Improving Discharge Safety in a Pediatric Emergency Department.

BACKGROUND AND OBJECTIVES: Discharge from the emergency department (ED) involves a complex series of steps to ensure a safe transition to home and follow-up care. Preventable, discharge-related serious safety events (SSEs) in our ED highlighted local vulnerabilities. We aimed to improve ED discharge by implementing a standardized discharge process with emphasis on multidisciplinary communication and family engagement. METHODS: At a tertiary children's hospital, we used the model for improvement to revise discharge care. Interventions included a new discharge checklist, a provider huddle emphasizing discharge vital signs, and a scripted discharge review of instructions with families. We used statistical process control to evaluate performance. Primary outcomes included elimination of preventable, discharge-related SSEs and Press Ganey survey results assessing caregiver information for care of child at home. A secondary outcome was number of days between preventable low-level (near-miss, no or minimal harm) events. Process measures included discharge checklist adoption and vital sign acquisition. Balancing measures were length of stay (LOS) and return rates. RESULTS: Over the study period, there were no preventable SSEs and low-level event frequency improved to a peak of >150 days between events. Press Ganey responses regarding quality of discharge information did not change (62%). Checklist use was rapidly adopted, reaching 94%. Vital sign acquisition increased from 67% to 83%. There was no change in the balancing measures of median LOS or return visit rates. CONCLUSIONS: The development and implementation of a standardized discharge process led to the elimination of reported discharge-related events, without increasing LOS or return visits.

Use of intrapulmonary percussive ventilation (IPV) in the management of pulmonary complications of an infant with osteogenesis imperfecta.

Osteogenesis imperfecta (OI) is a genetic disorder characterized by abnormal collagen formation and short stature. These patients present with frequent vertebral, rib, and long bone fractures. There are many respiratory complications associated with OI including pneumonia, the most common cause of mortality in the severe forms of the disease. We present a case of an infant with OI (type III/IV) and significant tracheobronchomalacia who had required multiple hospitalizations for recurrent atelectasis and respiratory failure in the setting of acute respiratory infections. External chest percussion and vibration were avoided because of the risk of rib fractures. intrapulmonary percussive ventilation (IPV) was initiated during an acute illness with good effect, and continued successfully after discharge from hospital. We conclude that IPV represents a safe and effective alternative to airway clearance in infants with OI.

Use of the mechanical in-exsufflator in pediatric patients with neuromuscular disease and impaired cough.

BACKGROUND: Impaired cough secondary to weakness from neuromuscular disease (NMD) can cause serious respiratory complications, including atelectasis, pneumonia, small airway obstruction, and acidosis. The mechanical in-exsufflator (MI-E) delivers a positive-pressure insufflation followed by an expulsive exsufflation, thereby simulating a normal cough. Use of the MI-E in adults with impaired cough results in improved cough flows and enhanced airway clearance. However, only limited reports of MI-E use in children exist. OBJECTIVE: To determine the safety, tolerance, and effectiveness of the MI-E in a pediatric population. METHOD: Retrospective medical record review. PARTICIPANTS: Sixty-two patients (34 male patients) observed in a pediatric pulmonary program with NMD and impaired cough in whom MI-E therapy was initiated. Median age at initiation of MI-E use was 11.3 years (range, 3 months to 28.6 years). Diagnoses included the following: Duchenne muscular dystrophy (17 patients); spinal muscular atrophy, types I and II (21 patients); myopathy (12 patients); other nonspecific NMD (12 patients). Mechanical ventilation via tracheostomy was used in 29 patients, and 25 patients used noninvasive ventilation. RESULTS: The median duration of use was 13.4 months (range, 0.5 to 45.5 months). One infant died before using MI-E at home. Five patients chose not to continue MI-E therapy. Complications were reported in two patients, but ultimately they used the MI-E device. Chronic atelectasis resolved in four patients after beginning MI-E therapy, and five patients experienced a reduction in the frequency of pneumonias. CONCLUSION: In 90% of our study population, the use of an MI-E was safe, well-tolerated, and effective in preventing pulmonary complications.

Stress protection by a fluorescent Hsp27 chimera that is independent of nuclear translocation or multimeric dissociation.

