurately identify children hospitalized with a tracheostomy using routinely collected health data. METHODS: Chart reviews were performed at the Children's Hospital of Eastern Ontario (CHEO) and the London Health Sciences Center (LHSC) to establish a true positive cohort of pediatric patients with tracheostomies admitted between 2008 and 2016. A multidisciplinary team developed algorithms of diagnostic and procedural codes contained within the Canadian Institute for Health Information Discharge Abstract Database. Algorithms were tested and refined against the true-positive and true-negative cohort. The accuracy of the diagnostic codes related to tracheostomy complications was also evaluated. RESULTS: A chart review identified 158 unique children with tracheostomies (77 at CHEO, 81 at LHSC) with 901 individual admissions (401 at CHEO, 507 at LHSC). The best algorithms for identifying children with a tracheostomy had a sensitivity and specificity of more than 99%, a positive predictive value (PPV) of 94.0% and negative predictive value (NPV) of 100%. The algorithm for the identification of tracheostomy-related complications had a sensitivity of 76.7%, a specificity of 65%, PPV of 52.3%, and an NPV of 84.7%. CONCLUSIONS: This study provides an algorithm for the accurate identification of children hospitalized in Canada with a tracheostomy, facilitating population-level epidemiological research and quality improvement initiatives.

A National Survey of Resources to Address Sepsis in Children in Tertiary Care Centers in Nigeria.

Background: Infections leading to sepsis are major contributors to mortality and morbidity in children world-wide. Determining the capacity of pediatric hospitals in Nigeria to manage sepsis establishes an important baseline for quality-improvement interventions and resource allocations. Objectives: To assess the availability and functionality of resources and manpower for early detection and prompt management of sepsis in children at tertiary pediatric centers in Nigeria. Methods: This was an online survey of tertiary pediatric hospitals in Nigeria using a modified survey tool designed by the World Federation of Pediatric Intensive and Critical Care Societies (WFPICCS). The survey addressed all aspects of pediatric sepsis identification, management, barriers and readiness. Results: While majority of the hospitals 97% (28/29) reported having adequate triage systems, only 60% (16/27) follow some form of guideline for sepsis management. There was no consensus national guideline for management of pediatric sepsis. Over 50% of the respondents identified deficit in parental education, poor access to healthcare services, failure to diagnose sepsis at referring institutions, lack of medical equipment and lack of a definitive protocol for managing pediatric sepsis, as significant barriers. Conclusions: Certain sepsis-related interventions were reportedly widespread, however, there is no standardized sepsis protocol, and majority of the hospitals do not have pediatric intensive care units (PICU). These findings could guide quality improvement measures at institutional level, and healthcare policy/spending at the national level.