A chimeric protein consisting of enhanced green fluorescent protein (EGFP) fused to the N-terminus of human Hsp27 conferred stress protection in human A549 lung carcinoma and murine L929 cells that were stably transfected to express the chimera constitutively. The resultant protection was comparable with that in the same cell lines when they were transfected to express corresponding levels of Hsp27. Unlike L929 cells, A549 cells exhibit endogenous Hsp27 expression, whose expression was inhibited in proportion to the amount of fluorescent chimera expressed, suggesting that the A549 cells recognized the latter as Hsp27. Upregulation of Hsp27 or chimeric Hsp27 in all transfected cell lines (stable or transient transfection) caused no measurable change in cellular glutathione levels, indicating that glutathione played no role in the stress protection associated with either protein. Chimeric Hsp27 had a monomeric molecular weight of 55 kDa (that of Hsp27 plus EGFP) in both cell types and formed a 16-mer complex twice as massive as that formed by Hsp27. Heat shock or sodium arsenite induced phosphorylation of both chimeric Hsp27 and Hsp27, which resulted in the disaggregation of Hsp27 multimers in both cell types and disaggregation of 20% of the chimeric multimers in L929 cells. But chimeric Hsp27 multimers did not disaggregate after stress in A549 cells. Epifluorescence and confocal microscopy demonstrated that chimeric Hsp27 was restricted to the cytoplasm under normal growth conditions and after heat shock in all cells. This study supports the conclusions that Hsp27 stress protection requires neither its translocation into the nucleus nor the dissociation of its multimeric complex. Furthermore, it demonstrates that fluorescent chimeras of heat shock proteins can be functional and used to observe the protein's distribution within living cells.

Pulmonary function in technology-dependent children 2 years and older with bronchopulmonary dysplasia.

Somatic and pulmonary growth coincide with resolution of hypoxemia by 2 years of age in most children with bronchopulmonary dysplasia (BPD). However, a distinct subgroup of children with BPD continue to require mechanical ventilation and/or supplemental oxygen beyond 2 years of age. This study tested the hypothesis that indices of pulmonary function would be significantly worse in children with BPD 2 years and older who remained technology-dependent secondary to hypoxemia, compared to those of age-matched children with BPD who were normoxemic. We measured pulmonary mechanics in 21 oxygen- or ventilator-dependent children with BPD 2 years and older (BPDO2 group; mean age+/-SD, 30.2+/-6.5 months) and in 19 children with BPD who had been weaned off mechanical ventilation and supplemental oxygen for at least 6 months (control group; mean age, 30.1+/-5.5 months). Respiratory rate and tidal volume were measured after sedation with chloral hydrate, and dynamic compliance and expiratory conductance were calculated using the esophageal catheter technique. Maximal flow at FRC (V'(maxFRC)) and ratio of forced-to-tidal flows at midtidal volume were obtained by the rapid thoracic compression technique. FRC was determined by nitrogen washout. There were no statistically significant differences in most measured indices of pulmonary mechanics between the BPDO2 and control groups. However, V'(maxFRC)/FRC was higher in controls compared to subjects in the BPDO2 group (0.81+/-0.40 sec(-1) vs. 0.34+/-0.21 sec(-1), P<0.003). We conclude that most indices of pulmonary function in children with BPD 2 years and older do not reflect the need for mechanical ventilation or supplemental oxygen. We speculate that measurements of lung elastic recoil and tests of distribution of ventilation and pulmonary perfusion may be more sensitive in differentiating normoxemic and hypoxemic children with BPD 2 years and older.

Behaviour of DNA, protein and acid hydrolases in response to thyroxine in isolated tail tips ofXenopus-larvae.

Analysis of factors influencing survival of tail tips ofXenopus larvae "in vitro" has shown that prevention of infection by antibiotic pretreatment of donor tadpoles and amputated tips is most critical. In tail tips exceeding not more than 1/3 of the body length, maintenance of N-content and regenerative capacity are superior in Niu-Twitty and Steinberg's saline than in Holtfreter's solution, all media being supplemented by 0.04 % sulfathiazole. Addition of nutrient ingredients to saline (glucose, Parker's medium 199, serum protein) does not improve viability of tail explants.In isolated tail tips 2.5×10-7M L-thyroxine (T4) induces involution "in vitro", resulting in losses of about 85% in DNA and 70% of protein respectively after 12 days of treatment. A significant decrease in DNA occurs after three days, and for protein after 6 days of hormone treatment, when tail fins are almost fully resorbed.Statistical analysis of the regression curves for decrease in DNA and protein, produced by different concentrations of T4, indicates the presence of an upper threshold (2.5×10-7M) and a lower threshold (2.5×10-8M) of sensitivity to hormone. Intermediate concentrations affect the latency time required for onset of DNA and protein loss, lengthening it at lower concentration.In tail tips exposed to 2.5×10-7M T4 a concurrent rise in activity of cathepsins, DNase and acid phosphatase has been demonstrated. The specific activities of these acid hydrolases are significantly higher in T4-treated tails after four days of hormone administration, this response proceeding detectable loss in protein by two days. Extent and duration in the rise of activity are characteristic for each enzyme, the increase in both specific and total activities being highest for cathepsins, intermediate for DNase and lowest for acid phosphatase.